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.
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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."
Given this presentation, what is your differential diagnosis for axis I and axis II, according to the DSM-IV-TR criteria?
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.)
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.)
Given the patient’s presentation and DSM-IV-TR criteria, could you make the diagnosis of posttraumatic stress disorder (PTSD)?
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.)
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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.
Given this presentation, what is your differential diagnosis for axis I and axis II, according to the DSM-IV-TR criteria?
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.
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.)
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.
E5. False. It is present in cultures around the world.
E7. False. It is approximately five times more common among first-degree biological relatives of those with the disorder than in the general population.