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?

Selective serotonin reuptake inhibitor; anorgasmia, insomnia

Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts

Tricyclic antidepressants; hypomania, suicidal thoughts

Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain

Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects

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?

Histrionic personality disorder

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?

Histrionic personality disorder

A 38-year-old woman presents to her primary care physician for complaints of insomnia. She states that for the last 8 months, she has had difficulty falling asleep. Additionally, she awakens in the middle of the night or early morning and cannot fall back to sleep. When further questioned, she reports decreased appetite with a 12-lb. weight loss in the last 6 months. She was recently demoted at her work as a baker due to trouble focusing and coordinating orders and excess fatigue. She feels she is to blame for her family's current financial status given her demotion. She is given a prescription for fluoxetine at this visit with follow-up 2 weeks later. At the follow-up visit, she reports no improvement in her symptoms despite taking her medication consistently. What is the most appropriate next step in management?

Increase dose of current medication

Long-term management strategies for USMLE Step 2 CK: High-Yield Psychiatry Lessons

General Principles - The Long Haul

Psychotherapy is the cornerstone of management for all personality disorders (PDs).
- Focus on building a strong, stable therapeutic alliance.
- Set realistic, long-term goals; aim for management, not cure.
Pharmacotherapy is adjunctive; it does not treat the PD itself but can manage specific symptoms or comorbid conditions:
- SSRIs for depression, anxiety, or impulsivity.
- Antipsychotics for psychotic features or severe agitation.
- Mood stabilizers (e.g., valproate, lamotrigine) for affective instability.
Consistency in care and clear boundaries are crucial to prevent splitting and manipulation.

⭐ Dialectical Behavioral Therapy (DBT) is the first-line and most effective treatment for Borderline Personality Disorder, demonstrably reducing self-harm and hospitalizations.

Psychotherapy - The Therapy Toolkit

Cluster B (Borderline PD): Cornerstone of treatment; multiple evidence-based modalities exist.
- Dialectical Behavior Therapy (DBT): Gold standard. Integrates cognitive-behavioral techniques with mindfulness. Focuses on four key skill modules:
  - Mindfulness: For non-judgmental awareness.
  - Distress Tolerance: To manage crises without impulsivity.
  - Emotion Regulation: To control intense, labile moods.
  - Interpersonal Effectiveness: For healthier relationship skills.
- Other modalities: Mentalization-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), and Schema-Focused Therapy (SFT).
Cluster A & C Disorders:
- Supportive Psychotherapy: Often the primary approach. Aims to build trust, improve social skills, and enhance adaptive coping.
- Psychodynamic Psychotherapy: Explores unconscious conflicts, especially for avoidant or obsessive-compulsive traits.

⭐ DBT Core Principle: The central dialectic in DBT is the synthesis of acceptance (validation) and change (problem-solving), which is crucial for patients who feel chronically invalidated.

Pharmacotherapy - Symptom Tamers

No FDA-approved medications for personality disorders; used off-label for specific symptom domains.
Affective Dysregulation & Impulsivity (BPD):
- SSRIs (e.g., Fluoxetine) are often first-line for mood & anxiety.
- Mood stabilizers (e.g., Lamotrigine, Topiramate) can ↓ impulsivity and mood lability.
- Second-Gen Antipsychotics (SGAs) (e.g., Aripiprazole, Olanzapine) in low doses.
Cognitive-Perceptual Symptoms (Cluster A/B):
- Low-dose antipsychotics (e.g., Risperidone) for paranoia or magical thinking.
Anxiety (Avoidant PD):
- SSRIs are preferred; use benzodiazepines with extreme caution due to dependence/abuse risk.

⭐ High-Yield: For Borderline Personality Disorder (BPD), polypharmacy is a significant risk. The best evidence supports using specific agents for targeted symptoms (e.g., SGAs for anger/transient psychosis) rather than treating the entire disorder with one drug.

High-Yield Points - ⚡ Biggest Takeaways

Psychotherapy is the cornerstone of management for all personality disorders; pharmacotherapy is adjunctive.

Dialectical Behavior Therapy (DBT) is the first-line treatment for Borderline Personality Disorder, specifically targeting self-harm and emotional dysregulation.

Medications treat symptom clusters (e.g., mood lability, impulsivity, psychosis), not the underlying disorder.

SSRIs are often used for impulsivity and affective instability.

Second-generation antipsychotics can manage transient psychosis or severe agitation.

Establishing firm boundaries and maintaining a consistent therapeutic framework is critical for success.

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Long-term management strategies