A 33-year-old man comes to the office with his wife due to marital difficulties. His wife says, "I came back from a work trip last week, and now my husband is convinced I'm having an affair with my coworker." She says that he is constantly demanding to look at her phone and has grabbed it from her several times. The husband says that he has always struggled with his temper, that he shouts with little provocation and his moods go up and down throughout the day. His wife asks if medication would help "balance him out." She describes how he binges on alcohol "every few months" when he feels low. He has had 2 minor car crashes while intoxicated and bought expensive cars after each one, which resulted in significant debt. Prior to their marriage 2 years ago, the patient had multiple short-lived relationships, each of which ended abruptly. He says, "My ex-girlfriends were terrible-they never cared about me." The patient expresses remorse for upsetting his wife and begs her not to leave him. Which of the following is the most likely diagnosis?

Question

A 33-year-old man comes to the office with his wife due to marital difficulties.  His wife says, "I came back from a work trip last week, and now my husband is convinced I'm having an affair with my coworker."  She says that he is constantly demanding to look at her phone and has grabbed it from her several times.  The husband says that he has always struggled with his temper, that he shouts with little provocation and his moods go up and down throughout the day.  His wife asks if medication would help "balance him out."  She describes how he binges on alcohol "every few months" when he feels low.  He has had 2 minor car crashes while intoxicated and bought expensive cars after each one, which resulted in significant debt.  Prior to their marriage 2 years ago, the patient had multiple short-lived relationships, each of which ended abruptly.  He says, "My ex-girlfriends were terrible-they never cared about me."  The patient expresses remorse for upsetting his wife and begs her not to leave him.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d77d_902e_bc81_7b13e8d9d23c_MD0003_00 Several features of this patient's behavior are suggestive of borderline personality disorder (BPD), including his (longstanding) pattern of unstable relationships (eg, wife, former girlfriends), mood instability, inappropriate anger (eg, grabbing phone, shouting), and impulsivity (eg, binging on alcohol, buying expensive cars). Patients with BPD may also develop transient paranoia and psychotic symptoms (eg, delusional jealousy) during times of stress. Angry outbursts and impulsive behavior commonly occur in response to feeling abandoned (eg, this patient's aggressive behavior when feeling that his wife is rejecting him). Splitting (ie, seeing self and others as all good or all bad) is also characteristic of BPD and can lead to alternating displays of loving and hateful behavior. Self-injury, although common, is not required for the diagnosis. (Choice A) The diagnosis of bipolar II disorder requires at least one episode of hypomania (ie, elevated or irritable mood with increased energy lasting ≥4 days) and at least one episode of major depression (ie, duration ≥2 weeks). In comparison, mood states in BPD tend to be reactive to circumstances and last hours to days, such as this patient's moods that fluctuate throughout the day and his alcohol binges (followed by impulsive purchasing behavior after minor car collisions) when he feels low. (Choice C) Delusional disorder is characterized by persistent delusions lasting ≥1 months, whereas psychotic symptoms in BPD are transient. This patient's additional symptoms (eg, impulsive behavior, unstable mood) are not consistent with delusional disorder. (Choice D) Disruptive mood dysregulation disorder is a childhood condition characterized by repeated temper tantrums. This definition is inconsistent with the patient's age, and the diagnosis should not be made for the first time after a patient is age 18. (Choice E) Paranoid personality disorder (PPD) involves a pervasive pattern of suspicion and mistrust of others. This patient's paranoia is not pervasive but has been triggered by the stress associated with a fear of abandonment. PPD does not explain this patient's mood instability or impulsivity. Educational objective: Borderline personality disorder is characterized by mood instability, inappropriate anger, impulsivity, and unstable relationships. Self-injury is common but not required for diagnosis. Patients may have transient psychotic symptoms in times of stress. References: Borderline personality disorder in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/25134872) Borderline personality disorder and unmet needs. (http://www.ncbi.nlm.nih.gov/pubmed/28871714)

A 33-Year-Old Man Comes to the Office with His Wife