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

Jeffrey S. Forrest, MD; Alexander B. Shortridge


September 18, 2020


This patient's presentation and reported history most strongly correlate with a diagnosis of borderline personality disorder (BPD). BPD is a pervasive pattern of behavior characterized by unstable interpersonal relationships, self-image, and affect, as well as impulsive self-harming behavior.[1] The term "borderline personality" was first coined by Adolph Stern in 1938 to describe his patients who "bordered" between psychosis and neurosis.[2]

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a diagnosis of BPD requires the presence of five or more of the following personality characteristics[1]:

  • Frantic efforts to avoid real or imagined abandonment

  • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization (in which a person assigns exaggeratedly positive characteristics to the self or others) and devaluation (in which a person assigns exaggeratedly negative characteristics to the self or others), commonly referred to as "splitting"[3]

  • Identity disturbance, with a markedly and persistently unstable self-image or sense of self

  • Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating)

  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

  • Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

  • Chronic feelings of emptiness

  • Inappropriate, intense anger or difficulty in controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights)

  • Transient, stress-related paranoid ideation or severe dissociative symptoms

The prevalence of BPD is as high as 5.9%, with women accounting for most cases.[4] In psychiatric settings, this estimate increases to about 15% to 28%.[5] Data from family studies have demonstrated that the prevalence of BPD among first-degree relatives of affected patients is 4- to 20-fold higher than in the general population.[6]

The ways in which BPD personality patterns are generated are diverse and multifactorial. Environmental factors have been identified in BPD pathogenesis, including childhood maltreatment (found in as many as 70% of patients with BPD), adoption, maternal separation, poor maternal attachment, inappropriate family boundaries, parental substance abuse, and serious parental psychopathology.[7] Posttraumatic stress disorder and BPD can co-occur.  

Certain genetic factors may also play a role in the onset of BPD. Data from twin studies show that the heritability of BPD is higher than 50%.[7] Of note, these same studies found a higher concordance of BPD for monozygotic than for dizygotic twins. Alterations in the social reward and empathy networks of the brain caused by dysregulation of the oxytocinergic system may contribute to BPD pathology.[8]


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