Borderline personality disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Borderline personality disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Borderline personality disorder US Medical PG Question 1: A 23-year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits to a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous 2 weeks. On morning rounds, the patient reports that the nurses are incompetent but the doctors are some of the best in the world. The patient's vitals are stable and her wrist lacerations are very superficial requiring only simple dressings without sutures. The patient is discharged a few days later and she feels well. Which of the following is the most appropriate initial treatment for this patient?
- A. Amitriptyline
- B. Fluoxetine
- C. Dialectical behavior therapy (Correct Answer)
- D. Cognitive behavioral therapy
- E. Lithium
Borderline personality disorder Explanation: ***Dialectical behavior therapy***
- The patient's presentation with **recurrent self-harm**, **mood instability** following a brief relationship, and **splitting** ("nurses are incompetent but doctors are the best") are classic features of **borderline personality disorder (BPD)**.
- **Dialectical behavior therapy (DBT)** is the gold-standard and most effective initial treatment for BPD, specifically targeting **emotional dysregulation**, self-harm, and suicidal behaviors.
*Amitriptyline*
- **Amitriptyline** is a **tricyclic antidepressant (TCA)**, primarily used for depression and chronic pain.
- While antidepressants might be used *adjunctively* for comorbid mood symptoms in BPD, they are not the primary or most appropriate *initial* treatment for the core features of BPD itself, and TCAs have a high overdose risk.
*Fluoxetine*
- **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)**, commonly used for depression, anxiety disorders, and some eating disorders.
- Similar to other antidepressants, SSRIs may treat comorbid depressive or anxiety symptoms in BPD but do not address the fundamental **personality organization issues** or behavioral patterns like self-harm and splitting characteristic of BPD.
*Cognitive behavioral therapy*
- **Cognitive behavioral therapy (CBT)** is effective for a wide range of mental health conditions, including depression and anxiety, by focusing on changing negative thought patterns and behaviors.
- While elements of CBT are incorporated into DBT, **DBT is specifically adapted and more effective for BPD** due to its emphasis on **emotion regulation**, distress tolerance, and interpersonal effectiveness skills, which are crucial for this patient's presentation.
*Lithium*
- **Lithium** is a mood stabilizer primarily used to treat **bipolar disorder**.
- Although there can be some overlap in symptoms (e.g., mood swings), the patient's presentation is more indicative of BPD due to the **recurrent self-harm, interpersonal instability**, and **splitting**, rather than the distinct mood episodes seen in bipolar disorder.
Borderline personality disorder US Medical PG Question 2: A 23-year-old woman presents to the emergency room for a self-inflicted laceration of her distal volar forearm. The patient states that she knew her husband was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist. In the emergency department the bleeding is stopped and the patient is currently medically stable. When interviewing the patient, she is teary and apologizes for her behavior. She is grateful to you for her care and regrets her actions. Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating. The patient states that she struggles with her romantic relationship though she deeply desires them. On physical exam you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts. You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious. Which of the following personality disorders is the most likely diagnosis?
- A. Borderline (Correct Answer)
- B. Dependent
- C. Antisocial
- D. Histrionic
- E. Avoidant
Borderline personality disorder Explanation: ***Borderline***
- The patient exhibits **impulsivity** (self-harm), **unstable relationships**, fear of abandonment (husband's "sexual thoughts"), and rapid mood shifts (tearful apology followed by fury), which are characteristic of Borderline Personality Disorder.
- Recurrent self-harm and previous presentations for similar reasons (struggling with online dating) highlight a pattern of **unstable self-image** and coping mechanisms.
*Dependent*
- While individuals with Dependent Personality Disorder desire relationships, their primary feature is an excessive need to be cared for, leading to **submissive behavior** and fear of separation, rather than the dramatic impulsivity and anger seen in the patient.
- The patient's fury and self-harm suggest a more volatile and emotionally dysregulated presentation than typically associated with dependency.
*Antisocial*
- Antisocial Personality Disorder involves a pervasive pattern of **disregard for and violation of the rights of others**, often involving deceitfulness, impulsivity, and lack of remorse. The patient's apology and regret for her actions are inconsistent with this diagnosis.
- There is no evidence of habitual law-breaking, exploitation of others, or a general callous disregard for others' feelings, which are core features of antisocial personality.
