Pharmacotherapy role in personality disorders US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Pharmacotherapy role in personality disorders. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Pharmacotherapy role in personality disorders US Medical PG Question 1: A 35-year-old man is brought to the emergency department by his wife. She was called by his coworkers to come and pick him up from work after he barged into the company’s board meeting and was being very disruptive as he ranted on about all the great ideas he had for the company. When they tried to reason with him, he became hostile and insisted that he should be the CEO as he knew what was best for the future of the company. The patient’s wife also noted that her husband has been up all night for the past few days but assumed that he was handling a big project at work. The patient has no significant past medical or psychiatric history. Which of the following treatments is most likely to benefit this patient’s condition?
- A. Antidepressants
- B. Valproic acid (Correct Answer)
- C. Haloperidol
- D. Psychotherapy
- E. Clozapine
Pharmacotherapy role in personality disorders Explanation: ***Valproic acid***
- This patient presents with symptoms highly suggestive of a **manic episode**, including grandiosity (believing he should be CEO), decreased need for sleep (up all night for days), pressured speech (ranting), and impulsivity with poor judgment (disruptive behavior at a board meeting).
- **Valproic acid** is a **first-line, guideline-recommended mood stabilizer** for acute mania. It is particularly effective for managing the core symptoms of mania including mood elevation, irritability, and impulsivity.
- It has a relatively rapid onset of action and a favorable side effect profile compared to typical antipsychotics, making it an excellent choice for initial management of acute mania in the emergency setting.
*Antidepressants*
- Administering **antidepressants** during a manic or hypomanic episode can exacerbate symptoms, potentially leading to a rapid cycling pattern or worsening mania.
- Antidepressants are primarily used for depressive episodes in bipolar disorder, typically in conjunction with a mood stabilizer, never as monotherapy in a patient presenting with mania.
*Haloperidol*
- **Haloperidol** is a typical antipsychotic that can be used for acute agitation in mania, but it does not address the underlying mood dysregulation.
- While it may help with immediate behavioral control, mood stabilizers like valproic acid or lithium are preferred as primary treatments because they target the core pathophysiology of bipolar disorder.
- Haloperidol also has a higher risk of extrapyramidal symptoms and does not prevent future mood episodes.
*Psychotherapy*
- **Psychotherapy** is a crucial component of long-term management for bipolar disorder but is not effective as a sole treatment for acute mania.
- Patients in acute mania are often too agitated, impulsive, and lack sufficient insight to meaningfully engage in therapeutic interventions.
- Psychotherapy should be initiated after mood stabilization with pharmacotherapy.
*Clozapine*
- **Clozapine** is an atypical antipsychotic reserved for treatment-resistant schizophrenia or treatment-resistant bipolar disorder, particularly with prominent psychotic features that have not responded to multiple other medications.
- Given its significant side effect profile, including agranulocytosis requiring regular blood monitoring, it is not a first-line or even second-line treatment for an initial presentation of mania.
- This patient has no psychiatric history and requires standard first-line treatment, not a medication reserved for refractory cases.
Pharmacotherapy role in personality disorders US Medical PG Question 2: A 45-year-old man is brought to the physician by his wife for the evaluation of abnormal sleep patterns that began 10 days ago. She reports that he has only been sleeping 2–3 hours nightly during this time and has been jogging for long periods of the night on the treadmill. The patient has also been excessively talkative and has missed work on several occasions to write emails to his friends and relatives to convince them to invest in a new business idea that he has had. He has chronic kidney disease requiring hemodialysis, but he has refused to take his medications because he believes that he is cured. Eight months ago, he had a 3-week long period of persistent sadness and was diagnosed with major depressive disorder. Mental status examination shows psychomotor agitation and pressured speech. Treatment of this patient's condition should include which of the following drugs?
