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REVIEW   |    
Patient Management Exercise for Personality Disorders
B. Harrison Levine, M.D., M.P.H.; Ronald C. Albucher, M.D.
FOCUS 2005;3:385-395.
View Author and Article Information

CME Financial Disclosure
B. Harrison Levine, M.D., M.P.H., Department of Psychiatry, University of Michigan Health System.

No affiliations with commercial supporters.

Ronald C. Albucher, M.D., Adjunct Clinical Assistant Professor of Psychiatry, University of Michigan Medical School.

No affiliations with commercial supporters.

Copyright 2005 American Psychiatric Association

This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the basis of the information provided, making your decisions as you would with a real-life patient.

Questions are presented at "decision points" that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections.

You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.

You are a psychiatrist in private practice. Susan, a 28-year-old divorced woman, was referred after release from an inpatient psychiatric unit at a local hospital. She was admitted 3 weeks prior for worsening symptoms of depression and a suicide attempt, in which she overdosed on a total of 3 grams of acetaminophen, 20 mg of alprazolam, 4000 mg of valproic acid, and 10 mg of risperidone. After a brief stay on the general medical ward, she was transferred to the inpatient psychiatric unit for further observation and stabilization of her mood. This was her fourth suicide attempt in the past year, and it was her sixth psychiatric hospitalization, four of which had occurred in the past 2 years. You agreed to see her as part of the patient’s discharge disposition because the referral came from a colleague who felt you would be best suited to treat her given your experience with patients whose primary diagnosis falls under axis II.

You receive a copy of her admission note and discharge summary. You learn that the patient was born to a New York City family and was the oldest of three children, with one brother and one sister. She alleged physical, sexual, and emotional abuse by her father, her uncle, and her father’s friend beginning at age 6 and continuing for 3 years. She was taken from her family by child protective services and placed in foster care for 9 months, then reunited after the father moved away. No charges were brought against him, but her mother often told her, "This is all your fault. He only tried to help you." When questioned further about her experiences, she responded, tearfully, "I can’t talk about them. I’m sorry. I just put that stuff away and there it will stay. People just want to hurt me. I’ve never known love."

She attended private school and did well in her classes until her junior year, when her grades began to dip. She started using alcohol to excess on weekends, drinking to the point of passing out, and by the time she was a senior she was also smoking marijuana and using Ecstasy. She made her first suicide attempt that year by superficially cutting her wrists. The injuries did not require hospitalization, but her family sent her to a private inpatient substance abuse rehabilitation center; she spent 30 days there, became sober, and began to attend Alcoholics Anonymous meetings. She relapsed approximately 2 months later, then spent another week in an intensive outpatient rehabilitation program. After that, she remained sober through college. Her cutting became habitual, and she continued to cut her thighs periodically with an antique pocket knife her uncle had given her that she kept in her purse—the same uncle who allegedly sexually abused her. She could go for several months at a time without cutting, but certain triggers, sometimes real, sometimes imagined, would cause her to return to this self-mutilating behavior. She admitted to cutting for approximately 2 weeks prior to her most recent admission.

She had a series of casual sexual relationships during her years at a small New England college, some with men and some with women. She maintained a long-term relationship with her boyfriend, who attended an Ivy League school 100 miles away, and did not tell him about her affairs. Her relationships with her peers were rocky, and she developed a reputation for being "moody," often turning on her friends for alleged slights. On two occasions her friends reported to her that she had disappeared from her dormitory room and returned 2 or 3 days later, disheveled, tired, wearing the same clothes, but unclear where she had been. Her friends assumed that she had been "partying hard" on Ecstasy, and no one pursued the incidents any further.

