This case report examines the relationship between borderline personality disorder (BPD), trauma, and polyembolokoilamania, a rare condition characterized by compulsive foreign body insertion through a 62-year-old male patient. His severe trauma history, stemming from a prison assault at age 23, intertwines with BPD traits, revealing psychological mechanisms behind his compulsive behaviors. The patient is presented to the emergency room with shards of glass and a box cutter blade lodged in his rectum, marking a troubling escalation in his pattern of foreign object insertion. This incident resulted in physical harm he could not address, underscoring his emotional turmoil and maladaptive behavior. The case illustrates how polyembolokoilamania can serve as a coping mechanism related to unresolved trauma and repetition compulsion, reflecting Freud’s theories on reliving past traumas. A comprehensive treatment approach, including trauma-focused therapy and dialectical behavior therapy, was used to tackle his complex condition. This report emphasizes the need for interdisciplinary collaboration to address both the psychological and medical aspects of such cases, highlighting the importance of understanding the mechanisms driving self-destructive behaviors in individuals with traumatic histories.

Borderline personality disorder, Polyembolokoilamania, Trauma, Compulsion, Reenactment.

Polyembolokoilamania, characterized by repetitive insertion of foreign objects, was rooted in the patient’s unresolved trauma and BPD traits. The compulsion to re-enact past trauma, a form of repetition compulsion, serves as a maladaptive coping mechanism. To better understand the psychodynamic reasons for patients’ behavior, we turned to Freud’s theory of repetition compulsion, which continues to be relevant for contemporary debates, even though it may not serve as the sole foundation for modern psychoanalysis. Michael S. Levy delves into the perplexing concept of the repetition compulsion in psychology. This phenomenon remains somewhat mysterious, as its origins and purpose are not entirely understood. Although it is often theorized that the repetition compulsion might serve to master past traumas, the achievement of such mastery is infrequent.[1]

Freud’s initial observation of the repetition compulsion is central to the discussion, as discussed in Levy’s “A conceptualization of the repetition compulsion.” He noted that individuals tend to compulsively repeat painful situations and emotions from their past. Patients, in both their perception and behavior, are driven to relive past experiences as if they were happening in the present. Freud described how patients are compelled to reenact and repeat repressed material from their past as if it were a current experience, rather than remembering it as part of their history.[2] This perpetual reoccurrence of traumatic experiences is a core aspect of the repetition compulsion. The wide-reaching nature of repetition compulsion is another key point highlighted in the article. It transcends different theoretical approaches in psychology and is observed across various contexts. Given its ubiquity and significance, the article emphasizes that any theory of mental functioning should address the structure, purpose, and etiology of repetition compulsion.

The article also proposes a framework for conceptualizing the repetition compulsion, particularly in the context of attempting to master past trauma. Survivors of childhood trauma often find themselves reenacting and repetitively reliving their traumatic experiences, sometimes leading to revictimization. Freud understood the relationship between the repetition compulsion and reenactments of traumatic events, and applying it to the case, his polyembolokoilamania can be viewed as a response to posttraumatic stress.

Alongside Levy, Holowchak, and Lanham’s writing underscores the importance of understanding the repetition compulsion in various psychological contexts. This enigmatic phenomenon plays a significant role in individuals’ lives, often causing distress and suffering. It prompts the need for theoretical frameworks that can shed light on its structure, purpose, and origins, ultimately contributing to a deeper understanding of human psychology and behavior. Holowchak and Lanham, in their article “Repetition, the compulsion to repeat, and the death drive: an examination of Freud’s doctrines” discusses Freud’s theories of repetition, compulsion, and the death drive, and it would be imperative to focus this analysis and its relevance to the concept of polyemboliokomania. Holowchake and Lanham highlight Freud’s late-in-life contemplation of the death drive, a theory that faced strong opposition due to humanity’s naive belief in innate goodness. The article examines Freud’s use of repetition as it leads to the compulsion to repeat and the death drive. It explores the origins of these concepts, their theoretical underpinnings, and their implications for psychoanalysis. The authors, M. Andrew Holowchak and Michael Lavin, have differing perspectives on Freud’s work, with Holowchak being critical of Freud’s errors and Lavin considering himself a Freudian.[3]

This study examines the convergence of BPD, trauma, and polyembolokoilamania, a rare manifestation of self-destructive behavior. The patient’s history of trauma provides insight into the underlying psychological mechanisms driving compulsive foreign body insertion.

62-year-old male who was brought into the emergency room by emergency medical services (EMS), presenting with 2 pieces of shard glass and a box cutter blade inside of his rectum. On multiple occasions, the patient reported inserting foreign objects in his rectum, usually objects found in the street. Usually, he feels immediate regret and is able to remove the foreign object. Unfortunately, this time the shards of glass penetrated his rectal wall, and he was unable to remove the glass or the blades. He claims he has done this in the past, usually with a box cutter or razor. Two years prior, a similar incident occurred, and surgery was required to remove the foreign objects. Physical examination by the surgical team revealed that the patient had an abdominal incision from a prior exploratory laparotomy and repair.

