JULIE-

DIAGNOSES: DEPRESSION; BPD

MANY URGENT REFERRALS TO PSYCHIATRY

SEVEN SUICIDE ATTEMPTS DURING 2002

DRUG USE: COCAINE ADDICTION AGED 27-30; AMPHETAMINE; CANNABIS; ECSTASY. NO HEROIN OR INJECTED DRUGS

ALCOHOL: DAILY USE: ‘UP TO SIXTY UNITS PER WEEK’ SELF REPORT

WAS LIVING WITH FATHER, LATER HOMELESS NOW HOSTEL

CHILDHOOD AND ADOLESCENCEThis is not well documented in the case notes. Julie reports an unhappy childhood because her father was strict and shouted at the children a lot. She had an older sister Mary and has a younger brother Julian but has not spoken to him for the last year. She reports no CSA or physical abuse but says she thinks she has ‘something suppressed’ from her childhood. She reports emotional invalidation and mental bullying by her father who she says used to humiliate her. He used to call her ‘woof’ and ‘dog’. Her relationship with her mother is not described in the notes, but is currently described as ‘poor’.

Julie’s parents split up when she was 10 years old. The reasons for this have not been described. She was bullied at middle school for being ‘ugly and having bug eyes’. She changed schools three times during her middle school years. At 13 she says she started to bang her head against walls, punch herself in the face and pull out her hair. She also started cutting herself at this age. She has reported being raped aged 16yrs but little is written about this in the notes. She took her first overdose aged 17yrs.

She left school at 16 with a few GCSEs and worked in bars and holiday camps. She began college but dropped out in order to get away from home.

ADULT LIFEShe met her future husband and moved in with him when she was 19. They moved to several cities on the mainland in quick succession. They married when she was 24, separated when she was 27 and divorced when she was 29. She has described her husband as having ‘extreme reactions to things’ including kicking a door down on one occasion. Little else is known about this marriage.

Julie’s older sister Mary was diagnosed with personality disorder in her late teens. She had an alcohol problem and was refused admission to several mental health establishments around the country, according to Julie. In desperation she decided to set fire to her legs outside a police station. She reportedly told Julie ‘if I do this they’ll have to admit me to hospital’. As she bent down to light her petrol-soaked legs, her hair set alight and she died a

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painful death by fire. Nothing is documented about Julie’s reaction to this event, but she now has various thoughts and feeling about it, including ‘I can’t kill myself because I can’t put my parents though that again’, feeling angry with Mary because she has ‘taken my chance’, feeling responsible for not protecting her and a strong belief that eventually she is doomed to end up the same way.

Mary’s death also seems to have severely impacted upon Julie’s father, who stopped his well-paid job immediately (aged 52) and has not worked since. He has been observed by several health care professionals to have his own mental health needs, but has refused treatment.

Julie reports beginning to use drugs and alcohol seriously around 25years old, along with her husband. After they split she moved to Munich where her cocaine addiction developed further.

Julie reports being raped again at the age of 30yrs. She considers this her fault as she was drunk at the time and not fully conscious so unable to defend herself.

A relationship with a partner of one year ended when he left for another woman. Julie jumped into a river hoping to be carried out to sea.

She moved back in with her father in England two weeks after this attempt and their relationship became strained, so she left.

FAMILY DETAILS

Julie reports her father is depressed, neglects himself, rarely cooks and the house is in a mess. Her father strongly disagrees with this and says the problem is Julie’s unreasonable behaviour which causes him too much stress. It seems Julie experiences a cycle of worrying about and trying to care for her father, which leads to her feeling responsible for his welfare and a failure when she does not succeed. She then gets angry with him and recalls how damaging his behaviour towards herself and her brother and sister has been. He usually criticises her efforts or her behaviour and an outburst results, when she says ‘terrible things’ to him and sometimes physically attacks him. Later she feels guilty and ashamed, strengthening her belief in herself as a bad person.

The notes do not allow for such speculation in terms of her relationship with her mother. She has a step father who she does not like. No other important figures (grandparents, other relatives, family friends) are reported in the notes, but these figures may not have been investigated.

Similarly, we are unclear why her relationship with her surviving brother has deteriorated.

