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

Jeffrey S. Forrest, MD; Alexander B. Shortridge


September 18, 2020

Clinicians should be aware of the current frameworks used to diagnose BPD. The DSM-5 utilizes two models of diagnosis: categorical and dimensional.[9] BPD is conventionally diagnosed using a categorical model (ie, a patient either does or does not receive a diagnosis by meeting specified criteria).[10] A dimensional model of diagnosis characterizes a condition based on a spectrum of prominent traits.[9] Given that five of the nine DSM-5 criteria must be met to receive a diagnosis by the current categorical standard, presentations may vary significantly among patients described as having the same condition. To address this variation, the categorical approach is often used in conjunction with a dimensional approach.[10]

One approach that may prove useful in performing a dimensional diagnosis of BPD is the Five Factor Model. The Five Factor Model describes personality on a continuum based on five characteristics: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness.[11] It has been demonstrated that BPD can be differentiated from other personality disorders based on specific differences in Five Factor Model traits.[12]

Although BPD shares many characteristics with bipolar affective disorders, they are entirely distinct diagnostic entities. Both conditions may involve dramatic shifts in mood; however, the timing, duration, intensity, and pattern of the mood shifts may be very different. BPD is characterized by affective instability: "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)."[1] Conversely, bipolar disorders feature episodes of affective extremes, high or low, that may last for days, weeks, or months. Patients with BPD typically shift from euthymia to anger, whereas patients with bipolar disorders tend to shift from depression to elation.[13] Although BPD and bipolar disorders are different conditions, it is possible for the two to occur concomitantly in the same individual.[14]

To further differentiate BPD from bipolar disorders, it is worth examining the sleep disturbances associated with both conditions. Patients with BPD experience sleep disturbances such as increased sleep-onset latency, low sleep efficiency, and nightmares.[15] In contrast, patients with bipolar disorders commonly experience a reduced need for sleep (not merely decreased sleep) during a manic episode and (excessive sleepiness (hypersomnia) during depressive episodes.[16] Note that the patient in this case stated that he always felt the need and desire to sleep, despite clearly having difficulty in sleeping.

Clinicians should be aware of the ego-syntonic nature of BPD behaviors. Personality disorders consist of ego-syntonic patterns of behavior.[17] This means that the problematic conduct exhibited is not inherently distressing to the person performing it.[1] The patterns may feel natural or even instinctive. Their personality is not ego-alien to them. However, it is important to make the distinction that the consequences of ego-syntonic behaviors may well become very distressing for such a patient, even if the performance of the behavior is not. In the case presented, the patient reports a history of frequent self-mutilation and casually endorses doing so as a regular coping mechanism.

By contrast, the features of mood disorders such as major depression or bipolar disorder are typically ego-dystonic[17]; the behaviors are, or ultimately become, inherently distressing to the person who exhibits them.


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