*Histrionic*
- Histrionic Personality Disorder is characterized by excessive **emotionality** and **attention-seeking behavior**, often through provocative actions (like dressing revealingly). However, the patient's severe self-harm, unstable relationships, intense abandonment fears, and rapid mood swings are more indicative of borderline personality.
- While the revealing dress might suggest some histrionic traits, the overarching presentation of chronic relationship instability, impulsivity, and self-mutilation points more strongly to Borderline Personality Disorder.
*Avoidant*
- Avoidant Personality Disorder involves extreme **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, leading to avoidance of social interactions despite a desire for intimacy.
- The patient's active pursuit of relationships, even if unstable, and her dramatic, impulsive behaviors are inconsistent with the core features of social avoidance and timidity seen in Avoidant Personality Disorder.
Borderline personality disorder US Medical PG Question 3: A 23-year-old woman is brought to the emergency department by her boyfriend 10 minutes after ingesting at least 15 acetaminophen tablets. She has been admitted to the hospital several times in the past few months after attempted self-harm. She claims that her boyfriend is “extremely selfish” and “does not care for her.” She says she feels lonely and wants her boyfriend to pay attention to her. Her boyfriend says that they have broken up 10 times in the past year because she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and can vary from states of “exuberance and affection” to states of “depression.” On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?
- A. Dependent personality disorder
- B. Borderline personality disorder (Correct Answer)
- C. Bipolar II disorder
- D. Cyclothymic disorder
- E. Narcissistic personality disorder
Borderline personality disorder Explanation: ***Borderline personality disorder***
- Patients with **borderline personality disorder** often exhibit a pattern of **unstable relationships**, impulsive behaviors (like self-harm attempts), intense mood swings lasting hours, and efforts to avoid abandonment, consistent with this patient's presentation.
- The patient's description of her boyfriend, her history of self-harm attempts, and her rapid, fluctuating mood states ("exuberance and affection" to "depression") are characteristic features.
*Dependent personality disorder*
- This disorder is characterized by an excessive need to be cared for, leading to **submissive and clinging behavior**, and fears of separation. While she fears abandonment, the **mood swings** and **aggressiveness** point away from this diagnosis.
- Patients with dependent personality disorder rarely exhibit the **impulsive self-harm** and dramatic, aggressive outbursts described.
*Bipolar II disorder*
- Bipolar II disorder involves episodes of **hypomania** and **major depression**, with mood episodes typically lasting days to weeks, not just "a few hours" as described here.
- The prominent features of **unstable relationships**, impulsivity, and chronic feelings of emptiness are more characteristic of a personality disorder than bipolar II.
*Cyclothymic disorder*
- Cyclothymic disorder involves chronic, fluctuating moods with numerous periods of **hypomanic symptoms** and **depressive symptoms** over at least two years, but these symptoms are less severe and do not meet criteria for full hypomanic or major depressive episodes.
- While there are mood fluctuations, the **intensity**, **self-harm behavior**, and **interpersonal instability** observed are more typical of borderline personality disorder.
*Narcissistic personality disorder*
- Narcissistic personality disorder is characterized by a pervasive pattern of **grandiosity**, a need for admiration, and a lack of empathy.
- While the patient blames her boyfriend, her primary motivation appears to be a fear of abandonment and a desire for attention, rather than a sense of entitlement or inflated self-importance.
Borderline personality disorder US Medical PG Question 4: A 20-year-old man comes to the physician because of decreasing academic performance at his college for the past 6 months. He reports a persistent fear of “catching germs” from his fellow students and of contracting a deadly disease. He finds it increasingly difficult to attend classes. He avoids handshakes and close contact with other people. He states that when he tries to think of something else, the fears “keep returning” and that he has to wash himself for at least an hour when he returns home after going outside. Afterwards he cleans the shower and has to apply disinfectant to his body and to the bathroom. He does not drink alcohol. He used to smoke cannabis but stopped one year ago. His vital signs are within normal limits. He appears anxious. On mental status examination, he is oriented to person, place, and time. In addition to starting an SSRI, which of the following is the most appropriate next step in management?
- A. Cognitive-behavioral therapy (Correct Answer)
- B. Psychodynamic psychotherapy
- C. Motivational interviewing
- D. Interpersonal therapy
- E. Group therapy
Borderline personality disorder Explanation: **Cognitive-behavioral therapy**
- **Cognitive-behavioral therapy (CBT)**, specifically **Exposure and Response Prevention (ERP)**, is the most effective psychotherapy for **obsessive-compulsive disorder (OCD)**, which this patient's symptoms strongly suggest.
