Many patients who mutilate themselves as Kisha did have borderline personality disorder. During the interview, and later in a separate conversation with Kisha's mother, I looked hard for borderline dynamics and borderline symptoms. Besides Kisha's obvious, although unacknowledged, proclivity for turning disappointment into physical self-injury, I could not identify any.
Kisha denied any further intention or plan to harm herself. I took her at her word, for the moment anyway. But I knew she was not finished with these self-destructive acts. Kisha did not need to be hospitalized. She did need immediate, intense outpatient therapy with someone who knew how to draw her out and help her put words to the feelings-whatever they were, wherever they came from-that were eating at her from the inside and causing her to mutilate herself on the outside. Fortunately, her parents had insurance. I referred her to a nationally known psychiatric hospital in the city for outpatient care.
"Maureen," 37, was brought to the ER by her parents. "I've been very depressed," she said when I asked why she had come. The day before Maureen had gone to another ER, specifically, she told me, "to get a different antidepressant." She was taking fluoxetine (Prozac), prescribed by a general practitioner two years earlier, with little or no benefit. Denied this medication, she became, by her own account, "hysterical" and "ran out" of the ER without receiving discharge instructions.
"I feel like I have hit rock bottom," Maureen told me. "I cry all the time. I feel like I have no control over myself." She had been seen by two psychiatrists briefly 15 years earlier, but had received no treatment since, in spite of periodic recurrences of her depression. "I feel as depressed now as ever," she said. "I have no hope of getting better." The depression had become worse during the preceding three months. During that time, her sleep had increased from seven to 10 hours a night. Also, her appetite had increased somewhat, and she had gained five pounds (she appeared slightly overweight).
Maureen had two years of college and worked as a photographer for a company that supplied photos of sports events for high school and college yearbooks. Her job was competitive and stressful. At certain times of the year she worked up to 80 hours a week, often facing deadlines. "I put more pressure on myself than the job does," she said with no apparent regret. In spite of her increasing depression during the past three months, Maureen's boss was satisfied with her work, but Maureen did not feel she was performing well. Everything required more effort now. It was harder to concentrate. Maureen found what she did less interesting, and she cut back her social activities considerably. She got little joy from work and contact with friends. Losing her edge made her feel guilty.
Clearly, Maureen was having an episode of major depression. From her story and from the fact that she had been on fluoxetine for two years, an underlying dysthymic disorder was also quite likely, giving her what is known as "double depression." She also experienced a good deal of anxiety and took clonazepam (Klonopin) as needed. Maureen denied ever using illicit drugs or abusing alcohol. The toxicology screen was positive only for barbiturates. (She took [butalbital and acetaminophen] for headaches; the hospital's benzodiazepine test did not detect clonazepam at therapeutic levels.)
Maureen insisted she had no intention or plan to harm herself, but added, "I can't imagine living my life this way indefinitely." Fifteen years earlier, she had "tried to get up the nerve to take a bottle of pills," but could not. Five years earlier, she had sat in her car with the motor running and the garage door shut for five minutes, but terminated this potentially lethal act because, she told me, she "couldn't go through with it."
When I asked Maureen why she thought she was feeling depressed, she did not acknowledge a single negative factor in her life (unlike Kisha, she did at least admit to having symptoms of depression). Questioning her about her marriage, job, finances and family produced no revelations. She had supportive parents, a relatively secure if stressful job she liked and excelled at, and no financial problems. She had been married for about 15 years, had no children and thought her relationship with her husband was good.
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