Her mood continued to deteriorate during college. Despite maintaining high grades, she had increasing thoughts of suicide and made at least two more attempts by overdosing on medications she took from friends. None of these attempts required hospitalization. Eventually one of her friends convinced her to seek psychiatric help, and she began seeing a therapist weekly and a psychiatrist every 6 weeks for medical management. She was started on citalopram, but after 1 week she complained of stomach pain and jitteriness and was switched to venlafaxine. This drug seemed to help her for approximately 3 months, when she was switched to bupropion because of sexual side effects. During the next 2 years she reports having been on valproic acid, lithium, carbamazepine, risperidone, fluoxetine, paroxetine, buspirone, clonazepam, lorazepam, and temazepam. Currently she takes 60 mg of duloxetine daily, 40 mg of aripiprazole twice daily, and 150 mg of trazodone at bedtime. Her therapies mostly consisted of psychodynamic psychotherapy and cognitive behavior therapy, with which she experienced marginal improvement of symptoms. Her last psychiatrist was convinced that she had bipolar I disorder, but she quit seeing him when he refused to prescribe alprazolam for her.

The patient shows up to her scheduled appointment 10 minutes late, and before she can remove her stylish leather coat, she explains that it is not her fault that she is not on time, but her current boyfriend "simply refused to realize how important these appointments are." Her coat is appropriate for the fall weather, but her black skirt rides quite high on her thighs. She is wearing a low-cut blouse, and her hair has magenta highlights. She sits down opposite you, crosses her legs, and says, "I know the deal. I tell you all about my history of sexual, emotional, and physical abuse by my father, my uncle, and my father’s best friend—oh, and my brother, too—and how many times I’ve tried to kill myself. I actually love my uncle despite all of that. He was the nicest one in my family. He is an architect, so I know he’s smart. You ask me what meds I’m on, if I’m still suicidal, and then we change the meds."

She says her current medications have been working for the past 6 months, but she heard there is a new sleeping pill, eszopiclone, and she would like to try it. Before you have a chance to say anything, she continues: "I graduated magna cum laude with a degree in psychology, so I know a lot. You can talk to me like an equal." Her story continues with a brief history of her work experience as a copy editor for a well-known fashion magazine in New York City, which she quit after 6 months because, she says, "the boss kept grabbing my ass and it was bringing back bad memories. She was convinced I was a dyke, but I’m not completely dyke. Just some of the time. I’d say I’m a dyke during the week and totally heterosexual on the weekends. Do you think that’s strange? Anyway, that boss was an idiot, and I didn’t want to work there anyway."

She tells you she felt lonely and had no friends she could trust in New York, despite having family who live there. "Most people just don’t get me. They think I’m full of shit or they have their pretty lives and they have no idea what it is to struggle. I can’t stand most people. They really irritate me. I often start screaming at them for no reason. I know that freaks them out, but fuck it. They don’t understand me. Some of them, my girlfriends in college, tried to help me, but I didn’t let them." Her last relationship was a marriage that ended in divorce after 3 years because her husband, the same long-term boyfriend from her early college days, was unfaithful and she "could not be married to someone I can’t trust." Before the marriage, they had gone through a series of breakups and reconciliations from the time she was a senior in high school. "We should not have gotten married," she says, "especially after being together for so long. We used to fight all the time because he was jealous. He hated when I spoke to anyone, even girls. But he knew I could go either way, so I guess he had a reason to be jealous." She laughs. "Of course, I did cheat on him all the time. But I had to. I’m a girl! He would not come visit me. He was an asshole from the first day I met him. I used to think he was my dream man until I got to know him. Then it was a matter of how to get rid of him." You notice she punctuates a lot of her sentences with exaggerated sighs, snorts, and chortles. "He was also jealous that I was smarter than him. I tried never to make him feel insecure. God, that would be the last thing I would do. I like to help people. I don’t want them to be intimidated by me." Then she becomes tearful. "I was abused," she sobs. "I’ll never get over it. I don’t care if you make me comatose."

She admits to drinking at least three or four times during the week, sometimes by herself "to help me sleep. These drugs just don’t do it." She has tried to cut down on her drinking—"because I think it’s going to make me fat at some point, at least if I start eating as well"—and on her use of other drugs. "I like Ecstasy, I have to admit. It makes you feel loved by everybody. I don’t have that in my life without E. But I know it’s not good to keep doing that. I started with just one tab, but now I need at least six to get going. I usually keep two more for later. But I know someone whose brain turned to mush." She admits to having had sexual relations in the past with two different men who were drug dealers in order to obtain drugs when she was low on cash. "I’ll never do that again," she says. "They were both just mean assholes about it. I mean, I was willing to give them a little, you know, but they were violent. They liked to hold me down and make me scream for them. I had bruises."

