self harming and substance misuse and volatile relationships case presentation

1. SELF-HARMING, SUBSTANCE
MISUSE
AND VOLATILE RELATIONSHIPS
Presented by-Abhishek Kohli
Group 32 semester 9
Guided by Dr Alina Volnaya

2. Case presentation
• A 19-year-old woman with a 6-year history of self-harm attends the emergency
department. Her self-harm is usually in the form of cutting, but every few weeks when
she feels things are getting on top of her, she takes an overdose. The overdoses are
usually impulsive and precipitated by a row with her boyfriend or mother. The
relationship with the boyfriend is volatile and the police have been called out on
more than one occasion when things have become heated and violent. The woman
has alleged domestic violence but then retracts her allegations and the police have
not taken any action against her boyfriend. There is also a long history of substance
misuse, usually alcohol but she has also dabbled in all sorts of illegal substances.
When under the influence she has had unprotected sex with men other than her
boyfriend and has become pregnant on two occasions. Both times she chose to end
the pregnancy feeling that if she did not her boyfriend would leave her. After each
termination she had a period when she described herself as ‘constantly suicidal.

3. Mental state examination
• Her eye contact is fleeting. She is distraught and shouting that she just
wants to be left alone so that she can kill herself. She is verbally
abusive and threatening violence if she is not given what she wants.
She is irritable and agitated. She is unkempt and looks like she has
recently been in a fight. Her speech is rapid but coherent. Objectively
her mood is labile and subjectively she says that she is depressed and
life is not worth living. She says she is suicidal and wants to kill
herself. She is angry as she feels she is being thwarted in this. She
says there is no point in living especially as her boyfriend has broken
up with her. There is no evidence of any psychotic features and she is
orientated in time, place and person

4. Personality disorder
• NOTE
People with personality disorders have experiences
and behaviour that are markedly outside their societal
norms. This demonstrates itself in enduring ways,
impacting upon relationships, interpersonal functioning,
emotion regulation, affective responses, impulse control
and attributions about self and others.

5. Questions
• • Given the definition of a personality disorder above,
does this person have a personality disorder?
• • What is the differential diagnosis?

6. ANSWER
• The differential diagnosis is acute intoxication (alcohol/drugs), depression or
emotionally unstable personality disorder (EUPD). The most likely primary diagnosis is
EUPD. An alternative way of conceptualizing this involves the use of a multi-axial
formulation that considers not only diagnosis but psychosocial factors and
development. It includes an understanding of early life experiences and maladaptive
coping and care seeking, as well as any organic or intellectual factors. The rich
explanatory power of multi-axial classification systems makes them helpful for
designing interventions. Very stressful or chaotic childhoods are commonly reported
(e.g. physical and sexual abuse, neglect, hostile conflict and early parental loss or
separation). This often means that the features leading to the presentation are long-
standing so long-term therapeutic interventions may be helpful. Multi-axial systems
used in adulthood and childhood are slightly different

7. EUPD
• EUPD is a condition characterized by impulsive actions, rapidly shifting moods, and
chaotic relationships. There are two types (impulsive and borderline). With both of these
there is
• • Impulsivity without thought of the consequences (e.g. unprotected sex or dangerous
substance abuse)
• • Lack of self-control with outbursts of intense anger or violence The impulsive type is
characterized by emotional instability and an inability to control impulses, with episodes
of threatening behaviour and violence occurring particularly in response to criticism by
others.

8. .
• The borderline type is also characterized by emotional instability. People with
this type of personality disorder may experience severe doubts about their
self-image, aims and sexual preferences that cause upset and distress. It is
common to experience a strong and debilitating sense of emptiness and this
can lead to self-harm and suicide threats. They are liable to become involved
in intense but unstable relationships with regular emotional crises.
Completed suicide occurs in around 8%–10% of individuals with this
disorder, and self mutilation acts (e.g. cutting or burning) and suicide threats
and attempts are very common. Recurrent job losses and broken marriages
are common

9. Co-morbidity with mood disorders
• Co-morbidity with mood disorders, substance misuse, eating disorders (usually
bulimia) or posttraumatic stress disorder (PTSD) is common. This disorder is
more frequent in females than males.
• Emotional instability and impulsivity are very common in adolescents, but most
adolescents grow out of this behaviour. Personality disorder diagnoses are not
made in adolescence because of the ongoing development of personality and
the stigmatizing nature of the diagnosis. It should therefore only be carefully and
cautiously applied. This disorder, like all personality disorders, is usually worse in
the young adult years and gradually decreases with age. Into the 30s and
beyond, the majority of individuals have attained greater stability in their
relationships and working lives.

