A 22-year-old woman is brought to the emergency department after overdosing on benzodiazepines. On presentation, her speech is slurred and her gait is unsteady. She is admitted to the hospital and improves with supportive care. When questioned later, she states that she had wanted to die because her boyfriend of 4 months ended their relationship a week ago. Currently she is less depressed and no longer suicidal, and feels that "he was the worst person for me." The patient describes "mood swings" since she was a teenager characterized by feelings of severe depression lasting from a few hours to several days. She has a history of 2 suicide attempts involving medication overdose. The patient has been treated with fluoxetine but stopped taking it 6 months ago because "it didn't seem to make a difference in how low I was feeling."
Which of the following is the most likely diagnosis?

Question

A 22-year-old woman is brought to the emergency department after overdosing on benzodiazepines.  On presentation, her speech is slurred and her gait is unsteady.  She is admitted to the hospital and improves with supportive care.  When questioned later, she states that she had wanted to die because her boyfriend of 4 months ended their relationship a week ago.  Currently she is less depressed and no longer suicidal, and feels that "he was the worst person for me."  The patient describes "mood swings" since she was a teenager characterized by feelings of severe depression lasting from a few hours to several days.  She has a history of 2 suicide attempts involving medication overdose.  The patient has been treated with fluoxetine but stopped taking it 6 months ago because "it didn't seem to make a difference in how low I was feeling." 
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c05b_1dba_8f63_45a7f5348f9e_MD0005_00 This patient's suicide attempt following the end of a relationship and her history of longstanding mood instability and recurrent suicide attempts are suggestive of borderline personality disorder (BPD). Patients with BPD experience marked instability in mood, self-image, impulse control, and relationships. Their relationships typically involve extremes of idealization and devaluation (splitting) as demonstrated by this patient's changing view of her boyfriend. Acute depression, intense anger, and suicidal threats and behavior are often triggered by feelings of rejection and abandonment. In contrast to primary mood disorders, the mood shifts in BPD occur in response to situational stressors and typically last a few hours, rarely more than a few days. This patient's rapid improvement and history of poor response to antidepressants are characteristic of BPD. (Choice A) Acute stress disorder is characterized by symptoms of intrusion, negative mood, dissociation, avoidance, and arousal within a month of exposure to a traumatic event. (Choices B and E) Although mood disorders may co-occur, this patient does not have distinct mood episodes of sufficient duration to diagnose unipolar or bipolar depression. Bipolar II disorder is characterized by major depressive episodes (requiring a duration >2 weeks) and hypomanic episodes (requiring a duration >4 days). Major depressive disorder involves major depressive episodes with no history of (hypo)mania. This patient's rapid and brief mood shifts (lasting from hours to days) in response to interpersonal triggers are better explained as the mood reactivity associated with BPD. (Choice D) Fears of abandonment are also characteristic of dependent personality disorder, but these individuals lack the impulsivity, uncontrolled anger, and history of unstable, intense relationships seen in BPD. Feelings of rejection typically lead to increasing submissiveness rather than rage and impulsive suicidal behavior. Educational objective: Borderline personality disorder (BPD) involves a persistent pattern of unstable relationships and self-image, mood instability, impulsivity, and recurrent suicidal behavior. BPD is characterized by transient mood shifts in response to situational stressors rather than sustained mood changes seen in mood disorders. References: Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? (http://www.ncbi.nlm.nih.gov/pubmed/25536097) Assessment and emergency management of suicidality in personality disorders. (http://www.ncbi.nlm.nih.gov/pubmed/18638651)

A 22-Year-Old Woman Is Brought to the Emergency Department After