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Decision Point A

Given this presentation, what is your differential diagnosis for axis I and axis II, according to the DSM-IV-TR criteria?

 
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Decision Point B

Given the information presented, how would you assess her suicide risk? What steps should you take? (There may be more than one correct answer. Mark as many as you believe are correct. Points are deducted for incorrect answers.)

  • B1.____Definite. The patient has made several attempts in the past and was just hospitalized for a suicide attempt, and you know that 8%–10% of borderline patients successfully commit suicide. You should create a contract for safety and develop a clear safety plan with this patient immediately.

  • B2.____Likely. The patient has made several attempts in the past. She has not made any since her last discharge, and she showed up (albeit late) at her appointment to see you. This is a good sign that she is trying to help herself and is not engaged in self-destructive behavior. However, her last attempt was so recent that she cannot be fully trusted. Create a contract for safety with the patient and develop a clear safety plan immediately.

  • B3.____Impossible to say. There are no guaranteed methods for assessing the likelihood of a person’s committing suicide. We only have statistical evidence that suggests that this patient is in a high-risk category. This does not mean that she will or will not commit suicide.

  • B4.____Impossible to say. You need to assess her suicide risk by asking pertinent questions about her feelings of rejection, her fear of abandonment, and how she is managing the transition from the structured environment of the hospital to living on her own.

  • B5.____Impossible to say. Assess her suicide risk as suggested in B4, but consider that she has some comorbid disorders that increase the likelihood that she will make another attempt in the immediate future. You can manage her as an outpatient, and if she begins to demonstrate deterioration of mood and increased suicidal ideation, send her to the closest emergency room for safety. Meanwhile, arrange for her to begin a dialectical behavior therapy group and/or individual therapy at your outpatient clinic. Additionally, the patient requires substance use treatment, which is categorically imperative to any success in other therapies.

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Decision Point C

According to current evidence supported by two or more randomized, placebo-controlled, double-blind trials, what are the most effective psychopharmacological treatment recommendations for affective dysregulation symptoms, impulse-behavioral dyscontrol symptoms, and cognitive-perceptual symptoms in patients with borderline personality disorder? For each class, fill in the appropriate drugs if they meet the above mentioned evidence-based criteria. (One point is given for each correctly placed drug. Two points are deducted for incorrect answers.)

 
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Decision Point D

Given the patient’s presentation and DSM-IV-TR criteria, could you make the diagnosis of posttraumatic stress disorder (PTSD)?

  • D1.____Yes. The patient suffered multiple sexual assaults as a young woman.

  • D2.____No. Sexual assault by itself is not enough to make the diagnosis.

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Decision Point E

What is the epidemiology of borderline personality disorder? For each statement, answer "true" or "false." (Two points are given for correct answers, and 2 points are deducted for incorrect answers.)

  • E1. ____ It is the second most common personality disorder in clinical settings, after narcissistic and histrionic personality disorders, which are tied for first at 15% each.

  • E2. ____ It is the most common personality disorder in clinical settings, present in 20% of all psychiatric outpatients and 30%–35% of psychiatric inpatients.

  • E3. ____ It is the most common personality disorder in clinical settings, present in 10% of all psychiatric outpatients and 15%–20% of psychiatric inpatients.

  • E4. ____ The diagnosis of borderline personality disorder tends to be made among females, with a female-to-male ratio of 3:1.

  • E5. ____ The disorder is primarily found in Western, more socioeconomically advanced countries.

  • E6. ____ Borderline personality disorder occurs in an estimated 2% of the general population.

  • E7. ____ There is no biological component to the disorder. It is typically the result of childhood traumas, especially sexual abuse.

High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−5) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2 and above) indicate a decision that is nonproductive and potentially harmful.