- CBT helps patients challenge distorted thoughts and gradually expose themselves to feared situations while preventing compulsive rituals, thus breaking the cycle of obsessions and compulsions.
*Psychodynamic psychotherapy*
- This therapy focuses on **unconscious conflicts** and **past experiences** to understand current symptoms.
- While it can be helpful for some mental health conditions, it is generally **less effective** than CBT for the specific, highly ritualized symptoms of OCD.
*Motivational interviewing*
- **Motivational interviewing** is a patient-centered counseling style designed to address **ambivalence about change** and enhance intrinsic motivation.
- It is often used in substance abuse or lifestyle changes, but it does not directly teach coping skills for OCD symptoms or address the underlying thought patterns.
*Interpersonal therapy*
- **Interpersonal therapy (IPT)** focuses on the patient's **current interpersonal relationships** and social functioning.
- While social difficulties can arise from OCD, IPT does not directly target the obsessions and compulsions that are central to the disorder.
*Group therapy*
- **Group therapy** can provide support and a sense of community, but for a severe condition like OCD, **individual therapy** (especially CBT/ERP) is typically recommended first due to the highly individualized nature of obsessions and compulsions.
- It may be a complementary approach, but usually not the most appropriate initial next step given the intensity of the patient's symptoms.
Borderline personality disorder US Medical PG Question 5: A 25-year-old woman is brought to the emergency department by her boyfriend after she cut her forearms with a knife. She has had multiple visits to the emergency department in the past few months for self-inflicted wounds. She claims that her boyfriend is the worst person in the world. She and her boyfriend have broken up 20 times in the past 6 months. She says she cut herself not because she wants to kill herself; she feels alone and empty and wants her boyfriend to take care of her. Her boyfriend claims that she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and vary from states of exuberance and self-confidence to states of self-doubt and melancholy. On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?
- A. Dependent personality disorder
- B. Borderline personality disorder (Correct Answer)
- C. Bipolar II disorder
- D. Cyclothymic disorder
- E. Histrionic personality disorder
Borderline personality disorder Explanation: ***Borderline personality disorder***
- This patient exhibits characteristic features of **borderline personality disorder**, including **impulsivity** (self-harm), **unstable relationships** (frequent breakups, idealization/devaluation of boyfriend), **affective instability** (rapid mood swings lasting hours), and feelings of **emptiness** and **abandonment**.
- **Self-harm** in BPD is often a coping mechanism for intense emotional pain or a way to elicit care, rather than a genuine suicide attempt, as stated by the patient.
*Dependent personality disorder*
- Characterized by an **excessive need to be cared for**, leading to submissive and clinging behavior and fears of separation, which is not the primary presentation here.
- While there is a desire for care, the prominent features of **impulsivity**, **affective instability**, and **unstable relationships** are not typical of dependent personality disorder.
*Bipolar II disorder*
- Involves episodes of **hypomania** and **major depression**, with mood swings typically lasting for at least **four days** (hypomania) or **two weeks** (major depression), much longer than the hours described here.
- The patient's presentation emphasizes **interpersonal instability** and **self-harm** more than episodic mood disturbances.
*Cyclothymic disorder*
- Involves **numerous periods of hypomanic symptoms** and numerous periods of **depressive symptoms** for at least two years, but these symptoms are less severe than full-blown hypomanic or major depressive episodes.
- The rapid mood shifts within hours and the intensity of **interpersonal dysfunction** and **self-harm** are more indicative of borderline personality disorder.
*Histrionic personality disorder*
- Characterized by **excessive emotionality** and **attention-seeking behavior**, often sexually provocative, and using physical appearance to draw attention.
- While emotionality is present, the **self-harm**, **emptiness**, and **rapid mood shifts** are not core features of histrionic personality disorder.
Borderline personality disorder US Medical PG Question 6: A 19-year-old man presents to the emergency room after a suicidal gesture following a fight with his new girlfriend. He tearfully tells you that she is “definitely the one," unlike his numerous previous girlfriends, who were "all mean and selfish” and with whom he frequently fought. During this fight, his current girlfriend suggested that they spend time apart, so he opened a window and threatened to jump unless she promised to never leave him. You gather that his other relationships have ended in similar ways. He endorses impulsive behaviors and describes his moods as “intense” and rapidly changing in response to people around him. He often feels “depressed” for one day and then elated the next. You notice several superficial cuts and scars on the patient’s arms and wrists, and he admits to cutting his wrists in order to “feel something other than my emptiness.” Which of the following is the most likely diagnosis for this patient?
