Ms.T is a 25 year old single woman of Indian origin who lives in Phoenix on a student visa pursuing her master’s degree in information technology.
“Am I Broken”, “ I am empty from inside”
Ms. T was referred by the local hospital for an evaluation after she had cut her wrists around two weeks ago. She informed me that she had cut herself four additional times in these two weeks.
She said she was thankful that R was her boyfriend and that he cared so much for her as she was “unable to trust anyone before”. She complained that she had cut herself four times with razor blades and described watching herself do this as if from a distance, numb and dead inside and feeling little pain. Ms. T informed me that at these times she felt fat, unattractive, unlovable and worthless. These cutting episodes were directly related to the non-availabilty of R when she threatened to commit suicide unless he came and gave her company.
She met R almost a year ago when she came to study at the graduate school. He was in the same group as hers during a course and started interacting with him. Whenever she saw R with his girlfriend, she would rush to her dorm and skip classes for that day. She was getting irritable, and would get upset if her mother called because “she would ask only about her grades”. In response to the stress of six to seven months, she developed fluctuating sad moods, withdrew herself from everyone around her, would sleep for extended periods of time and go on binge eating sprees on junk food which caused her to gain almost 25 lbs in 6 months. She felt isolated, lonely and when her roommate invited her to a weekend party, she went in her pajamas. R was also at that party with a new girlfriend and she saw them drinking alcohol.
She took a few shots for the first time in her life and took the initiative to dance. In the process she twisted her ankle and fell on the floor. She felt ashamed, judged and got very upset with her clumsiness. When some students laughed at her, she couldn’t handle the pressure and slashed her wrist with a broken piece of glass she had found laying on the floor. She could then feel the blood spilling all around her but was numb. She asked R to take her to the ER in his car. Upon initial assessment and dressing of the wound, she was discharged with a referral to my office.
Ms. T was born and raised in India before she moved to the US around one year ago to pursue her master’s degree in information technology. She was the older of two children who were raised by their mother. Her father apparently left her mother when she was around 7 years old and her mother never talked about him. She grew up in an academic household as her mother was a school teacher. Ms. T studied her way into the prestigious Indian Institute of Technology and became famous in her neighborhood. While in college, she went through phases of defiance with her mother and complained that “the Indian education system took away her childhood”.
She would get easily upset when criticized and get argumentative with people around her. While in college, she associated with a rebellious group that looked down upon the previous generation as “failures”. She wanted to break the orthodoxy in Indian society, and fix the “broken system”. Interestingly, while in college her friendships did not last for more than one to two months as she couldn’t trust them. R was her only glimmer of hope and she did not want to lose him. However, she denied being in a relationship with R and was not sure whether he regarded her as his girlfriend.
Discussion:
Although mood disorder and borderline personality can often occur together, they may also be confused with each other. The diagnosis of Borderline Personality Disorder is frequently used inappropriately and pejoratively for individuals who are temporarily irritable, demanding, manipulative, self-destructive and impulsive. Such behavior does not warrant a diagnosis of Borderline Personality Disorder unless the features have an early onset, a pervasive impact and more or less chronic course.
Treatment Planning:
In treating patients with Borderline Personality Traits, the clinician must first focus on the target symptoms of depression, substance use and impulse control issues. After these have been evaluated and treated, psychotherapy should focus on Cognitive Distortions and Restructuring of perceptions. This is also regarded as Dialectical Behavior Therapy and the approach should involve problem areas of interpersonal rejection sensitivity, self destructive aggressive behavior, depersonalization and a tendency to perceive the world without shades of gray. It is important to prevent regression as it might lead to suicidal tendencies. Long term psychotherapeutic relationships should go a long way in allowing the patient a steady responsible approach towards life challenges.