A 22-year-old woman is hospitalized due to suicidal ideation. The patient describes feelings of intense sadness, emptiness, and despair for the past week following the breakup of her month-long romantic relationship. For the past week, she has had difficulty falling and staying asleep but has had no change in appetite, energy level, or concentration. She feels betrayed by her boyfriend and is furious at her parents for turning against her. Since the breakup, the patient has been going to bars, engaging in unsafe sex, and drinking excessively. She describes having intense mood swings since adolescence and has a history of 2 suicide attempts involving an overdose of sleeping pills. Which of the following is the most likely diagnosis?

Question

A 22-year-old woman is hospitalized due to suicidal ideation.  The patient describes feelings of intense sadness, emptiness, and despair for the past week following the breakup of her month-long romantic relationship.  For the past week, she has had difficulty falling and staying asleep but has had no change in appetite, energy level, or concentration.  She feels betrayed by her boyfriend and is furious at her parents for turning against her.  Since the breakup, the patient has been going to bars, engaging in unsafe sex, and drinking excessively.  She describes having intense mood swings since adolescence and has a history of 2 suicide attempts involving an overdose of sleeping pills.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3638_1899_9249_ed25063ddbd5_MD0001_00 This patient's depression, suicidal ideation, and impulsivity in the setting of feeling rejected are characteristic of borderline personality disorder (BPD). Individuals with this disorder exhibit a persistent pattern of unstable and intense relationships beginning in adolescence or early adulthood. They experience marked mood reactivity to interpersonal stresses and frequently alternate between extremes of idealizing and devaluing others (defense mechanism of splitting). Difficulty controlling anger, impulsivity (eg, substance use, unsafe sex), recurrent suicidality, and self-mutilating behavior (eg, cutting, burning) are common. Individuals with BPD frequently seek clinical attention due to suicidal behavior or threats during an interpersonal crisis and comprise approximately 20% of psychiatric inpatients. (Choice A) Although bipolar II disorder and BPD can have similar clinical features, this patient has insufficient symptom quantity and duration to diagnose discrete episodes of hypomania and major depression required for the diagnosis of bipolar II disorder. BPD is characterized by transient mood shifts and impulsive behaviors that occur in response to environmental triggers (eg, relationship breakup). (Choice C) Individuals with dependent personality disorder fear abandonment but respond to relationship strain by trying to appease others, versus being impulsive and having uncontrolled anger as seen in BPD. (Choice D) Both borderline and histrionic personality disorders are characterized by attention-seeking behavior, but this patient's excessive anger and self-destructive behavior are more characteristic of BPD. (Choice E) This patient has insufficient symptom quantity and duration for a diagnosis of major depressive disorder (MDD). In MDD, ≥5 of the following symptoms are present for ≥2 weeks: depressed mood, sleep disturbances, anhedonia, guilt, decreased energy, concentration difficulty, appetite changes, psychomotor retardation or agitation, and suicidality. (Choice F) Patients with BPD may experience transient, stress-related paranoid ideation but do not exhibit the pervasive pattern of distrust and suspiciousness characteristic of paranoid personality disorder. (Choice G) This patient's alcohol misuse is a consequence, not the cause, of her behavioral disturbance. Educational objective: Borderline personality disorder is characterized by a persistent pattern of unstable relationships, mood lability, and impulsivity. Individuals with this disorder may exhibit suicidal ideation or behavior in the context of an interpersonal crisis in which they feel rejected or abandoned. __________ References: Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? (http://www.ncbi.nlm.nih.gov/pubmed/25536097) Borderline personality disorder in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/25134872) Using negative emotions to trace the experience of borderline personality pathology: interconnected relationships revealed in an experience sampling study. (http://www.ncbi.nlm.nih.gov/pubmed/25710731)

A 22-Year-Old Woman Is Hospitalized Due to Suicidal Ideation