- A. Triazolam
- B. Valproate (Correct Answer)
- C. Mirtazapine
- D. Fluoxetine
- E. Bupropion
Pharmacotherapy role in personality disorders Explanation: ***Valproate***
- This patient presents with classic features of a **manic episode** (decreased need for sleep, psychomotor agitation, pressured speech, grandiosity, increased goal-directed activity, impaired judgment) occurring after a prior depressive episode, indicating **bipolar I disorder**.
- **Mood stabilizers** are first-line treatment for acute mania. While **lithium** is traditionally considered the gold standard, this patient has **chronic kidney disease requiring hemodialysis**, making lithium relatively **contraindicated** due to its renal excretion and narrow therapeutic index.
- **Valproate** is an excellent alternative mood stabilizer for acute mania and maintenance therapy in bipolar disorder, and it is **hepatically metabolized**, making it safer in patients with **renal impairment**.
- Other options include atypical antipsychotics (e.g., olanzapine, quetiapine, aripiprazole), but valproate is the appropriate mood stabilizer choice given this clinical context.
*Triazolam*
- **Triazolam** is a short-acting benzodiazepine used for **insomnia**.
- While it may provide symptomatic relief for sleep disturbance, it does **not treat the underlying manic episode** and is not indicated as primary therapy for bipolar mania.
- Benzodiazepines may be used as adjunctive agents for acute agitation but are not definitive treatment.
*Mirtazapine*
- **Mirtazapine** is a tetracyclic antidepressant used for **major depressive disorder**.
- Antidepressant monotherapy in bipolar disorder can **precipitate or worsen manic episodes** and is contraindicated during an acute manic phase.
- If antidepressants are needed for bipolar depression, they should be combined with mood stabilizers.
*Fluoxetine*
- **Fluoxetine** is a selective serotonin reuptake inhibitor (SSRI) antidepressant.
- Like other antidepressants, using fluoxetine as monotherapy in a patient with bipolar disorder can **induce or exacerbate manic episodes**.
- It is inappropriate for treating acute mania.
*Bupropion*
- **Bupropion** is an atypical antidepressant (norepinephrine-dopamine reuptake inhibitor) used for depression and smoking cessation.
- It carries a **higher risk of inducing mania** compared to other antidepressants due to its dopaminergic activity.
- It is not appropriate for acute mania treatment and could worsen the patient's current symptoms.
Pharmacotherapy role in personality disorders US Medical PG Question 3: A 25-year-old woman presents to her college campus clinic with the complaint of being unable to get up for her morning classes. She says that, because of this, her grades are being affected. For the past 6 weeks, she says she has been feeling depressed because her boyfriend dumped her. She finds herself very sleepy, sleeping in most mornings, eating more snacks and fast foods, and feeling drained of energy. She is comforted by her friend’s efforts to cheer her up but still feels guarded around any other boy that shows interest in her. The patient says she had similar symptoms 7 years ago for which she was prescribed several selective serotonin reuptake inhibitors (SSRIs) and a tricyclic antidepressant (TCA). However, none of the medications provided any long-term relief. She has prescribed a trial of Phenelzine to treat her symptoms. Past medical history is significant for a long-standing seizure disorder well managed with phenytoin. Which of the following statements would most likely be relevant to this patient’s new medication?
- A. “This medication is known to cause anorgasmia during treatment.”
- B. “You will have a risk for cardiotoxicity from this medication.”
- C. “A common side effect of this medication is sedation.”
- D. “While taking this medication, you should avoid drinking red wine.” (Correct Answer)
- E. “While on this medication, you may have a decreased seizure threshold.”
Pharmacotherapy role in personality disorders Explanation: ***"While taking this medication, you should avoid drinking red wine."***
- Phenelzine is a **monoamine oxidase inhibitor (MAOI)**. MAOIs inhibit the breakdown of **tyramine**, an amine found in fermented foods like red wine, aged cheeses, cured meats, and pickled foods.
- Consuming tyramine-rich foods with an MAOI can lead to a **hypertensive crisis**, characterized by a sudden, severe increase in blood pressure which can cause headaches, palpitations, and potentially stroke.
