A 24-year-old man comes to the emergency department after injuring his arm. Following an argument with his girlfriend, the patient broke a vase and used a shard of glass to cut his wrist. He says, "I wasn't trying to kill myself. I just don't know how to deal with my anger." The patient says he has struggled with depression and anger problems since he was a teenager; this has led to difficulties with romantic relationships and has caused him to get fired from jobs. He was hospitalized at age 17 for a suicide attempt. The patient's bouts of depression are "too numerous to count," and he explains that his moods shift unpredictably from one minute to the next. Previous medication trials of fluoxetine and sertraline were ineffective and caused sexual side effects; he does not currently take any medications. The patient has a 2-cm, superficial laceration on his left forearm; physical examination is otherwise normal. He has no suicidal ideation, hallucinations, or delusions. Which of the following is the most appropriate treatment for this patient's condition?

Question

A 24-year-old man comes to the emergency department after injuring his arm.  Following an argument with his girlfriend, the patient broke a vase and used a shard of glass to cut his wrist.  He says, "I wasn't trying to kill myself.  I just don't know how to deal with my anger."  The patient says he has struggled with depression and anger problems since he was a teenager; this has led to difficulties with romantic relationships and has caused him to get fired from jobs.  He was hospitalized at age 17 for a suicide attempt.  The patient's bouts of depression are "too numerous to count," and he explains that his moods shift unpredictably from one minute to the next.  Previous medication trials of fluoxetine and sertraline were ineffective and caused sexual side effects; he does not currently take any medications.  The patient has a 2-cm, superficial laceration on his left forearm; physical examination is otherwise normal.  He has no suicidal ideation, hallucinations, or delusions.  Which of the following is the most appropriate treatment for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d7e6_6481_bc81_93dde96e6afc_MD0003_00 This patient's unstable moods, recurrent suicidal behaviors, impulsivity, intense anger, and chaotic interpersonal relationships are consistent with borderline personality disorder (BPD). Acute onset of depression and suicidal behavior in response to interpersonal stressors (eg, feeling rejected or abandoned) and feelings of emptiness are characteristic. Mood instability is common in BPD and may be difficult to differentiate from mood symptoms in bipolar disorders. In contrast to primary mood disorders, the mood shifts in BPD occur in response to situational stressors and typically last minutes to hours as opposed to the days or weeks required to diagnose manic and depressive episodes. Psychotherapy is the treatment of choice for BPD, with the best evidence for dialectical behavioral therapy (DBT). DBT is a form of cognitive-behavioral therapy developed specifically for BPD. It integrates techniques of emotion regulation and principles of mindfulness and distress tolerance to target unstable moods, impulsivity, and suicidality. Pharmacological treatments do not treat the core pathology of BPD and are used adjunctively. (Choices A and G) Antidepressants such as bupropion and venlafaxine are not first-line treatments for BPD, and this patient's poor response to trials of selective serotonin reuptake inhibitors is typical. The chronic emptiness and loneliness seen in BPD generally does not respond to medication treatment. Antidepressants are indicated only if the patient meets criteria for a comorbid major depressive disorder or anxiety disorder. (Choice B) Couples counseling can be beneficial in improving communication and interpersonal skills. However, unlike DBT, it would not directly target this patient's core disturbances in self-image and affect regulation. (Choices D and F) Lithium and the anticonvulsant valproate are mood stabilizers used primarily in bipolar disorders. These medications are not used as primary treatment for BPD but can be considered as an adjunct to psychotherapy to target mood instability. (Choice E) Occupational therapy focuses on improving skills to perform everyday activities (eg, eating, dressing, cooking). This patient's struggle to maintain employment is due to his difficulty managing emotions, rather than an inability to complete everyday tasks. Acquiring emotional distress tolerance is a component of DBT. Educational objective: Dialectical behavioral therapy is the treatment of choice for borderline personality disorder. Pharmacotherapy is used as an adjunct to psychotherapy or to treat comorbid disorders. References: Borderline personality disorder in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/25134872)

A 24-Year-Old Man Comes to the Emergency Department After Injuring