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Decision Point A

Given this presentation, what is your differential diagnosis for axis I and axis II, according to the DSM-IV-TR criteria?

 
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Axis I

  • Major depressive disorder  (+2 points). Requirements include a 2-week history of symptoms that represent a change from previous functioning, including depressed mood or loss of interest or pleasure. In addition, patients must have at least five of nine symptoms listed in DSM-IV-TR and not meet criteria for mixed episode; symptoms cause clinically significant distress or impairment, are not due to direct physiological effects of a substance or a general medical condition, and are not better accounted for by bereavement.

    Our patient has exhibited depressive symptoms on and off since her junior year in high school, when her grades began to slip and she started experimenting with drugs and alcohol. The following year, her history of suicide attempts began, and at least one of them required medical intervention to save her life. Multiple suicide attempts may also be related to bipolar disorder or borderline personality disorder rather than only to major depression.

    At the same time, the picture of major depression becomes muddled by this patient’s extensive abuse of different street drugs and alcohol, which she uses to cause either unconsciousness or to allow herself to engage in extremely risky behaviors, such as extramarital affairs and disappearing for several days at a time to “party hard” without contacting friends. Consequently, it is difficult to separate the mood disorder from the substance abuse/dependence, which makes this diagnosis difficult. Once her substance use is under control, then a further assessment of her mood stability would be more appropriate and a clearer diagnosis could be made.

  • Rule out bipolar disorder  (+2 points). Requires abnormally and persistently elevated, expansive, or irritable mood lasting 4 days (hypomanic—bipolar II), or 7 days (manic—bipolar I). There must also be three or more of the following: inflated self-esteem or grandiosity; decreased need for sleep; hyperverbal, pressured speech; flight of ideas, racing thoughts; distractibility; increased goal-directed activity or psychomotor agitation; and excessive involvement in pleasurable activities that have a high potential for painful consequences.

    The same caveats exist for this diagnosis as for other mood disorders. This patient certainly demonstrates grandiosity; possibly decreased need for sleep, although that was not specifically asked; distractibility in her inability to focus on school work; definite increased goal-directed activities; and excessive involvement in risky behaviors. However, many of these symptoms could be related more to substance dependence/abuse, thus muddling this diagnosis as well. She did not exhibit any of the classic symptoms of being hyperverbal and having pressured speech or racing thoughts. This does not preclude a diagnosis of bipolar disorder, but it seems her symptoms may be more related to substance and alcohol use than to an another underlying disorder. Furthermore, as stated above, removal of the alcohol and substance use would allow for a clearer picture of any underlying mood disorder.

  • Polysubstance dependence  (+2 points). The patient clearly abuses a host of illicit street drugs, many of which are very dangerous—as she is well aware of (“I know someone whose brain turned to mush”). She also admitted to engaging in dangerous behaviors to obtain drugs, such as sleeping with drug dealers and engaging in violent sex against her will. Her use of higher doses demonstrates tolerance to the drugs. She spends a great deal of time obtaining them, and her school and friendships have suffered as a result. She attempted to obtain alprazolam from another physician and became angry when he would not supply it, and she seems now to be attempting to get medications from you. For these reasons, it is accurate to diagnose a polysubstance dependence.

  • Alcohol abuse  (−2 points), alcohol dependence  (−2 points). For alcohol dependence, there must be physiological dependence indicated by evidence of tolerance or symptoms of withdrawal. Alcohol abuse requires fewer symptoms and may be less severe in its destructive pattern, leading to significant social, occupational, or medical impairment.

    In alcohol dependence, alcohol use is continued despite the knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been worsened by alcohol (e.g., continued drinking despite knowing that an ulcer was made worse by drinking alcohol). This patient seems to be more alcohol dependent than an alcohol abuser; she did require at least two substance abuse treatment programs and relapsed shortly after each one. She drinks alone to help her sleep, and she has tried to cut down and is unable to do so. She admits to drinking three or four times per week; this is likely an underestimate, but even if it is not, it is still substantial enough for the diagnosis. In either case, however, given the totality of her substance use, she qualifies more specifically for polysubstance dependence.