10. Management and treatment
• he first step in management involves calming her down so
a proper assessment of such factors can take place.
• A risk assessment is crucial because her safety is a
concern. The social support available will need
exploration.
• Even if she is not actively suicidal, admission may be
unavoidable as there is a risk that she could harm herself
in this volatile state.

11. • There are several forms of therapy that have proven to
be effective for EUPD.
• Dialectical behavior therapy (DBT), Mentalisation
based therapy (MBT) and Schema therapy are some
examples.

12. Specific medication guidance
• Current practice and evidence for prescribing in EUPD, in the
absence of co-morbid psychiatric disorder, tends to be
organised around treatment of prominent symptom domains
including affective symptoms or affect dysregulation, cognitive
perceptual symptoms, impulsivity and aggression.

13. Antidepressants
• The limited evidence base indicates that SSRI's do not have a major role in treating
any of the symptom domains of EUPD. Amitriptyline has been shown not to be
effective, and both may cause behavioural disinhibition. Reboxetine has also been
reported to worsen symptoms. Other antidepressants require further research to
inform prescribing guidance. In addition, the risk of discontinuation symptoms in the
context of inconsistent compliance may be a significant factor for some patients and
the discontinuation reactions and side effects may make them feel worse. Side-
effects including sexual dysfunction should be considered.

14. Mood Stabilisers
• Although NICE does not recommend routine prescription of mood stabilisers in
EUPD, there is limited evidence of some effect for the prescription of sodium
valproate and topiramate in reducing affective symptoms or affect dysregulation and
impulsive aggression respectively. Significant risks of teratogenicity and potentially
serious side-effects limit prescription however. Available evidence indicates that
carbamazepine is not effective in treating EUPD, it can cause behavioral disinhibition
and that its propensity to interact with other drugs is of particular importance. While
lithium is licensed for aggressive and self-harming behavior its clinical utility in
treating EUPD is limited due to inconsistent compliance, lethality in overdose and
monitoring requirements. The Maudsley Guidelines suggests that the use of Lithium
may reduce mood variation,

15. Antipsychotics
Antipsychotics There is some evidence of positive effect for haloperidol in
reducing anger when prescribed in lower doses than for psychotic
disorders. However, this is based on a small number of participants.
Haloperidol is known to be associated with extrapyramidal symptoms and
can prolong the cardiac QTc interval. There is evidence from a small RCT
that Flupenthixol Decanoate is effective in reducing suicidal behavior, but
this has not been replicated. Second generation antipsychotics
Aripiprazole, Olanzapine and Quetiapine have shown some effect in
treating affective dysregulation and cognitive-perceptual symptoms

16. Benzodiazepines and
related drugs
While these drugs can be useful in improving sleep short-
term and in reducing anxiety in crises situations (up to 14
days), the intrinsic risk of dependence, potential for causing
disinhibition or paradoxical symptoms (e.g. aggression)
and impact on memory pose a significant challenge and
should not be prescribed long-term. Sedating
antihistamines such as promethazine may be a suitable
alternative in the first instance

17. Key Points
• The diagnosis of personality disorder requires detailed longitudinal history and should not
be made on the basis of one interview.
• • This disorder often presents through self-harm and suicidal threats, but impulsive
behaviour is common across various spheres of life.
• • Individuals with this disorder have often had chaotic childhoods and have inappropriate
social supports and coping mechanisms. Interventions are best directed towards
remedying these limitations rather than with pharmacotherapy