Initially, there was concern that the patient had possible Munchausen Syndrome, given his prior complaints, and because when speaking to the surgical team, he was fixated on surgery. He denied wanting to talk about why he chose to insert the foreign object, so a psychiatric consultation was requested. Patient expressed a desire to speak privately to the psychiatry team, highlighting his deep sense of shame.

The interview revealed that a patient had a past suicide attempt, taking a large dose of digoxin 2 years prior, and was ultimately admitted into a psychiatric facility. It also highlighted the prior post-traumatic stress disorder (PTSD), anxiety, and depression. Patient presented with compulsive foreign body insertion a hallmark of polyembolokoilamania.

Physical examination and imaging verified foreign objects within patient’s body cavities. His immediate regret, combined with evident remorse and embarrassment, revealed the emotional toll of his actions, a pivotal aspect of polyembolokoilamania.

Re-experiencing and re-enactment after adult trauma: Patient’s self-destructive behaviors can be understood through the lens of re-experiencing and re-enactment, common responses to adult trauma. Individuals with a history of trauma often engage in the re-enactment of their traumatic experiences, which can lead to a cycle of revictimization and self-destructive behaviors. This concept is crucial for understanding the patient’s compulsive foreign body insertion, as it reflects his attempt to confront and master past traumas through maladaptive means.[4] His actions represent an attempt to unconsciously confront and master past traumatic experiences, albeit in a distressing and harmful manner. To better understand re-enactment, Dr. James Chu categorizes reenactments into four main types. In the first category, individuals actively reenact traumatic experiences from their past to cope with and master them. Some of these efforts are adaptive and help resolve earlier traumas, while others are maladaptive and lead to continued distress, as seen with the patient. The other three categories involve unintentional reenactments. In cases of reenactments caused by rigid defenses, individuals unintentionally recreate traumatic situations because their rigid coping mechanisms backfire and lead to problems. Reenactments caused by affective dysregulation and cognitive reactions occur when intense emotions and cognitive reactions from the past get triggered in present relationships, leading to reenactments. Reenactments caused by ego deficits happen when psychological vulnerabilities resulting from past trauma make individuals susceptible to reenactments and revictimization.[5] It’s important to note that these categories are not mutually exclusive, and reenactments often involve elements from multiple categories.

The distinctions between adaptive and maladaptive reenactments can be complex, as coping mechanisms are shaped by various factors. Adaptive reenactments can provide an opportunity for individuals to work through their past trauma and integrate their feelings, while maladaptive reenactments often involve harmful behaviors that prevent true resolution of past traumas.[6] Brad Bowins, in “repetitive maladaptive behavior: beyond repetition compulsion” explores the phenomenon of repetitive maladaptive behavior, often referred to as repetition compulsion, which is a common reason people seek psychotherapy. Despite advancements in psychotherapy, treating repetitive maladaptive behavior remains challenging. This behavior does not lead to mastery, as it rarely resolves without therapeutic intervention and can be resistant to change. Bowins proposes a new framework for understanding this behavior, distinguishing between non-traumatic and traumatic origins, with some overlap. Repetitive maladaptive behavior of non-traumatic origin is believed to arise from an evolutionary process in which children absorb patterns of behavior displayed by caregivers. These patterns become ingrained in their personalities and are often repeated. Even when maladaptive, these behaviors persist due to their familiarity and compatibility with a person’s temperament. On the other hand, repetitive maladaptive behavior of traumatic origin involves the dissociation of cognitive and emotional components of trauma. This makes it challenging for individuals to integrate their traumatic experiences, leading to ongoing suffering and resistance to change. Traumatic events can produce dissociation-based defenses, perpetuating the repetition of trauma-related behavior. There is great difficulty in treating repetitive maladaptive behavior, especially when it is deeply rooted in a person’s personality.[7]

As in this case, the repeated hospitalizations and recurrent foreign object insertion that seems to only escalate highlight the maladaptive behavior as being integral to the patient’s well-being, fully embodying his trauma. Ultimately, changing these patterns involves conscious effort and repetition until the new behaviors become automatic, which is far more challenging when the behavior has been ongoing since childhood. It was imperative in our treatment to begin understanding the origins and mechanisms of repetitive maladaptive behavior to provide patients with an effective therapeutic intervention, as these behaviors have clearly had a significant impact on patients’ well-being and quality of life.

