A 19-year-old female high-school student is brought to your office by a friend who is concerned about the patient having cut her wrists. The patient denies that she was trying to kill herself, and states that she did this because she “just got so angry” at her boyfriend when she caught him sending a text message to another woman. She denies having a depressed mood or anhedonia, and blames her fluctuating mood on everyone who “keeps abandoning her,” making her feel like she’s “nothing.” She admits that she has difficulty controlling her anger. Her sleep quality and pattern appear normal, as does her appetite. She denies hallucinations or delusions. The wounds on her wrists appear superficial and there is evidence of previous cutting behavior on her forearms. Her vital signs are stable.
Which one of the following would be most beneficial for this patient?
Correct Answer E:
This patient displays most of the criteria for borderline personality disorder. This is a maladaptive personality type that is present from a young age, with a strong genetic predisposition. It is estimated to be present in 1% of the general population and involves equal numbers of men and women; women seek care more often, however, leading to a disproportionate number of women being identified by medical providers.
Borderline personality disorder is defined by high emotional lability, intense anger, unstable relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness. Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak when patients are in their early 20s, but completed suicide is most common after age 30 and usually occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a high short-term risk, and serve to communicate distress.
Inpatient hospitalization may be an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning, and pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in certain patients, psychotherapy is considered the mainstay of therapy, especially in a relatively stable patient such as the one described.
A 28-year-old female is brought to the emergency room by a distressed man, who states that she threatened to kill herself by holding a knife toward her arm after he tried to break up with her. She has visited the emergency room before for self-inflicted wounds and two psychiatric hospitalizations for overdosing on prescription pills. She was diagnosed with adjustment disorder as a teenager. The patient had been treated with escitalopram and clonazepam by her primary care physician. Her family history is significant for a mother, who committed suicide at the age of 42 years. The patient seems agitated stating that “no one understands her” and she is “better off dead.” Based on her presentation, what is her most likely diagnosis?
Correct Answer B:
Borderline personality disorder (BPD) is present in about 6% of primary care patients and persons in community-based samples and in 15-20% of patients in psychiatric hospitals and clinics. Patients with BPD often present with hypersensitivity to rejection and their fearful preoccupation with expected abandonment. Another commonly seen trait is splitting, characterized by black-and-white or all-or-nothing dichotomous thinking. It is a difficult condition to treat as suicide rate is about 8 - 10% and self-inflicted wounds are often seen. Many cases of BPD are initially misdiagnosed as depression or bipolar disorder. The primary treatment for BPD is psychotherapy. Atypical antipsychotics (e.g. olanzapine) and mood stabilizers (e.g. lamotrigine) may be used in conjunction with psychotherapy, but there are risks of overdosing and noncompliance.
→ Bipolar disorder (choice A) is not correct. Unlike patients with bipolar disorders, BPD patients are extremely sensitive to rejection and do not have periods of mania or elation.
→ Generalized anxiety disorder (choice C) often presents with a constant state of excessive, irrational worry. The patient does not present with these symptoms.
→ Major depressive disorder (choice D) is not correct. Although this patient seems depressed with suicidal intentions, unlike major depressive disorder, depressive episodes in BPD patients are marked by emptiness, shame, and a long standing negative self image.
→ Post-traumatic stress disorder (PTSD) (choice E) is not correct. There is no mention of an event in her life that had a traumatic effect on the patient to cause her described behavior. Therefore, PTSD is an unlikely diagnosis in this patient.
Key point:
Borderline personality disorder is a condition characterized by interpersonal hypersensitivity (fear of rejection and abandonment), affective dysregulation (uncontrollable anger, mood instability, feeling of emptiness), impulsivity (suicidal behavior, self-injury), and unstable self-image.
A 44-year-old man comes to the office for the first time for routine medical care. He has been referred to you by his psychiatrist who has informed you that the patient has paranoid personality disorder. He is unmarried, lives alone and has no close friends, but he occasionally attends family gatherings.
Which of the following is the best way to structure the physician-patient relationship with this patient?
The history of psychiatric illness in this patient is meant to be a red herring of sorts. The physician-patient relationship is the concept at the core of this question specifically, does the personality of the patient play a role in how a physician behaves? The answer generally speaking is no, it does not. Each patient should be approached in the same professional and courteous manner. All patients should be informed about issues concerning their care and they should be made to feel comfortable.
This standard approach may not be “effective” for all patients in that some patients may report that their physician is “cold” or “aloof” while others might report that the physician is “friendly” or “quite personable.” This is common when dealing with a diversity of patient types.
A 27-year-old woman comes to the office because of concerns about sexual function. The patient recently has remarried after being divorced from an abusive partner. She is currently unable to complete intercourse with her new husband due to intense vaginal pain on attempts at penetration. She was able to have intercourse successfully early in her first marriage. She is orgasmic with other stimulation but cannot tolerate digital or other penetration.
Which of the following is the most likely mechanism for this condition?
The successful completion of intercourse depends on both psychologic and physical factors. Although this patient is the victim of spousal abuse, there is no indication that she is unable to achieve sexual gratification (quite the opposite is true) suggesting that she is physically and psychologically able to achieve orgasm. The issue is rather pain with a specific form of sexual activity: vaginal intercourse. In the absence of other findings such as blood (cervical cancer), this is most likely due to vaginal muscle tension or spasm.
→ A change in vaginal flora may occur depending on the stage of menstruation, infection, antibiotic usage or diet, but this change is not associated with vaginal pain in the absence of vaginal discharge or smell.
→ A conversion disorder is a psychiatric illness whereby physical symptoms are manifest solely as a function of mental illness. As mentioned above, this patient appears to be quite able psychologically to attain orgasm. In addition, conversion disorder, according the DSM V, has specific diagnostic criteria. Among these is that the symptom or deficit is not limited to pain or sexual dysfunction.
Which one of the following is most important in the assessment and diagnosis of sexual dysfunction in women?
Correct Answer A:
A detailed history is the main tool for the assessment and diagnosis of sexual dysfunction, and is usually obtained from both partners. A physical examination, including a pelvic examination, is part of routine care, but it infrequently identifies a cause of sexual dysfunction. The possibility that laboratory testing will identify causes of sexual dysfunction is low.
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