A 25-year-old woman is brought to the emergency department by her mother due to suicidal ideation. The patient's mother found her in the bathroom holding a razor blade to her wrist and saying, "I might as well be dead." Her mother states, "She started a new relationship last week and thought he was her soul mate. But they got into an argument a few days later and then broke up. All of her relationships start and end like that." She adds that the patient has always been quick to anger and insecure about herself. The patient says that since middle school, she has had periods of sadness lasting 1-2 days in which she goes into "a bottomless black hole." She has a history of 3 prior suicide attempts. She had no significant improvement in her depressive symptoms with trials of escitalopram and venlafaxine, and currently takes no medications. The patient appears anxious and tearful; physical examination is otherwise unremarkable. Which of the following is the most likely diagnosis?

Question

A 25-year-old woman is brought to the emergency department by her mother due to suicidal ideation.  The patient's mother found her in the bathroom holding a razor blade to her wrist and saying, "I might as well be dead."  Her mother states, "She started a new relationship last week and thought he was her soul mate.  But they got into an argument a few days later and then broke up.  All of her relationships start and end like that."  She adds that the patient has always been quick to anger and insecure about herself.  The patient says that since middle school, she has had periods of sadness lasting 1-2 days in which she goes into "a bottomless black hole."  She has a history of 3 prior suicide attempts.  She had no significant improvement in her depressive symptoms with trials of escitalopram and venlafaxine, and currently takes no medications.  The patient appears anxious and tearful; physical examination is otherwise unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7e1_a98b_bc81_8b0f4e059d72_MD0003_00 This patient's history of unstable relationships, mood lability, anger, impulsivity, unstable self-image, and recurrent suicidal behavior is consistent with a diagnosis of borderline personality disorder (BPD). Patients with BPD may present for emergency care with acute dysphoria and suicidal threats or behavior in the setting of perceived rejection or abandonment. Their relationships often involve extremes of idealization and devaluation (ie, splitting). Chronic feelings of emptiness, difficulty being alone, and inappropriate anger are also typical. Patients with BPD may experience transient psychotic symptoms (eg, paranoia, delusions) under severe stress. The mood shifts in BPD occur in response to situational stressors, lasting usually a few hours and rarely more than a few days; this is in contrast to bipolar disorder in which, by definition, mood shifts must last longer than a few days. Psychotherapy (eg, dialectical behavior therapy), not pharmacotherapy, is the treatment of choice for BPD. (Choices A, B, and F) Although mood disorders may co-occur, this patient does not have distinct mood episodes of sufficient duration to diagnose major depressive disorder or a bipolar disorder. A major depressive episode requires ≥5 criterion symptoms to be present for ≥2 weeks. Bipolar I disorder is characterized by manic episodes (ie, mania lasting ≥7 days) with or without major depressive episodes. Bipolar II disorder consists of hypomanic (ie, hypomania lasting ≥4 days) and major depressive episodes. This patient's rapid and brief mood shifts in response to interpersonal triggers are not consistent either in character or duration with hypomania/mania and are better explained by the mood reactivity associated with BPD. criterion symptoms (Choice D) Individuals with dependent personality disorder also fear abandonment but lack the impulsivity, uncontrolled anger, and history of unstable, intense relationships seen in BPD. They react to fears of rejection with increasing submissiveness rather than emptiness and rage. (Choice E) Intense emotion, attention-seeking, and manipulative behavior can be seen in both BPD and histrionic personality disorder. However, this patient's recurrent suicidal behavior, excessive anger, and chronic emptiness are more characteristic of BPD. Educational objective: Borderline personality disorder is characterized by a persistent pattern of unstable relationships, mood lability, impulsivity, and recurrent suicidal behavior. Treatment involves psychotherapy with a behavioral focus (eg, dialectical behavioral therapy). References: Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? (http://www.ncbi.nlm.nih.gov/pubmed/25536097) Suicide attempts and self-injurious behaviors in adolescent and adult patients with borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28544496)

A 25-Year-Old Woman Is Brought to the Emergency Department by Her