PRISON HEALTH IN IMAGES
Borderline personality disorder and foreign body ingestion
C Íñigo-Barrio, Á López-López
Hospital Psiquiátrico Penitenciario de Alicante
(Prison Mental Hospital of Alicante)
We hereby present the case of a twenty nine years old single female inmate with no children hosted in the correctional facility of Alicante since June 2014 accused of a crime of assault and threats with a history of psychiatric pathology ever since 2009. The clinical picture was first diagnosed of eating disorder and ultimately of borderline personality disorder (BPD).
She is a patient with varied and continuing behavior disturbances such as: flooding her room, selfharm through foreign body ingestion (clips, pens, cutlery, etc.), irritability whenever her demands are not satisfied, a mobilizing attitude, lack of suicidal ideation, affective instability, lack of impulse and behavioral control and cognitive-perceptive difficulties.
Borderline personality disorder (BPD) is the most common personality disorder. Its prevalence is estimated to be around 2% and it entails a generalized disorder of emotional regulation systems with subjective malaise and functional impairment. These patients believe that behavior is the solution to all their problems and hence present high sensitivity and low threshold of reaction1-4.
There is interpersonal deregulation that translates into fear of abandonment, deregulation of identity leading to inner emptiness, behavioral deregulation leading to impulsive and self-harm behaviors and cognitive deregulation entailing dissociative response and paranoid ideation.
Beck and Freeman suggest dichotomous thinking, also known as "black or white thinking"2. These patients lack the ability to communicate and express their emotions, escape is their main defense mechanism with an inability to reconcile perceptions and feelings.
Our patient presents all of the aforementioned, and continuously tries to direct professionals through her demands. She has pursued urgent consultation on various occasions, undergoing thoracic and abdominal x-rays examination (See Figures 1, 2, 3, over eight gastroscopy procedures, one colonoscopy and over 5 CT. Multiple and various objects have been extracted (Figure 4).
Correctional facilities are difficult environments for treating these patients since such behaviors entail restriction and punishment actions and quite the contrary, BPD patients respond better to reinforcement than to punishment.
There is no specific treatment and none of the treatments used is more effective than the rest3.
Combined psychotherapeutic and pharmacological strategies are needed. Response to pharmacological treatment is poor. The treatment with stronger evidence is based on SSRIs to treat affective instability and lack of impulse control; and low doses of neuroleptics for anger and hostility.
Behavioral mindfulness techniques entail objectification of thoughts and emotions trying to make self-destructive behaviors go from egosyntonic to egodystonic and making patients reflect on its adverse consequences.
In prisons, BPD accounts for high rates of selfdestructive behaviors and completed suicides, and therefore awareness on the disorder and its approach is essential for professionals developing their tasks in these settings. The detection of severe cases would enable expert’s reports to recommend specific Units as the best settings for treating these patients. They could be hosted in such units, which already exist in our country, to undergo individualized and adapted treatment.
CORRESPONDENCE
Cristina Iñigo Barrio
e-mail: cinigob@coma.es
Hospital Psiquiátrico Penitenciario Alicante
BIBLIOGRAPHY
1. Millon T, editor. Trastorno de la personalidad en la vida moderna. Barcelona: Elsevier-Masson; 2006.
2. Beck AT, Freeman A. Cognitive Therapy of Personality Disorders. New York: Guilford Press; 1990.
3. Linehan MM. Cognitive-Behavioural Treatment of Borderline Personality Disorders. New York: Guilford Press; 1993.
4. Jimenez-Treviño L, Blasco-Fontecilla H, Braquehais MD, Ceverino-Dominguez A, Baca-Garcia E. Endofenotipos y conductas suicidas. Actas Esp Psiquiqtr 2011; 39 (1): 61-9.
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