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 effective treatment for this patient's condition?

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 effective treatment for this patient's condition?

Quizplus · Accepted Answer

Explanation: Psychotherapy is the first-line treatment for borderline personality disorder (BPD), with the best evidence for dialectical behavior therapy (DBT). DBT is a structured treatment developed for BPD that consists of weekly individual psychotherapy and group skills training for approximately one year. DBT techniques include skills training to target self-injurious behavior and impulsivity and mindfulness training to target emotional dysregulation. Other types of psychotherapy developed to treat BPD include schema-focused therapy, mentalization-based therapy, and transference-focused therapy. Medications (eg, mood stabilizers, antipsychotics, antidepressants) do not treat the core BPD pathology. They are used adjunctively to target specific symptom clusters associated with the disorder (eg, mood instability, impulsivity, aggression), or to treat comorbid disorders such as major depression. (Choices A and E) The antidepressants bupropion and venlafaxine are not first-line treatments for BPD. They would be appropriate to treat a comorbid major depressive disorder. (Choice C) Interpersonal psychotherapy is an evidenced-based treatment for depression, not BPD. It focuses on four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits. (Choice D) Valproate is a mood stabilizer used primarily in bipolar disorder. It can also be used as an adjunct to psychotherapy to target the mood instability and impulsivity in BPD, but it is not a first-line monotherapy. Educational objective: Dialectical behavior therapy is a first-line treatment for borderline personality disorder. Pharmacotherapy may be used as an adjunct, but it does not treat the core disorder. References: Psychological therapies for people with borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22895952) Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. (http://www.ncbi.nlm.nih.gov/pubmed/20044651) Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24191948)

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