Citation

Rutledge E, O'Regan M, Mohan D. Ir. J. Psychol. Med. 2007; 24(1): 40-41.

Copyright

(Copyright © 2007, Irish Institute of Psychological Medicine)

DOI

10.1017/S0790966700010156

PMID

unavailable

Abstract

Clozapine is an atypical anti-psychotic medication that has proved useful in the management of both psychotic and mood disorders and that has been shown to decrease aggression and the risk of suicide, which suggests that clozapine may be useful in the management of severe borderline personality disorder. Here we present the case of a 36 year old female with severe borderline personality disorder with symptoms of psychosis, aggression and violence. We discuss how treatment with clozapine resulted in a marked clinical improvement in this patient.; AuthorsConclusions:In our patient, use of clozapine has not resulted in a full rehabilitation with transfer back into the community but it has reduced high levels of nursing input required, days in seclusion and our patient's subjective experience of distressing symptoms. The continued use of clozapine in this case poses an ethical dilemma. On one hand, clozapine is likely to result in her diabetes being less responsive to treatment, thus exacerbating the rate of deterioration of her cirrhosis. Ultimately, this will bring forward the need for a liver transplant. However, on the other hand Ms Bs level of risk of harm mostly to herself and also to others, due to her impulsive behaviour, was unacceptably high. On balance and in consultation with the patient we have opted to continue clozapine. Having had a clozapine free period has demonstrated to us that the reintroduction and ongoing use of clozapine is likely to be of assistance in reducing future risk of morbidity and mortality, despite her physical complications. Despite limited data and poor methodological quality of papers published in this area, there is some evidence to suggest that a subgroup of borderline personality disordered patients with psychotic, impulsive and suicidal complaints may benefit from clozapine treatment. As one would expect, the intensity or severity of premeditated acts did not appear to be lessened by the addition of clozapine. Despite this, our patient has had a significant clinical improvement on clozapine.; Indications:1 patient with severe borderline personality disorder with symptoms of psychosis, aggression and violence. Coexisting diseases: grade IV liver cirrhosis, hepatitis C, and insulin dependent diabetes mellitus.; Patients:One 36-year-old female inpatient.; TypeofStudy:A case report describing the significant clinical improvement with Leponex treatment of a patient with severe borderline personality disorder with symptoms of psychosis, aggression and violence.; DosageDuration:Given at varying doses over 6 years; 300 mg in January 2006.; Results:Over the past 6 years, the patient was given varying doses of Leponex with overall benefit. Following a 3 year period of stability in a forensic setting, she was transferred to a local psychiatric hospital. She remained on Leponex, but within a number of months she had attempted assault of another patient. In consideration of her liver cirrhosis, hepatitis C and insulin dependent diabetes mellitus and an uncertainty regarding the efficacy of Leponex therapy, in March 2006 Leponex dose was gradually decreased, stopped and substituted with olanzapine. Within weeks her mental state had remarkably deteriorated. Incidence of self-harm episodes, psychotic symptoms and threats towards staff had significantly increased. Her time spent in seclusion increased as a consequence of her volatile mental state. In January 2006 with a 300 mg dose of Leponex, she attempted to seriously assault a fellow patient which was premeditated and not in the context of a deteriorating mental state. While waiting for a bed to become available in the forensic hospital, she was nursed in seclusion due to a lack of relational security in the local hospital, thus there was a peak in the seclusion graph, prior to any decrease in her Leponex levels. Upon her return to the forensic hospital she was no longer nursed in seclusion and a gradual decrease in Leponex was commenced due to concerns of her physical health. As her Leponex was discontinued over the following months, her time spent nursed in seclusion continued to increase, until Leponex was retreated in July 2006. As there was a decrease in the Leponex dosage; in November 2004 and in March 2006, there followed an exacerbation of her symptoms, particularly her symptoms of suicidal ideation and thoughts or acts of deliberate self-harm. Also an increase in psychotic-like symptoms was noted following a decrease in Leponex dose. Acts of premeditated aggression or harm towards others, such as the event which precipitated her readmission to the forensic hospital were less influenced by Leponex dose.; AdverseEffects:No adverse events were mentioned.; FreeText:The patient was born a few days premature. At the age of 13, she became pregnant with a baby girl. She was sexually abused by her father, brother and fathers' friends. At school, she was disruptive and she was referred to child psychiatric services because of her level of behavioral disturbance at 14 years. She was placed in foster care following allegations of sexual abuse at home at 15 years. At the age of 19, her oldest son was born. At 16 years, she was 1st admitted to a psychiatric hospital, following an overdose and impulsive self-cutting. Her propensity to arson has remained a feature of her subsequent admissions. Her impulsive behavior and affective instability had not been confined to episodes of harm directed towards her. She assaulted several people. She had a history of depression, mood lability, suicidal ideation, intent, transient psychotic symptoms (experiences of auditory hallucinations, perceptual distortions such as referential thinking, paranoid ideation and periods of dissociation).

Language: en

Keywords

adult; human; violence; female; case report; suicidal ideation; aggression; forensic psychiatry; psychosis; Borderline personality disorder; clozapine; Clozapine; article; mental health care; behavior disorder; child sexual abuse; borderline state; olanzapine; drug withdrawal; hepatitis C; artificial ventilation; insulin dependent diabetes mellitus; liver cirrhosis; foster care; drug dose reduction; prematurity; drug substitution; Self-mutilation behaviours