- This dietary counseling is **essential and immediately actionable** patient education when starting an MAOI.
*"This medication is known to cause anorgasmia during treatment."*
- While sexual dysfunction can occur with many antidepressants, **anorgasmia** is much more common and severe with **SSRIs (Selective Serotonin Reuptake Inhibitors)** than with MAOIs.
- MAOIs like phenelzine have a different mechanism of action and generally have a lower incidence of sexual side effects compared to SSRIs.
*"You will have a risk for cardiotoxicity from this medication."*
- **Cardiotoxicity** is a significant concern with **tricyclic antidepressants (TCAs)**, especially in overdose, due to their effects on cardiac sodium channels and potential for arrhythmias.
- While MAOIs can cause **orthostatic hypotension**, direct cardiotoxicity is not a primary concern with phenelzine.
*"A common side effect of this medication is sedation."*
- Phenelzine is generally considered **activating** rather than sedating, and can sometimes lead to insomnia or agitation.
- The patient's current hypersomnia is a symptom of her **atypical depression**, not a predicted side effect of phenelzine. In fact, phenelzine may help improve this symptom.
*"While on this medication, you may have a decreased seizure threshold."*
- This statement is actually **medically accurate** - MAOIs including phenelzine can lower (decrease) the seizure threshold, meaning they increase seizure risk.
- This is relevant given the patient's seizure disorder managed with phenytoin and warrants monitoring.
- However, the **dietary tyramine restriction** is the more critical and immediately actionable counseling point when initiating MAOI therapy, as hypertensive crisis can occur with the very first exposure to tyramine-rich foods.
Pharmacotherapy role in personality disorders US Medical PG Question 4: A 24-year-old male comes into the psychiatric clinic complaining of consistent sadness. He endorses feelings of worthlessness, anxiety, and anhedonia for the past couple months but denies feeling suicidal. He further denies any past episodes of feeling overly energetic with racing thoughts. Confident of the diagnosis, you recommend frequent talk therapy along with a long-term prescription of a known first-line medication for this disorder. What is the drug and what are some of the most frequently encountered side effects?
- A. Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts
- B. Tricyclic antidepressants; hypomania, suicidal thoughts
- C. Selective serotonin reuptake inhibitor; anorgasmia, insomnia (Correct Answer)
- D. Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain
- E. Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects
Pharmacotherapy role in personality disorders Explanation: ***Selective serotonin reuptake inhibitor; anorgasmia, insomnia***
- The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, worthlessness, anxiety, and anhedonia, without any history of manic or hypomanic episodes. **SSRIs** are considered first-line pharmacotherapy for this condition.
- Common side effects of SSRIs include **sexual dysfunction** (e.g., anorgasmia, decreased libido) and **insomnia** or agitation, especially during the initial weeks of treatment.
*Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts*
- While SSRIs are the correct drug class, **hypomania** is not a frequent side effect in patients without bipolar disorder. For patients with bipolar disorder, antidepressant monotherapy can induce hypomania or mania, but this patient denies such episodes.
- **Suicidal thoughts** can occur, particularly in young adults, during the initial phase of antidepressant treatment, but it is less common to frame it as a *frequently encountered side effect* in the general population compared to sexual dysfunction or sleep disturbances.
*Tricyclic antidepressants; hypomania, suicidal thoughts*
- **Tricyclic antidepressants (TCAs)** are generally not first-line due to their less favorable side effect profile compared to SSRIs, including significant anticholinergic effects and cardiovascular risks.
- As with SSRIs, **hypomania** is not a typical frequent side effect in unipolar depression, and while **suicidal thoughts** are a concern with antidepressants, TCAs carry a higher risk of lethality in overdose, making them less preferred initially.
*Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain*
- **Monoamine oxidase inhibitors (MAOIs)** are effective but are typically reserved for **refractory depression** due to their significant drug and food interactions (e.g., tyramine-induced hypertensive crisis).