- A. Bipolar I disorder
- B. Major depressive disorder
- C. Borderline personality disorder (Correct Answer)
- D. Bipolar II disorder
- E. Histrionic personality disorder
Borderline personality disorder Explanation: ***Borderline personality disorder***
- This patient exhibits characteristic features of **borderline personality disorder (BPD)**, including a pattern of **unstable relationships** marked by idealization ("definitely the one") and devaluation ("all mean and selfish").
- Other key features are **impulsivity** (suicidal gesture, cutting), **affective instability** ("intense" and rapidly changing moods), chronic feelings of **emptiness**, and a history of **self-harm** (superficial cuts and scars).
*Bipolar I disorder*
- While the patient describes rapidly changing and "intense" moods, the rapid shifts over days and reactivity to others are more characteristic of **mood lability** in BPD than distinct **manic or hypomanic episodes** lasting several days or longer, which define bipolar disorder.
- The suicidal gesture stemming from interpersonal conflict and fear of abandonment, combined with chronic self-harm, points strongly away from a primary mood disorder.
*Major depressive disorder*
- Although the patient reports feeling "depressed," the predominant features are not a persistent depressed mood or anhedonia but rather **unstable relationships**, **impulsivity**, and **affective dysregulation** beyond typical depressive symptoms.
- The "elated" periods described are also inconsistent with unipolar depression.
*Bipolar II disorder*
- This diagnosis requires a history of at least one **major depressive episode** and at least one **hypomanic episode**. While the patient describes mood shifts, they are described as "rapidly changing in response to people around him" and lasting for a day, which is more consistent with **affective instability** seen in BPD rather than sustained hypomanic episodes.
- The prominent features of self-harm and unstable relationships are not central to Bipolar II disorder.
*Histrionic personality disorder*
- Patients with **histrionic personality disorder** typically display excessive emotionality and attention-seeking behavior, often with a theatrical presentation.
- While there may be some overlap in attention-seeking aspects (suicidal gesture), the profound **instability of mood**, chronic **emptiness**, self-harm, and intense **fear of abandonment** are core to BPD and less characteristic of histrionic traits.
Borderline personality disorder US Medical PG Question 7: A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?
- A. Advanced paternal age
- B. Genetic predisposition (Correct Answer)
- C. Higher socioeconomic class
- D. Maternal obstetric complications
- E. Being married
Borderline personality disorder Explanation: ***Genetic predisposition***
- A strong **genetic predisposition** is a primary predisposing factor for bipolar disorder, as evidenced by a significantly higher concordance rate in monozygotic twins compared to dizygotic twins or the general population.
- The patient's presentation with **manic symptoms** (decreased need for sleep, euphoria, irritability, frenzied speech, flight of ideas, erratic behavior) following a history of a **major depressive episode** is highly suggestive of **bipolar I disorder**.
*Advanced paternal age*
- While advanced paternal age has been associated with an increased risk of some neurodevelopmental disorders like **schizophrenia** and **autism spectrum disorder**, its link to bipolar disorder is less robust and not considered the strongest predisposing factor.
- The primary risk factor for bipolar disorder involves heritability rather than specific parental age.
*Higher socioeconomic class*
- There is **no consistent evidence** to suggest that higher socioeconomic class is a predisposing factor for bipolar disorder.
- Bipolar disorder affects individuals across all socioeconomic levels.
*Maternal obstetric complications*
- Maternal obstetric complications, such as **prenatal infections** or **hypoxia**, have been implicated in the development of certain psychiatric disorders, particularly **schizophrenia**.
- However, for bipolar disorder, genetic factors play a far more significant and direct role than obstetric complications.
*Being married*
- **Marital status** does not serve as a predisposing factor for the development of bipolar disorder.
- While relationship challenges can be a consequence or stressor for individuals with bipolar disorder, marriage itself is not a cause.