  • Substance-induced mood disorder  (+2 points). The key would be whether the patient’s mood disorders are reversible with the cessation of her drug and alcohol use. Until she stops completely for a length of time, you will not be able to determine this. Consequently, it remains in the differential but is not conclusive.

  • Posttraumatic stress disorder  (−2 points). This patient was allegedly exposed to physical, emotional, and sexual abuse as a child between the ages of 6 and 9. She has also experienced violent sexual encounters with drug dealers. As a child, she likely felt fear, helplessness, or horror as she was abused by close relatives, people to whom she looked for guidance and safety. By accusing her of causing the incidents, her mother would not emotionally validate her experiences and instead blamed her.

    The patient did not admit to recurrent and intrusive distressing recollections of the abuse events, only that they happened. After further evaluation, such an admission might be elicited, but given the information provided, you cannot assume that this will occur. She did not endorse dreams of the events or dissociative flashback episodes, and she did not express intense psychological distress when she was confronted by a presumably similar event such as being violently sexually assaulted by drug dealers as an adult. She does avoid discussing the trauma and says that she is unable to discuss it, and she became tearful when she declined to discuss it. She feels detached and estranged from others—from friends, from family, from her ex-husband. She cannot feel “loved” unless she takes Ecstasy. She has difficulty falling asleep and has difficulty concentrating. She is also prone to irritability, and reports that she yelled at her college friends “for no reason” or because they did not understand her. Although she does not endorse the hypervigilant aspects of PTSD, she does endorse enough of the other symptoms for the diagnosis to be considered.

    Hence, further investigation would be required to rule out PTSD  (+1 point).

  • Generalized anxiety disorder  (−2 points). This patient does not describe an inability to control anxiety or worry. She does demonstrate some of the symptoms of anxiety, such as restlessness, difficulty concentrating, irritability, and sleep disturbance, but these may all be symptomatic of substance or alcohol dependence.

  • Substance-induced anxiety disorder  (−2 points). The patient does not describe panic attacks but has some anxiety symptoms. These are likely directly related to her substance and alcohol dependence.

  • Gender identity disorder  (−2 points). The patient demonstrates bisexuality, not a disturbance of her gender identification.

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Axis II

To have a personality disorder, a patient must have an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture in two or more of the following areas: cognition, affectivity, interpersonal, functioning, and impulse control. This patient clearly demonstrates deviations in all of these areas. She perceives others as less important than herself, she has unclear sexual preferences, and she does not appreciate the gravity of the dangerous situations into which she places herself, such as having sex with drug dealers (she thinks about what she will give them and then is surprised when they want something different). She may have been sexually harassed at her magazine job, but this is unclear as we are hearing only one side of the story. It is possible that she misconstrued her boss’s behavior to suit her own mistaken impression. She is considered "moody" and has extreme swings of mood. She is emotionally labile and is prone to "freaking out" and acting inappropriately. She has difficult, tumultuous relationships with her family, friends, and ex-husband, on whom she cheated extensively. Thus she demonstrates poor impulse control in areas related to sex, drugs, and jobs.

She most closely qualifies for an axis II diagnosis in cluster B, the "dramatic emotional" type. While she does have some of the characteristics of antisocial personality disorder (failure to respect lawful behaviors, deceitfulness, impulsivity, irritability, recklessness, consistent irresponsibility), she does not carry these traits to the extent required for this diagnosis. For example, she violates the law by using illegal drugs, but she does not sell drugs, is not involved in criminal activity, and does not repeatedly perform acts that are truly grounds for arrest. Most of her antisocial behaviors involve self-inflicted harm. She is deceitful and cheats on her boyfriend, but she does not con others for personal profit. She may do so on a weak scale for personal pleasure, but she has not given any indication of a more pervasive pattern. Impulsivity is a characteristic that is nonspecific. Her reckless disregard is directed more at herself and less toward others, even if they are injured by her behaviors. Again, the behavior does not indicate the more aggressive, illegal, and conniving behavior one finds with antisocial personality disorder. Finally, consistent irresponsibility is not as clearly diagnosed in her case, and, moreover, she is able to maintain a job, maintain relationships, and maintain enough consistent behaviors at work and elsewhere that this is not the source of her major troubles.