- While **orthostatic hypotension** and **weight gain** are known side effects of MAOIs, this class is not considered a first-line treatment for major depressive disorder.
*Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects*
- **TCAs** are indeed associated with side effects such as **orthostatic hypotension** and prominent **anticholinergic effects** (e.g., dry mouth, constipation, blurred vision, urinary retention).
- However, because of these more burdensome side effects and higher toxicity in overdose, TCAs are not generally considered the first-line medication choice, especially when SSRIs are available and safer.
Pharmacotherapy role in personality disorders US Medical PG Question 5: 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
Pharmacotherapy role in personality disorders 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.
Pharmacotherapy role in personality disorders US Medical PG Question 6: A 28-year-old woman is brought to a counselor by her father after he found out that she is being physically abused by her husband. The father reports that she refuses to end the relationship with her husband despite the physical abuse. She says that she feels uneasy when her husband is not around. She adds, “I'm worried that if I leave him, my life will only get worse.” She has never been employed since they got married because she is convinced that nobody would hire her. Her husband takes care of most household errands and pays all of the bills. Physical examination shows several bruises on the thighs and back. Which of the following is the most likely diagnosis?
- A. Schizoid personality disorder
- B. Separation anxiety disorder
- C. Avoidant personality disorder
- D. Dependent personality disorder (Correct Answer)
- E. Borderline personality disorder
Pharmacotherapy role in personality disorders Explanation: ***Dependent personality disorder***
- This patient exhibits a pervasive and excessive need to be taken care of, leading to **submissive and clinging behavior, and fears of separation**. Key features include difficulties making decisions, avoiding disagreement due to fear of loss of support, and preoccupation with fears of being left to care for herself.
- Her comments about her life getting worse if she leaves her husband, her inability to seek employment, and her husband managing all household affairs are consistent with her **reluctance to leave an abusive relationship** because of an exaggerated fear of being alone or unable to care for herself.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- Individuals with this disorder typically show **little interest in forming close relationships**, in contrast to the patient's clinging behavior.
*Separation anxiety disorder*
- Primarily marked by **excessive anxiety concerning separation from home or from those to whom the individual is attached**, often seen in childhood, but can occur in adults.
- While there is some anxiety about separation, the patient's broader pattern of submissive behavior, difficulty with independent functioning, and belief she cannot care for herself points more strongly to a **personality disorder** rather than an anxiety disorder focused solely on separation.
*Avoidant personality disorder*
- Involves extreme social inhibition, feelings of inadequacy, and **hypersensitivity to negative evaluation**.
- These individuals **desire social connection but avoid it due to fear of rejection**, which contrasts with the patient's clinging and submissive efforts to maintain a relationship.
*Borderline personality disorder*
- Characterized by significant **instability in moods, interpersonal relationships, self-image, and behaviors**.
- While there can be fear of abandonment, this disorder typically involves **impulsivity, intense anger, and frantic efforts to avoid abandonment**, which are not the primary features described in this patient.
Pharmacotherapy role in personality disorders US Medical PG Question 7: 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
Pharmacotherapy role in personality disorders 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.
Pharmacotherapy role in personality disorders US Medical PG Question 8: A 40-year-old man is brought to the emergency department by police officers due to inappropriate public behavior. He was at a pharmacy demanding to speak with the manager so he could discuss a business deal. Two weeks ago, he left his wife of 10 years and moved from another city in order to pursue his dreams of being an entrepreneur. He has not slept for more than 3-4 hours a night in the last 2 weeks. He has a history of bipolar disorder and diabetes. He has been hospitalized three times in the last year for mood instability. Current medications include lithium and insulin. Mental status examination shows accelerated speech with flight of ideas. His serum creatinine concentration is 2.5 mg/dL. Which of the following is the most appropriate next step in management with respect to his behavior?