Borderline personality disorder US Medical PG Question 8: A 38-year-old woman comes to the physician for a follow-up visit. She has a 2-year history of depressed mood and fatigue accompanied by early morning awakening. One week ago, she started feeling a decrease in her need for sleep and now feels rested after about 5 hours of sleep per night. She had two similar episodes that occurred 6 months ago and a year ago, respectively. She reports increased energy and libido. She has a 4-kg (8.8-lb) weight loss over the past month. She does not feel the need to eat and says she derives her energy ""from the universe"". She enjoys her work as a librarian. She started taking fluoxetine 3 months ago. On mental exam, she is alert and oriented to time and place; she is irritable. She does not have auditory or visual hallucinations. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
- A. Delusional disorder
- B. Cyclothymic disorder
- C. Schizoaffective disorder
- D. Bipolar II disorder (Correct Answer)
- E. Medication-induced bipolar disorder
Borderline personality disorder Explanation: ***Bipolar II disorder***
- The patient meets criteria for **Bipolar II disorder**: at least one **hypomanic episode** (current presentation) and at least one **major depressive episode** (2-year history with recurrent episodes).
- Current hypomanic features include: **decreased need for sleep** (feels rested after 5 hours), **increased energy and libido**, **significant weight loss** (4 kg in one month), **irritability**, and grandiose thinking ("derives energy from the universe").
- She has had **recurrent depressive episodes** over 2 years (episodes 1 year ago and 6 months ago), fulfilling the major depressive episode requirement.
- While the hypomania emerged after starting **fluoxetine**, antidepressants commonly **unmask underlying bipolar disorder** rather than cause a separate medication-induced condition. The diagnosis remains **Bipolar II disorder** per DSM-5-TR when there is evidence of an underlying mood disorder pattern.
*Medication-induced bipolar disorder*
- Substance/medication-induced bipolar disorder requires that symptoms occur **exclusively during substance use** without evidence of an independent bipolar disorder.
- This patient's **recurrent pattern** of mood episodes (multiple depressive episodes over 2 years) suggests an **underlying bipolar disorder** that was unmasked by antidepressant treatment, not a purely medication-induced condition.
- The temporal relationship with fluoxetine is significant but represents **antidepressant-induced switching** in bipolar disorder, not a separate diagnostic entity.
*Delusional disorder*
- Requires **non-bizarre delusions** persisting for at least one month as the predominant feature, without prominent mood symptoms.
- This patient's primary presentation is a **mood episode** (hypomania) with the "universe" comment being part of her elevated/expansive mood rather than a fixed, systematized delusion.
- Functioning remains relatively intact (still enjoys her work).
*Cyclothymic disorder*
- Involves numerous periods of **hypomanic and depressive symptoms** for at least 2 years, but symptoms never meet full criteria for hypomanic or major depressive episodes.
- This patient has **full hypomanic and major depressive episodes**, making Bipolar II disorder the more appropriate diagnosis.
- The severity of her current symptoms (significant sleep reduction, 4-kg weight loss, marked functional changes) exceeds cyclothymic disorder.
*Schizoaffective disorder*
- Requires a **major mood episode** concurrent with **criterion A symptoms of schizophrenia** (delusions, hallucinations) for at least 2 weeks, plus psychotic symptoms without mood symptoms for at least 2 weeks.
- This patient has **no hallucinations** and no clear psychotic symptoms independent of her mood state.
- Her elevated mood fully accounts for her presentation.
Borderline personality disorder US Medical PG Question 9: A 33-year-old man with documented antisocial personality disorder and substance use disorder is convicted of assault. The defense attorney requests psychiatric testimony that the defendant's personality disorder diminished his capacity to conform his conduct to the law. His history includes multiple prior convictions, repeated lying, failure to sustain employment, lack of remorse, and disregard for others' safety. However, he understood the wrongfulness of his actions and planned the assault in advance. Evaluate the relationship between antisocial personality disorder and criminal responsibility.
- A. Chronic pattern of behavior demonstrates inability to conform conduct to law
- B. Combination of personality disorder and substance use negates criminal responsibility
- C. Comorbid substance use disorder supports insanity defense
- D. Antisocial personality disorder does not meet criteria for insanity defense as patients retain capacity to understand wrongfulness (Correct Answer)
- E. Personality disorders qualify for diminished capacity due to impaired impulse control
Borderline personality disorder Explanation: ***Antisocial personality disorder does not meet criteria for insanity defense as patients retain capacity to understand wrongfulness***
- In forensic psychiatry, individuals with **antisocial personality disorder** are generally considered criminally responsible because they retain the **cognitive capacity** to distinguish right from wrong.
