Review Question - QID 103737

This patient likely has borderline personality disorder given her self-harm behavior and her splitting (stating the doctors are great and the nurses are poor) and would benefit from dialectical behavioral therapy (DBT).

Borderline personality disorder typically presents with unstable/volatile emotions, unstable relationships, splitting, desperate efforts to avoid abandonment, impulsivity, suicidal threats/mutilation, mood instability, transient and stress-related paranoid ideation, and difficult-to-control anger. DBT strives to validate a patient's feelings while informing the patient that some feelings and behaviors are maladaptive. Likewise, DBT seeks to make the patient aware of the consequences of his/her actions while reducing splitting and impulsiveness. For this reason, it is a preferred initial step in management. Subsequently, mood stabilizers should be started as well including lithium and valproic acid.

Incorrect Answers:
Answer 1: Amitriptyline (a tricyclic antidepressant or TCA) is not first-line for treating borderline personality disorder which requires a mood stabilizer. Also, TCAs may be contraindicated in patients who are suicidal, such as those with borderline personality disorder because of their significant toxicity in an overdose.

Answer 2: Cognitive behavioral therapy is not the specific therapy that is most helpful for patients with borderline personality disorder and is preferred for other common conditions such as anxiety or obsessive-compulsive disorder.

Answer 4: Fluoxetine is an SSRI that is appropriate for depression or anxiety; however, it is not an optimal first-line medication as a mood stabilizer would be preferred. It may improve depressive symptoms.

Answer 5: Lithium is a mood stabilizer that can be used in borderline personality disorder and may be started initially in this patient; however, for boards purposes, it is important to pick the least invasive initial step first which may be effective and spare this patient a potentially toxic medication.

Bullet Summary:
The most appropriate initial step in the management of borderline personality disorder is dialectical behavioral therapy.