Letter to the Editor: Multiple Invasive Procedures in a Patient with Borderline Personality: A Relationship?

| April 21, 2014 | 0 Comments

Cover_Mar-Apr_2014R. Jordan Bohinc, DO; Randy A. Sansone, MD; and Stephen McDonald, MD
Dr. Bohinc is a resident in the Department of Internal Medicine at Kettering Medical Center in Kettering, Ohio; Dr. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; and Dr. McDonald is a professor in the Department of Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Senior Medical Official for Education at Kettering Medical Center in Kettering, Ohio.

Innov Clin Neurosci. 2014;11(3–4):10–13

Funding/financial disclosures. No funding was received and the author has no conflicts of interest relevant to the content of this article.

Introduction. Borderline personality disorder (BPD) is a complex and challenging psychiatric dysfunction characterized by an intact social façade, self-regulation difficulties (e.g., mood, eating, and substance use disorders), and self-harm behavior (e.g., self-cutting, suicide attempts).1 While the extant literature describes patients with BPD with regard to invasive and surgical procedures, these references relate to either patients ingesting a foreign body2–4 or descriptions of BPD as a comorbid condition that might potentially complicate a legitimate surgical procedure.5–8 For example, Myint and Weiner discuss the potential management complications of individuals with BPD in the surgical setting.9 However, during a literature search of the PubMed database, we did not find any specific cases of patients with BPD undergoing multiple and diverse invasive procedures and/or surgeries—the focus of the present case report.

Case report. The patient was a 38-year-old, married, Causasian woman with a medical history characterized by numerous invasive and surgical procedures. These procedures included a subtotal thyroidectomy for a globus sensation, colonoscopy for anemia, esophagogastro-duodenoscopy for anemia, bilateral breast reduction for chronic back pain, an appendectomy for abdominal pain, diagnostic laparoscopy for abdominal pain, two caesarian sections, removal of a foreign body from the eye following a motor vehicle accident, and a myomectomy for menorrhagia. In addition, she suffered from obesity, hypertension, diabetes mellitus type 2, dysthymic disorder, anxiety, chronic pain, pseudoseizures, a prolactinoma, pseudotumor cerebri, hypothyroidism, a past pulmonary embolism, iron deficient anemia, and gastroesophageal reflux. Ongoing medications included acetazolamide, albuterol, potassium chloride, pravastatin, metformin, pantoprazole, warfarin, spironolactone, ferrous sulfate, and ondansetron.

In addition to her complex medical history of multiple and invasive medical procedures, the patient demonstrated a sufficient number of clinical features to meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria for BPD. For example, she was keenly fearful of abandonment (e.g., during her frequent hospitalizations, she would experience an emotional meltdown with the staff until they allowed her husband to remain overnight in the hospital room with her, which was not permitted by hospital policy). Her relationship with her husband was one of both dependency and conflict, vacillating between childlike verbal engagement and rage reactions. Moreover, the patient manifested a number of self-regulation difficulties, including obesity (body mass index [BMI]=33.1), analgesic narcotic misuse (e.g., as an inpatient, the patient frequently demanded intravenous narcotics without a clear indication; her multiple emergency department visits were characterized by leaving against medical advice after receiving intravenous narcotics), and rage reactions (e.g., the patient had repeated verbal outbursts toward the nursing staff, demanding to speak with attending physicians as well as hospital executives in the middle of the night when intravenous pain medications were refused; these incidents were extremely disruptive to fellow patients and staff). While the patient had no overt self-mutilation, her multiple invasive procedures and surgeries might be considered body violating, given the context of BPD. The subject also demonstrated a chronically labile and irritable mood that was punctuated with depression (note the prior diagnosis of dysthymic disorder) and emptiness. We were not aware of any stress-related paranoia or overt dissociative symptoms.

Discussion. Whether this patient’s multiple and diverse invasive procedures were fully and clinically justified remains unknown and perhaps irrelevant. However, the sheer number of procedures resonates with the characteristic pattern of medical over-utilization observed in patients with BPD.1 In addition, she demonstrated a history of substance misuse, which is a common finding among patients with this type of personality dysfunction (i.e., a lifetime prevalence of around 64%).10

The potential psychological functions of this patient’s multiple procedures could readily resonate with the typical psychological themes encountered in BPD. For example, these invasive procedures may have functioned as self-injury equivalents (i.e., self-injury behavior in a veiled form); a means of soliciting caring responses from others;11 a mode to reaffirm through invasive procedures a victim role that was legitimately established in childhood through early abuse experiences;1 a means to establish ongoing dependency; and a vehicle to segue into a chronic-pain lifestyle and secure controlled analgesics. In other words, while the content or substance of this subject’s presentation was fairly unique (multiple invasive procedures), the psychological themes and functions were likely to be identical to those typically observed in BPD.

This case underscores the importance of considering BPD in patients with multiple invasive and/or surgical procedures. Patients with BPD may display a clinical coat of many colors (i.e., various symptom presentations)—but it is still a coat (i.e., BPD).

References
1. Sansone RA, Sansone LA. Borderline Personality in the Medical Setting. Unmasking and Managing the Difficult Patient. New York: Nova Science Publishers, 2007.
2. Aalouane R, Lahlou F, Aarab C, et al. Recurrent voluntary ingestion of metallic objects in prison by a female patient. Encephale. 2013. DOI: 10.1016/j.encep.2013.06.002.
3. Frei-Lanter CM, Vavricka SR, Kruger TH, et al. Endoscopy for repeatedly ingested sharp foreign bodies in patients with borderline personality disorder: an international survey. Eur J Gastroenterol Hepatol. 2012;24:793–797.
4. Hermes D, Schweiger U, Warnecke KK, et al. Incorporation of multiple foreign bodies due to borderline personality disorder. Mund Kiefer Gesichtschir. 2005;9:53–58.
5. Huffman JC, Popkin MK, Stern TA. Psychiatric considerations in the patient receiving organ transplantation: a clinical case conference. Gen Hosp Psychiatry. 2003;25:484–491.
6. Akaho R, Sasaki T, Yoshino M, et al. Bone marrow transplantation in subjects with mental disorders. Psychiatry Clin Neurosci. 2003;57:311–315.
7. Weitzner MA, Lehninger F, Sullivan D, Fields KK. Borderline personality disorder and bone marrow transplantation: ethical considerations and review. Psychooncology. 1999;8:46–54.
8. Groenman NH, Sauer HC. Personality characteristics of the cosmetic surgical insatiable patient. Psychother Psychosom. 1983;40:241–245.
9. Myint SH, Weiner MF. Management of a borderline patient in a surgical setting. Psychosomatics. 1981;22:71–72.
10. Sansone RA, Sansone LA. Substance use disorders and borderline personality: common bedfellows. Innov Clin Neurosci. 2011;8:10–13.
11. Gunderson JG. Borderline Personality Disorder. Washington, DC: American Psychiatric Press Inc.; 1984.

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Category: Letters to the Editor, Medical Issues, Past Articles, Personality Disorders, Psychiatry, Suicidality

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