- A. Lithium and olanzapine
- B. Valproic acid and quetiapine (Correct Answer)
- C. Carbamazepine only
- D. Clozapine only
- E. Lithium and valproic acid
Pharmacotherapy role in personality disorders Explanation: ***Valproic acid and quetiapine***
- This patient presents with symptoms of **acute mania**, including **grandiosity**, **decreased need for sleep**, accelerated speech, and flight of ideas, in the context of bipolar disorder. His **elevated serum creatinine (2.5 mg/dL) indicates significant renal impairment**, which necessitates **lithium discontinuation**.
- The renal impairment may be due to **lithium-induced nephrotoxicity** (a known complication of chronic lithium therapy), making continuation of lithium both ineffective and potentially dangerous.
- **Valproic acid** is an effective mood stabilizer for acute mania and can be safely used in patients with renal impairment (hepatically metabolized), while **quetiapine**, an atypical antipsychotic, targets the psychotic symptoms and helps with **agitation and sleep disturbances**.
- This combination provides both mood stabilization and rapid control of acute manic symptoms.
*Lithium and olanzapine*
- The patient's **serum creatinine of 2.5 mg/dL indicates significant renal impairment**, making lithium, which is renally cleared and can be nephrotoxic, **contraindicated**.
- Continuing lithium in the setting of renal dysfunction increases risk of **lithium toxicity** and further renal damage.
- While olanzapine is effective for acute mania, continuing lithium would be unsafe given the patient's kidney function.
*Carbamazepine only*
- **Carbamazepine** is an alternative mood stabilizer for bipolar disorder, but **monotherapy with carbamazepine is insufficient** for managing severe acute mania with psychotic features and significant agitation.
- This patient requires both a mood stabilizer and an antipsychotic for rapid stabilization.
- Additionally, carbamazepine requires monitoring for **hematologic and hepatic side effects**.
*Clozapine only*
- **Clozapine** is reserved for **treatment-resistant cases** of bipolar disorder or schizophrenia that have failed multiple other agents.
- It requires intensive monitoring for life-threatening side effects including **agranulocytosis** (weekly/biweekly CBC monitoring) and myocarditis.
- It is **not appropriate as a first-line agent** for acute manic stabilization in the emergency setting.
*Lithium and valproic acid*
- **Lithium is contraindicated** in this patient due to his **elevated serum creatinine (2.5 mg/dL)**, which indicates significant renal impairment.
- While valproic acid would be appropriate, combining it with lithium would pose serious safety risks given the renal dysfunction.
Pharmacotherapy role in personality disorders US Medical PG Question 9: A 25-year-old male medical student presents to student health with a chief complaint of picking at his skin. He states that at times he has urges to pick his skin that he struggles to suppress. Typically, he will participate in the act during finals or when he has "too many assignments to do." The patient states that he knows that his behavior is not helping his situation and is causing him harm; however, he has trouble stopping. He will often ruminate over all his responsibilities which make his symptoms even worse. The patient has a past medical history of surgical repair of his ACL two years ago. His current medications include melatonin. On physical exam you note a healthy young man with scars on his arms and face. His neurological exam is within normal limits. Which of the following is the best initial step in management?
- A. Fluoxetine (Correct Answer)
- B. Dialectical behavioral therapy
- C. Interpersonal psychotherapy
- D. Clomipramine
- E. Supportive psychotherapy
Pharmacotherapy role in personality disorders Explanation: ***Fluoxetine***
- This patient's symptoms are consistent with **excoriation (skin-picking) disorder**, characterized by recurrent skin picking resulting in lesions and significant distress or impairment, often triggered by stress.
- **First-line treatment** is typically **cognitive-behavioral therapy (CBT)** with habit reversal training; however, among the options provided, **selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine represent the most evidence-based pharmacological approach.
- **SSRIs** are considered when psychotherapy is unavailable or as adjunctive treatment for excoriation disorder and comorbid anxiety/OCD symptoms, though evidence is mixed.
- Fluoxetine is the best option listed for initial management in this clinical scenario.
