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Difficulty: HardPersonality Disorders

A 24-year-old woman presents to the emergency department after sustaining superficial lacerations to her left forearm. Her roommate brought her in, stating the patient became deeply distraught after a man she had been dating for two weeks did not immediately reply to a text message. The patient tearfully explains she felt "completely hollow and abandoned." During the initial triage, the patient tells the nurse, "You are the only person who actually listens to me; everyone else here is heartless." Thirty minutes later, when the attending physician suggests a psychiatry consultation before discharge, the patient throws a cup of water at the wall and screams, "You are an incompetent, cruel doctor trying to lock me up!" The roommate notes that the patient has a history of impulsive spending sprees, frequent binge eating, and a chronically unstable mood. The patient is currently taking paroxetine for depressive symptoms. She asks the physician to prescribe tranylcypromine, stating that a friend takes it and it "works wonders for mood swings." The patient also mentions that during severe stress, she sometimes feels disconnected from her body and has transient thoughts that people are plotting against her, which typically resolve within a day.

Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

  1. Dialectical behavior therapy is the most appropriate first-line psychotherapy to address the patient's underlying pathology.Answer
  2. The patient's alternating behavior of idealizing the triage nurse and devaluing the attending physician exemplifies the defense mechanism of splitting.Answer
  3. C
    Adding tranylcypromine to the patient's current paroxetine prescription is a safe and effective strategy for managing her mood lability.
  4. D
    The patient's transient paranoid thoughts confirm a diagnosis of brief psychotic disorder because the symptoms lasted less than one month.
  5. E
    The physician is legally required to breach confidentiality and contact the patient's employer due to the potential risk her erratic behavior poses to workplace harmony.

Answer

The correct statements are that dialectical behavior therapy is the first-line psychotherapy, and the patient's behavior exemplifies the defense mechanism of splitting.
The patient's presentation of affective instability, recurrent self-harm, chronic feelings of emptiness, and intense interpersonal relationships is classic for Borderline Personality Disorder (BPD). Dialectical behavior therapy (DBT) is the most effective, first-line psychotherapeutic intervention for BPD. Furthermore, her behavior of viewing the nurse as perfectly good and the physician as entirely bad exemplifies splitting, which is the hallmark defense mechanism used by patients with BPD to handle complex, conflicting emotions.

Step-by-Step Solution

1
Analyze the patient's clinical presentation.
The patient exhibits fears of abandonment, identity disturbance, impulsivity, recurrent self-harm, affective instability, and transient stress-related paranoia.
Identifying these clinical features is necessary to confirm the diagnosis of Borderline Personality Disorder (BPD).
2
Evaluate psychotherapy and defense mechanisms associated with the diagnosis.
Dialectical behavior therapy is identified as the gold-standard treatment, and the patient's dichotomous view of staff is recognized as splitting.
BPD management relies on specific targeted psychotherapies rather than medications, and splitting is its core defense mechanism.
3
Assess the incorrect distractors regarding pharmacology, diagnosis, and ethics.
Pharmacological combination of SSRIs and MAOIs is ruled out due to dangerous interactions; brief psychotic disorder is ruled out due to insufficient symptom duration; and confidentiality breaches are ruled out due to lack of an imminent threat.
Eliminating distractors ensures they violate specific medical and ethical standards.

Key Concept

Diagnosis of Borderline Personality Disorder, its primary defense mechanism (splitting), and its primary evidence-based treatment (dialectical behavior therapy).
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Topics

Personality Disorders

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