Case 34: A teenager in “constant crisis”

01The case

A 19-year-old woman is brought for a consultation by her parents, just after a short stay in a toxicology ward. Her problems began about four years ago, with sudden swings of mood and frequent wishes to die. She has had "crises" in which she screams that she hates everyone, breaks things and cries. These pass quickly, and she becomes kind again, but she tends to judge the people around her in extremes. She makes friends easily and is soon let down by them. Several times she has got very drunk and had casual sex with strangers, and she has harmed herself on impulse many times. In the interview she says she does not know who she is or what she wants, that she feels empty inside and that she is at a dead end. Her parents call her state a "constant crisis".

02Summary

Diagnosis

Borderline personality disorder, in ICD-10 emotionally unstable personality disorder, borderline type, and in ICD-11 personality disorder with a borderline pattern.

What points to it

• Onset in adolescence and a lasting, stable pattern, rather than episodes of illness with recovery in between.
• Emotional instability: intense, short-lived outbursts of anger and distress.
• Impulsive, self-damaging behaviour: binge drinking, risky sex, repeated self-harm.
• Unstable relationships, swinging between idealising people and being disappointed in them.
• A disturbed sense of self and chronic feelings of emptiness.
• Repeated suicidal wishes, and now a stay in a toxicology ward: find out whether it followed an overdose or heavy drinking.

What else it could be

Mood swings this brief and reactive are not bipolar disorder, whose episodes last days to weeks, but a depressive episode can coexist and should be looked for. Also consider alcohol or drug misuse, complex PTSD after trauma, ADHD and an eating disorder, all of which often come with it.

Management

• Assess suicide risk first: what she took, what she meant by it, how she feels now about being alive, and any plans. Her repeated self-harm and recent poisoning put her at raised risk.
• Listen without judging and acknowledge her distress. Ask about trauma, alcohol and drugs, and about what triggers her crises.
• Agree a crisis plan with her, and involve her parents if she agrees.
• Long-term structured psychotherapy is the core: dialectical behaviour therapy, especially for self-harm, or mentalisation-based therapy, with a consistent team.
• Medication only for a separate disorder such as depression, or very briefly in a crisis. Avoid several drugs at once, and give small amounts, given the risk of overdose.

Outlook

Better than once thought. Long-term studies find that a third to a half of people, and in some studies most, no longer meet the criteria after ten years or more, especially with therapy, and self-harm and impulsivity ease first. Feelings of emptiness and difficulties with work and relationships often last longer, and the risk of suicide stays raised.