Diagnostic challenges and treatment: Diagnosing polyembolokoilamania required identifying its unique characteristics in the context of trauma and BPD. A comprehensive treatment approach that included trauma-focused therapy and dialectical behavior therapy was implemented to address both issues and reduce self-destructive behaviors. The phenomenon of trauma reenactment is particularly relevant for survivors of sexual abuse who may display BPD symptoms. These individuals often unconsciously re-enact their traumatic experiences as a means of processing and coping with their past. Recognizing this behavior in the diagnostic process is crucial, as it can perpetuate a cycle of revictimization and self-destructive actions. A deeper understanding of trauma-related behaviors is essential for providing effective treatment and support for survivors.[8]

Cologne & Ault discuss the historical context and contemporary aspects of rectal foreign bodies, which have been a part of anorectal trauma. They investigated the first report on managing retained rectal foreign bodies and determined that they date back to the 16th century, with modern case reports appearing in 1919. Over time, there have been numerous case reports and studies on this topic, but the greatest innovation comes with the advancement in technology and management. The management of this issue has evolved with the introduction of laparoscopic, endoscopic, and minimally invasive surgical techniques. They also highlight the epidemiology of rectal foreign bodies, noting that the average age at presentation is 44 years, with a higher prevalence among male patients. The incidence varies, and it is often underreported since many patients do not seek medical attention due to embarrassment or other reasons.[9] The types of foreign bodies vary widely and can include household objects, personal items, and even drugs. Reasons for insertion range from autoeroticism and concealment to attention-seeking behavior, accidents, assault, and constipation relief.[10] Some patients seek help immediately, while others may wait up to two weeks before seeking evaluation. The passage emphasizes the importance of diagnosing rectal foreign bodies, as patients may be reluctant to disclose their condition due to embarrassment. Healthcare professionals need to maintain professionalism and be nonjudgmental in their approach, as these objects may have been inserted under various circumstances, including assault or psychiatric disorders.

Accurate diagnosis and appropriate treatment are crucial in managing this condition. Dr. James Chu’s article also emphasizes that reenactments can lead to continued victimization and distress and that understanding and addressing them is crucial in therapy. Therapy should begin with a strong therapeutic alliance, ensuring the patient’s safety and addressing any immediate issues. Exploratory therapy can help individuals understand the patterns of dysfunction in their lives and why they engage in reenactments. This process often involves exploring the patient’s childhood experiences, acknowledging the original trauma, and working through the intense feelings associated with it. Ultimately, therapy aims to help patients integrate their traumatic experiences and develop more adaptive ways of coping with their emotions and relationships. Of note, there are also documented cases where individuals with polyembolokoilamania have been successfully treated using alternative therapeutic approaches. For instance, one case involved a man who was treated with electroconvulsive therapy, demonstrating the potential for effective intervention in such complex cases.[11]

Gradual improvements were observed as a patient engaged in therapeutic interventions in the inpatient hospital setting. Patient was re-started on low-dose Lexapro and Abilify, which was their medication regimen prior to hospitalization. As the most recent hospitalization was incited by a trigger of the patient’s PTSD, it is important to highlight pharmacological treatment of PTSD in the setting of polyembolokoilamania. There is evidence to suggest that a combination of antidepressants and atypical antipsychotics can be utilized for patients with PTSD, which addresses symptoms of both depression and anxiety associated with trauma.[12] Collaboration among mental health professionals and medical experts played a pivotal role in facilitating recovery from the intertwined complexities of trauma, BPD, and polyembolokoilamania.

This case report highlights the intricate interplay of trauma, BPD, and polyembolokoilamania, focusing on the emotional and psychological dimensions of the patient’s experience. Enhanced interdisciplinary collaboration is essential for navigating the challenges posed by polyembolokoilamania and achieving favorable patient outcomes. Understanding re-experiencing and re-enactment after adult trauma provides valuable insights into the underlying mechanisms driving such behaviors.

We would like to thank Dr. Mitchell Kho for their invaluable support and assistance throughout this report. We also appreciate the support from Crozer-Chester medical center and their medical staff for providing the necessary resources and facilities. Finally, we extend our gratitude to the patient for their willingness to share their experience, which made this report possible.

This case report received no specific funding from any public, commercial, or not-for-profit organizations.

Corresponding Author: 
Sarah Azim
Department of Psychiatry
Crozer-Chester Medical Center, USA
Email: sarah.azim@crozer.org

Co-Authors:
Mitchell Kho
Department of Psychiatry
Medical Director, Adult Inpatient Psychiatry Unit
Crozer-Chester Medical Center, USA

Nathaniel Pineda
Department of Orthopaedic Surgery
Drexel University College of Medicine, USA

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

This case report was conducted in accordance with the ethical standards of the institutional review board. Informed consent was not obtained from the patient, as consent was not necessary under specific guidelines for case reports. All identifiable information has been removed to protect the patient’s confidentiality and privacy. The report focuses solely on clinical findings and treatment outcomes to contribute to medical knowledge while respecting the patient’s rights.

The author declares no conflict of interest.

None

https://doi.org/10.63096/medtigo3084117

Sarah A, Mitchell K, Nathaniel P. Borderline Personality Disorder, Trauma, and Compulsive Foreign Body Insertion (polyembolokoilamania) in a 62-year-old Patient. medtigo J Neurol Psychiatry. 2024;1(1):e3084117. doi:10.63096/medtigo3084117 Crossref