- The legal system distinguishes between a "cannot conform" (e.g., severe psychosis) and a "will not conform" (personality disorder); since the defendant **planned the assault**, he demonstrated **volitional control**.
*Chronic pattern of behavior demonstrates inability to conform conduct to law*
- A history of repeated legal infractions reflects a **choice to disregard social norms** rather than an organic or psychotic inability to process reality.
- Under most legal standards, inclusive of the **M'Naghten Rule**, a repetitive criminal history does not constitute the "mental disease or defect" required for an **insanity defense**.
*Combination of personality disorder and substance use negates criminal responsibility*
- Combined pathology does not equate to a loss of **mens rea** (guilty mind); substance use is often viewed as **voluntary intoxication**, which rarely excuses criminal acts.
- The presence of these disorders does not inherently impair the defendant's **rational understanding** of the wrongfulness of the specific criminal act.
*Comorbid substance use disorder supports insanity defense*
- **Substance use disorders** are specifically excluded from the definition of "mental disease or defect" in the context of the **insanity defense** in many jurisdictions.
- To qualify for insanity, a condition must typically involve a disconnection from reality, whereas substance use is considered a **behavioral choice** with known legal risks.
*Personality disorders qualify for diminished capacity due to impaired impulse control*
- **Diminished capacity** is a specific legal defense that usually requires a severe mental impairment that prevents the formation of **specific intent**, which is not seen here as the defendant **planned the assault**.
- While patients with personality disorders exhibit **impulsivity**, they still possess the foundational **legal sanity** required to be held responsible for premeditated actions.
Borderline personality disorder US Medical PG Question 10: A 26-year-old woman presents requesting cosmetic surgery consultation. She is preoccupied with achieving the 'perfect' appearance, has undergone multiple procedures, and expresses disappointment with each result. She describes herself as special and destined for greatness, becomes enraged when her primary care physician suggested psychiatric evaluation, and states she will report him for 'not understanding her needs.' She expects special treatment in the clinic and becomes irritated when kept waiting. On mental status exam, she shows intact reality testing. Analyze the most likely underlying personality structure.
- A. Histrionic personality disorder with attention-seeking behavior
- B. Obsessive-compulsive personality disorder with perfectionism
- C. Borderline personality disorder with identity disturbance
- D. Narcissistic personality disorder with difficulty tolerating narcissistic injury (Correct Answer)
- E. Body dysmorphic disorder with poor insight
Borderline personality disorder Explanation: ***Narcissistic personality disorder with difficulty tolerating narcissistic injury***
- The patient exhibits core features of **Narcissistic Personality Disorder (NPD)**, including a **grandiose sense of self-importance**, beliefs of being "special," and an extreme **sense of entitlement** regarding special treatment in the clinic.
- Her enraged reaction to the suggestion of a psychiatric evaluation is a classic example of **narcissistic rage**, which occurs after a **narcissistic injury** (a threat to one's inflated self-image or perceived perfection).
*Histrionic personality disorder with attention-seeking behavior*
- While both can involve vanity, histrionic patients are typically **emotionally labile** and seek any kind of attention, rather than specifically requiring **admiration and status**.
- This patient's **grandiosity** and entitlement differ from the **theatricality** and shallow emotional expression characteristic of histrionic behavior.
*Obsessive-compulsive personality disorder with perfectionism*
- Perfectionism in OCPD is driven by **rigidity**, a need for **control**, and preoccupation with rules rather than a desire for a "perfect" grandiose physical appearance.
- Unlike this patient, individuals with OCPD are typically **ego-syntonic regarding their work ethic** but lack the **arrogance** and self-aggrandizement seen here.
*Borderline personality disorder with identity disturbance*
- Borderline patients primarily experience **affective instability**, **fear of abandonment**, and chronic feelings of emptiness, which are not described in this scenario.
- While both can involve rage, borderline rage is usually triggered by **rejection or loss**, whereas this patient's rage stems from a blow to her **ego and superiority**.
*Body dysmorphic disorder with poor insight*
- Although she is preoccupied with her appearance, the pervasive pattern of **grandiosity**, **lack of empathy**, and **entitlement** suggests a personality structure rather than an isolated body image disorder.
- Patients with **Body Dysmorphic Disorder (BDD)** usually present with shame or distress over specific "defects" rather than a belief that they are **"destined for greatness."**
More Borderline personality disorder US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