Julie reports having no friends. She says she drives everyone away because of her extreme outbursts. She also withdraws from intimate relationships

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before they begin to get serious, in case the other person sees the ‘real’ Julie (which they would not like).

Since she split with her husband Julie reports sexually promiscuous behaviours which involve unprotected sex, often in an intoxicated state.

CURRENT SYMPTOMS AND PRESENTATION

SymptomsJulie complains of mood swings, lack of energy and motivation, lethargy and at other times says she has ‘euphoric’ highs when she is the life and soul of the party. Her sleep is consistently disturbed with nightmares and early wakening (which could be rebound from alcohol intoxication). She reports ‘short-term memory’ problems by which she means she often has difficulty remembering what happened last week. She has somatic problems including sleep disturbance, bodily tension and digestive disturbance. She suffers from panic attacks in crowded places and social occasions. Anger is poorly controlled and she has been physically violent to those close to her.

Self-harm/suicideAlthough self harm is reported to have begun at 13 and suicide attempts at 17, these seem to have become truly dominant after the break up of Julie’s marriage. Since then she has had numerous serious suicide attempts (seven recorded during 2002) and parasuicidal episodes. She is usually impulsive in the final instance in these, but can ruminate about suiciding for days before actually acting on the urge. Drink is usually involved in the chain of behaviours leading up to the event. Suicide methods have included overdosing, hanging, drowning, stepping out under trams and trains, fast driving (she does not currently drive). Self-harm includes cutting with razor blades and knives, stabbing herself with a screwdriver, pulling out her hair, punching herself in the head and face, banging her head on the wall. Harm to others includes punching them with her fist, although she has never been arrested for this nor seems to have caused lasting damage. She also destroys personal belongings of value to her.

Drinking and using drugs to excess and promiscuous sexual behaviour place her at risk of harm from others.

She stockpiles prescribed drugs for use in overdosing, also saves blades. She obtains street drugs such as diazepam if she cannot obtain these from her GP.

Interpersonal styleShe always tries to be nice to people and please them, but seems to always fail. She thinks the reason for this is that they see her ‘real self’ which she despises. One of the costs of always trying to please others is that one’s own needs are not met, often creating resentment, physical and mental exhaustion and physical illness, all of which are emotionally dysregulating and likely to leave the person vulnerable to outbursts of anger. Having these outbursts

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then confirms previous beliefs that one is bad and unworthy, along with the ‘outside/inside’ idea of the self as an appearance only.

Julie has a sense of being responsible for each negative event that occurs to other people she cares about, and for each negative event which occurs to herself. She only occasionally takes responsibility for positive events, and this only briefly.

Julie is very sensitive to criticism. She often misperceives herself to be criticised, but also she is often criticised. If she perceives the criticism as unjustified she often verbally or sometimes physically attacks the person or storms out of the room. If she thinks the criticism is just, she often withdraws and her urges to self harm increase.

According to Julie, no-one has ever ‘been there’ for her. She says she would never ask for help for fear of being turned down. She has difficulty relating to many professional helpers, as she often accuses them of doing nothing for her.

If you met Julie, you would most probably be charmed. She is outgoing, amusing, and caring. She is very attentive to others and full of truly wise advice on how they could find ways through problems. She is very intelligent and can hold conversations about profound issues in life, although if the conversation got technical she would soon start telling you how stupid she is. Attempts on your part to reassure her about her ability would surely fail.

ATTITUDE AND APPROACH TO DBTJulie has been told about Borderline Personality Disorder and greeted this with some relief. She said it finally made sense for her of ‘what’s been happening all these years’. She told her father about ‘what it means to have BPD’ although his reaction is not reported and may not have been what she had hoped for.

She is really looking forward to the treatment so that she can get on with the rest of her life. She wishes her sister Mary could have had the same chance. She is a little concerned about the 50% success rate, saying it would be ‘just my luck to be in the failed brigade’.

She is worried about being in a group and thinks everyone will see what an idiot she is.

She hopes perhaps one day to have children and would really like to complete her pilot’s licence. She would like a career perhaps in the holiday travel market, she loves going abroad.

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