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Question

Difficulty: MediumPersonality Disorders

A 21-year-old female university student presents to the student health center accompanied by a residence hall advisor. The patient is visibly distraught, weeping uncontrollably, and stating that her life is 'completely empty' after a three-week romantic relationship ended abruptly the previous night. Physical examination reveals several superficial, linear scratches on her left volar forearm. She admits to making these marks with a safety pin, stating, 'I just needed to feel something.' The advisor mentions that the patient has a history of intense, unstable friendships, often idolizing peers before suddenly turning against them. The patient's medical history includes a diagnosis of 'atypical depression,' for which she currently takes phenelzine. During the interview, she mentions that last night she briefly suspected the campus security was tracking her phone, but she now realizes this was an irrational thought. She denies any current suicidal ideation or plan. Which of the following are appropriate next steps in the ongoing management of this patient? (Select all that apply.)

  1. Provide a referral for dialectical behavior therapyAnswer
  2. Establish clear, firm boundaries regarding the parameters of future clinical interactionsAnswer
  3. C
    Prescribe fluoxetine to target her acute mood lability and depressive symptoms
  4. D
    Diagnose schizophreniform disorder due to her paranoid ideation and begin risperidone
  5. E
    Contact her parents immediately without her consent to ensure she has adequate supervision

Answer

The most appropriate management steps for this patient include referring her for dialectical behavior therapy (DBT) and establishing clear, consistent clinical boundaries.
This patient's presentation—characterized by an intense fear of abandonment, unstable relationships, emotional lability, chronic feelings of emptiness, superficial self-injury, and transient stress-related paranoia—is highly consistent with borderline personality disorder (BPD). The primary, evidence-based treatment for BPD is dialectical behavior therapy (DBT), which focuses on emotional regulation, distress tolerance, and mindfulness. Additionally, patients with BPD often test limits and engage in splitting (idealizing and then devaluing providers). Therefore, establishing clear, consistent, and firm boundaries regarding communication and clinical availability is an essential component of management to ensure a stable therapeutic framework.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and history.
The patient displays emotional lability, chronic feelings of emptiness, superficial non-suicidal self-injury, intense unstable relationships, and transient stress-related paranoia.
Identifying the core pattern of symptoms is necessary to establish the primary psychiatric diagnosis of borderline personality disorder (BPD).
2
Determine the appropriate psychotherapeutic and interpersonal interventions for BPD.
Dialectical behavior therapy (DBT) is the evidence-based treatment of choice, and setting firm clinical boundaries prevents splitting and excessive dependency.
Psychotherapy is the mainstay of treatment for BPD, and clear boundaries protect both the patient and the therapeutic relationship.
3
Evaluate the proposed pharmacological and ethical interventions in the distractors.
Adding fluoxetine to phenelzine causes serotonin syndrome. Transient paranoia does not meet the timeline for schizophreniform disorder. Superficial self-harm does not justify breaching an adult's confidentiality.
To rule out contraindicated or inappropriate clinical actions based on patient safety and diagnostic criteria.

Key Concept

Management of borderline personality disorder (BPD)
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Topics

Personality Disorders

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