She does demonstrate strong histrionic and narcissistic personality traits. For histrionic personality traits, she does enjoy being the center of attention, but it is not necessary for her. She is sexually provocative (including, for example, when she entered your office), and she is somewhat promiscuous. It would appear from her story that she uses her physical appearance and sexuality to draw attention to herself. She is noted to have some affected speech, but not overly so. Her presentation is definitely dramatic, and she is somewhat suggestible by others or circumstances. Finally, it seems she sees many of her relationships in black-or-white terms, over- or undervaluing relationships, considering them to be more intimate than they may be, or the opposite.

For narcissistic personality traits, she seems grandiose, inflating her self-importance and exaggerating her personal achievements. She is not preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. She expresses some aspect of feeling "above others," but not to the point where she is unable to associate with anyone "beneath her" (notably when it comes to acquiring drugs). She requires admiration, but it would not seem excessively so. There is no enduring sense of entitlement and interpersonal exploitation (except with some love entanglements and perhaps to get more drugs, but these are not personality disorders but rather means to an end—which itself is related to a different psychiatric diagnosis). She is empathic but does not spend a great deal of time being envious or demonstrating arrogant haughty behaviors or attitudes. Not enough to warrant the diagnosis.

  • Thus, one possible diagnosis for the differential on axis II is mixed personality disorder  (+2 points).

    The pattern of her behaviors and personality are enduring, inflexible, and pervasive across a broad range of personal and social situations. These patterns have caused disruptions in her personal, social, educational, and occupational pursuits. The onset was during childhood, and the patterns are not better accounted for by another psychiatric disorder, except perhaps drug and alcohol dependence. However, if she was raped when she was 6 to 9 years old, which preceded her first self-destructive behaviors, we are likely to side with the personality disorder’s preceding the alcohol and drug use disorders.

  • Borderline personality disorder  (+2 points). The patient’s personality disorder most closely follows the criteria for borderline personality disorder, as indicated by her meeting at least five of the nine DSM-IV-TR criteria:

    Frantic efforts to avoid real or imagined abandonment. She engages in multiple, often risky sexual relationships with men and women to satisfy a need to be wanted. She uses her sexuality to obtain drugs and maintain relationships with drug dealers, although, again, this is more likely a consequence of her substance dependence. She uses Ecstasy because it makes her feel “loved,” which she is unable to feel among friends or family.

    Long pattern of tumultuous relationships, often characterized by extremes of idealization or devaluation. She thinks her uncle, who molested her, is smart because he’s an architect, and she loves him despite the molestation. She hated her boss at the magazine and said she’s an idiot. She thinks she is smarter than others and exaggerates her accomplishments, such as graduating from college magna cum laude. She at first adored her husband and then decided he was not worthy of her and sought ways to break off the relationship.

    Identity disturbance. She is not sure whether she is bisexual or heterosexual. She never fully explains what she thinks of herself, only how she reacts to others and how others are making her life more difficult.

    Impulsivity. Clearly stated impulsivity in areas that are self-damaging, such as sex and substance abuse.

    Recurrent suicidal behavior, gestures, self-mutilating behaviors.

    Affective instability due to a marked reactivity of mood in the form of “freaking out” and being known as “moody.”

    Chronic feelings of emptiness—none elicited.

    Inappropriate, intense anger or difficulty controlling anger. Again, “freaking out.”

    Transient, stress-related paranoid ideation or severe dissociative symptoms. “People just try to hurt me. I’ve never known love.”

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Decision Point B

  • B1. +2 The statistic of 8%–10% for successful suicides is correct for borderline patients. This patient theoretically is at increased risk because of her previous attempts, and her comorbid disorders, such as alcohol and substance abuse, exacerbate the risk severalfold. Moreover, her life, personal and occupational, is very unstable. Contracting for safety has its limitations; a safety plan is of high priority. This patient could probably best benefit from dialectical behavioral therapy to help her in the long run in developing effective and safe coping strategies, regulating her emotions, and learning to tolerate stress. We cannot say, however, that her risk is definite. Determining suicide risk is not a science. Often it is the patient we think is the most safe who surprises us.

