An Enraged 36-Year-Old Man With Razorblade Slashes on His Arms

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

September 18, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 36-year-old man is brought to the emergency department on a temporary detention order (involuntary hold) after an evaluation by the municipal crisis assessment team. The patient had been extremely upset during a disagreement with his significant other. He had become disproportionately enraged and proceeded to yell, throw possessions, and break his phone. He then used a razor blade to make numerous superficial slashes on the inside of both of his forearms. At that point, his concerned adoptive parents called the behavioral health crisis unit.

During his intake evaluation, the patient reports that he has injured himself on many prior occasions, including punching himself and using a cigarette lighter to burn himself on various places on his body. When asked what made him upset enough to want to do these things, the patient states, "Everyone hates me, they always leave me!" He then becomes hostile toward the evaluator and says, "The other intake counselor was much better than you. People like you are the reason I want to hurt myself!" A brief review of hospital records reveals that the patient has had multiple similar presentations over the past several years.

On follow-up evaluation, the patient reveals that conflicts in his personal relationships are commonplace. He says, "I don't even know who I am anymore. People are all just using me." The patient states that he is frequently reckless in his behavior, explaining, "Sometimes I go out and hook up with people on dating apps just to feel something. I always just feel empty afterward."

The patient acknowledges occasionally starving himself when he is not having a good day. He has significantly unstable moods. He explains, "Some days, it feels like everything is awesome, but within a few hours or a day I wake up and realize that it all just sucks." When asked how long this has been going on, he says, "I've always been this way."

The patient has occasional difficulty in getting to sleep; however, he states that he always feels the need and desire to sleep, he is simply unable to do so at times. When asked whether he ever attempted suicide before, he recounts, "One time I took 10 ibuprofen pills to show my parents how hateful they are." The patient denies current plans or intentions for suicidal action but states, "Sometimes I get tired and just don't want to feel anything anymore. It's always hot or cold, there's nothing ever in the middle." When asked about his parents and his significant other, he says, "I would not actually hurt them, but I hope they feel bad when I cut myself."

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