*Dialectical behavioral therapy*
- **Dialectical behavioral therapy (DBT)** is primarily used for **borderline personality disorder** and chronic suicidality, focusing on emotion regulation and distress tolerance.
- While some of its techniques could be broadly helpful, it is not the primary or most effective treatment for excoriation disorder specifically.
- **CBT with habit reversal training** would be preferred over DBT for this condition.
*Interpersonal psychotherapy*
- **Interpersonal psychotherapy (IPT)** is an evidence-based treatment mainly for **depression** and some eating disorders, focusing on improving interpersonal relationships and social functioning.
- It does not directly target the compulsive behaviors or urge suppression central to excoriation disorder.
*Clomipramine*
- **Clomipramine**, a tricyclic antidepressant (TCA), is effective for **obsessive-compulsive disorder (OCD)**, but it has a less favorable side effect profile than SSRIs.
- Due to its side effects and lower tolerability, it is usually reserved for cases resistant to SSRIs, making it not the best initial pharmacologic step.
*Supportive psychotherapy*
- **Supportive psychotherapy** aims to alleviate symptoms, maintain self-esteem, and improve coping skills, offering a general supportive environment.
- While it can be helpful as an adjunct, it lacks the specific behavioral or pharmacological mechanisms needed for effective treatment of excoriation disorder.
Pharmacotherapy role in personality disorders US Medical PG Question 10: A 34-year-old female presents to a counselor at the urging of her parents because they are concerned that she might be depressed. After recently breaking up with her long-term boyfriend, she moved back in with her parents because she could not handle making decisions alone. Soon after their breakup, she started going on 5–7 dates a week. She has been unemployed for 3 years, as her boyfriend took care of all the bills. In the past year, she thought of looking for a job but never felt confident enough to start the process. Her mom arranges her doctor's appointments and handles her car maintenance. She describes feeling uneasy when she is alone. She has hypothyroidism treated with levothyroxine. She does not smoke or drink alcohol. Vital signs are normal. Mental status exam shows a neutral affect. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?
- A. Avoidant personality disorder
- B. Histrionic personality disorder
- C. Borderline personality disorder
- D. Separation anxiety disorder
- E. Dependent personality disorder (Correct Answer)
Pharmacotherapy role in personality disorders Explanation: ***Dependent personality disorder***
- The patient exhibits a pervasive and excessive need to be cared for, leading to **submissive and clinging behavior** and fears of separation, as evidenced by her inability to make decisions, reliance on parents, and discomfort when alone.
- Her history of unemployment and reliance on her boyfriend, followed by moving back with parents and having her mom handle appointments and car maintenance, strongly supports an inability to function independently and an excessive need for reassurance and support, characteristic of **dependent personality disorder**.
*Avoidant personality disorder*
- This disorder is characterized by a pervasive pattern of **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, which are not the primary features here.
- While she may lack confidence in looking for a job, her constant search for new relationships (5-7 dates a week) and reliance on others for decision-making point away from the **social avoidance** central to this diagnosis.
*Histrionic personality disorder*
- This disorder is marked by **excessive emotionality** and **attention-seeking behavior**, often through seductive or provocative means.
- Although she is actively dating, the core issue appears to be her need for care and support rather than a desire to be the center of attention or dramatize her emotions.
*Borderline personality disorder*
- Characterized by a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, such as **frantic efforts to avoid abandonment** or **recurrent suicidal behavior**.
- While she might fear abandonment (expressed as uneasiness when alone), the overall clinical picture lacks the impulsivity, mood swings, self-harm, or intense anger typically seen in borderline personality disorder.
*Separation anxiety disorder*
- This disorder typically manifests with excessive fear or anxiety concerning separation from attachment figures, often seen in childhood, but can occur in adults.
- While she expresses **uneasiness when alone**, the pervasive pattern of **submissive behavior**, difficulty making decisions, and chronic dependency on others for all aspects of life points more towards a personality disorder rather than an anxiety disorder primarily focused on separation.
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