Borderline

I saw a patient last Friday who I swear was a schizophrenic. She had voices in her head telling her to stab her family and herself, she was depressed, psychomotor retarded, she'd space out as we talk, very blunt affect. I thought she was classic schizoaffective with depression. I looked over her notes and couldn't understand why she was labelled with borderline personality.

Today I interviewed her again with my RMO, and my RMO picked her for borderline straight away. What did I miss?

I had picked up her auditory hallucinations and suicidal ideation thinking I've found the mother-load, and tunnel-visioned myself. As it was pointed out after, that her thought process was clearly not disorganised. Apart from her hallucinations, she had none of the symptoms of a schizophrenic (it helps that she's more talkative and happier today, but it still made me look like an idiot). I rang up her old hospital for a copy of her past admissions, she's had numerous suicide attempts, some of the lethality were questionable. Paracetamol won't kill unless you have taken enough; saying you have Over-Dosed when there's nothing to be found in the blood can't really kill you either. She's also trialled numerous antipsychotics, including clozapine, to no effect.

I realised that she is not psychotic at all. I've been fooled by her alleged list of symptoms. To my comfort, there were other doctors that thought she was schizo as well, which explained all the anti-psychotics that she was put on. She was probably not being factitious, but still, I was annoyed with her fooling me. So I looked up borderline personality disorder to educate myself.

Biggest clue for these patients are repeated suicide attempts (or some form of self harm). 50-70% of them had history of being sexually assaulted. I did read that in her notes, and she started to present to the hospital some short time afterwards. I started to feel really bad for her. She's never had a romantic relationship, chronically depressed, went through ECT, she was a cutter...she eventually reported the sexual assault to authority, the offender (who was family) became alcoholic and died 2 years ago, so she feels exceedingly guilty...the social history is a mess...

And it doesn't help that I can identify quite a few of the symptoms myself.