  • B2. +3 As stated above, it is impossible to ascertain the likelihood of the patient’s making another suicide attempt, but given her circumstances, risk factors, and poor social supports, it seems likely that without intervention she will try again. Again, one intervention for which there is some empirical evidence on helping with suicidal ideation, mood stabilization, and better control of mood is dialectical behavior therapy.

  • B3. +1 This is true. However, you should attempt a more informed assessment of her risk by asking pertinent questions, as in B4.

  • B4. +2 This is true, and you are asking for more information to substantiate your opinion of her risk for suicide. However, this answer does not provide further steps to take.

  • B5. +5 This is true, and beginning both dialectical behavioral therapy and substance abuse treatment, typically the latter before the former if not both at the same time, is necessary for the greatest impact on the patient’s ability to develop better coping strategies, stay away from risky behaviors, and manage a hopefully more stable mood.

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Decision Point C

According to current evidence supported by two or more randomized, placebo-controlled, double-blind trials, what are the most effective psychopharmacological treatment recommendations for affective dysregulation symptoms, impulse-behavioral dyscontrol symptoms, and cognitive-perceptual symptoms in patients with borderline personality disorder? For each class, fill in the appropriate drugs if they meet the above mentioned evidence-based criteria. (One point is given for each correctly placed drug. Two points are deducted for incorrect answers.)

 
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Decision Point D

  • D1. −2 A diagnosis of PTSD requires that the individual experienced, witnessed, or was confronted by an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. In addition to the experience, the individual’s response must also have involved intense fear, helplessness, or horror. In children this may be expressed instead by disorganized or agitated behavior. Although this patient may have experienced sexual assault, she does not exhibit enough of the symptoms and behavioral changes for a diagnosis of PTSD, as stated below in D2.

  • D2. +2 A diagnosis of PTSD requires the following: the traumatic event is persistently reexperienced; persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness; persistent symptoms of increased arousal (not present before the trauma); duration of the disturbance is more than 1 month; and the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Our patient does not currently endorse any of these symptoms. In fact, she still “loves” one of her former abusers, her uncle. It is possible that she experienced PTSD as an acute syndrome earlier in her life, but she does not offer any suggestion of this. Additionally, not having been diagnosed with PTSD does not preclude the deleterious effects of early sexual assault.

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Decision Point E

E1. False. It is the most common, seen in 10% of outpatients, 15%—20% of inpatients, and 30%—60% of clinical populations with a personality disorder.

E2. False. It is the most common, but see E1.

E3. True.

E4. True.

E5. False. It is present in cultures around the world.

E6. True.

E7. False. It is approximately five times more common among first-degree biological relatives of those with the disorder than in the general population.

 
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American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2004. Washington, DC, American Psychiatric Publishing,  2004
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams Wilkins,  2003
 
Schatzberg AF, Nemeroff CB: Essentials of Clinical Psychopharmacology. Washington, DC, American Psychiatric Publishing,  2001
 
Shea SC: The Practical Art of Suicide Assessment. Hoboken, NJ, Wiley,  2002
 
Stone MH: Abnormalities of Personality: Within and Beyond the Realm of Treatment. New York, Norton,  1993
 
Frankenburg FR, Zanarini MC: Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study. J Clin Psychiatry  2002; 63:442—446
 
Zanarini MC, Frankenburg FR: Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study. J Clin Psychiatry  2001; 62:849—854
 
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References

American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2004. Washington, DC, American Psychiatric Publishing,  2004
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams Wilkins,  2003
 
Schatzberg AF, Nemeroff CB: Essentials of Clinical Psychopharmacology. Washington, DC, American Psychiatric Publishing,  2001
 
Shea SC: The Practical Art of Suicide Assessment. Hoboken, NJ, Wiley,  2002
 
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