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  <p class="ltrs-br-ltr-br-title"><span class="bold">Escalating Ingestion of Razor Blades in a Patient With Borderline Personality Disorder</span></p>
  <p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> The means employed in self-injury vary widely among patients with borderline personality disorder and so may the magnitude of the damage inflicted. Deliberate foreign body ingestion (DFBI) constitutes a distinct behavioral syndrome that is frequently associated with borderline personality disorder. While with other forms of self-injurious behavior the patient usually achieves an immediate release of tension, such release is not generally the case in DFBI, as is illustrated in the present case.</p>
  <p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
  <p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> A 23-year-old woman who had previously been diagnosed with borderline personality disorder, according to <span class="italic">ICD-10</span> criteria, presented with an increase in self-injurious behaviors after a recent miscarriage. The patient herself contacted police regarding increasing suicidal tendencies, which led to her admission to a psychiatric ward. Physical examination at admission revealed old scars and superficial cuts on arms and legs as well as new deep cuts all over her torso. The patient received individual psychotherapy sessions as well as group skills training. During her stay, she repeatedly swallowed quartered pieces of broken razor blades, which she wrapped in wads of chewing gum. During the span of several weeks, she swallowed in excess of 30 such razor blade pieces essentially without complications. She always notified staff sometime after the act. Ingestion of razor blade pieces was confirmed by x-ray (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1A</a></span>). For the most part, these fragments were passed with no difficulty. However, several larger pieces were recovered endoscopically either for diagnostic purposes or because the patient had complained of pain in her abdomen.</p>
    <div id="figure-2"> <a href="#" onclick="createFigure('f1'); return false;"><img src="14l01719f1.jpg" alt="Figure 1" id="f1" border="0" /></a>
      <p class="click-to-enlarge">Click figure to enlarge</p>
    </div>
  <p class="ltrs-br-ltr-br-body-text">In all, the patient underwent 4 gastroscopy or colonoscopy sessions (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1B and 1C</a></span>). Luckily for the patient, no transmural lesions had occurred. At this point, it was deemed impossible to discharge the patient from the hospital because she was considered at acute risk of suicide.</p>
  <p class="ltrs-br-ltr-br-body-text">Subsequently, she attempted to swallow one-half of a 2-edged razor blade without chewing gum, which resulted in immediate esophageal perforation and, consequently, in mediastinal emphysema and an esophagotracheal fistula. The patient required intensive care and several courses of endoscopic sponge therapy to close the esophageal defect. During this time, she was regularly seen by liaison psychiatry. She gradually began to engage more actively in psychotherapeutic treatment. In parallel, self-injurious behaviors decreased, and the patient was eventually discharged. An elective readmission for dialectical behavior therapy was scheduled.</p>
  <p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
  <p class="ltrs-br-ltr-br-body-text">Deliberate foreign body ingestion is a frequent occurrence in patients with borderline personality disorder, but may also occur in patients with psychosis, malingering, and pica. The latter condition is defined as the persistent ingestion of nonnutritive materials such as chalk or clay at an age at which this behavior is developmentally inappropriate. The course of DFBI is frequently chronic. Treatment is difficult. Evidence-based therapeutic interventions are largely lacking.<span class="htm-cite"><a href="#ref1">1</a></span> In borderline personality disorder, most self-injurious behaviors are a means of affect regulation and frequently lead to a swift release of tensions. In general, this release does not appear to be the reason behind DFBI.<span class="htm-cite"><a href="#ref1">1</a></span> The main drivers behind DFBI in borderline personality disorder seem to be an inappropriate need for attention as well as a desire to test the limits of the therapeutic relationship. Management of DFBI in borderline personality disorder poses a great challenge because of potentially lethal complications and the need for rapid medical attention. Here, it is the special role of the consultant-liaison psychiatrist to bridge the gap between medical and physical health care and to support medical and surgical colleagues in grappling with countertransference issues commonly involved in treating such patients. In our experience, it is frequently during the early period after a major complication has occurred that the patient becomes more open to psychotherapeutic interventions. Ideally, general psychiatric management and stabilization will gradually enable the patient to benefit from a specific psychotherapeutic intervention such as dialectical behavior therapy.<span class="htm-cite"><a href="#ref1">1</a>,<a href="#ref2">2</a></span></p>
  <p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 1.&#9;</span>Poynter BA, Hunter JJ, Coverdale JH, et al. Hard to swallow: a systematic review of deliberate foreign body ingestion. <span class="italic">Gen Hosp Psychiatry</span>. 2011;33(5):518–524. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=21851984&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1016/j.genhosppsych.2011.06.011"><span class="pubmed-crossref">doi:10.1016/j.genhosppsych.2011.06.011</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 2.&#9;</span>Gitlin DF, Caplan JP, Rogers MP, et al. Foreign-body ingestion in patients with personality disorders. <span class="italic">Psychosomatics</span>. 2007;48(2):162–166. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=17329611&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1176/appi.psy.48.2.162"><span class="pubmed-crossref">doi:10.1176/appi.psy.48.2.162</span></a></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Hagen Kunte, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><a href="mailto:hagen.kunte@charite.de">hagen.kunte@charite.de</a></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Christian Jürgensen, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Lutz Harms, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Sebastian Lang, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Johannes Rentzsch, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Golo Kronenberg, MD</span></p>
  <p class="ltrs-br-ltr-br-author"><span class="bold">Rainer Hellweg, MD</span></p>
  <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Departments of Neurology (Drs Kunte and Harms), Gastroenterology (Dr Jürgensen), and Psychiatry and Psychotherapy (Drs Lang, Rentzsch, Kronenberg, and Hellweg), Charité-Universitätsmedizin Berlin, Berlin, Germany.</p>
  <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported.</p>
  <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support: </span>None reported.<span class="semibold-ital"> </span></p>
  <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Additional information:</span> The authors have obtained signed consent from the patient with explicit permission to publish all of the patient’s data and materials. All authors have read the manuscript and approved submission. </p>
  <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span><span class="italic"> </span>January 22, 2015.</p>
  <p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2015;17(1):</span><span class="doi">doi:10.4088/PCC.14l01719</span></p>
  <p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2015 Physicians Postgraduate Press, Inc.</span></p>
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