Borderline personality disorder

Antisocial personality disorder is a pervasive, adult pattern of disregard for and violation of others' rights, with deceitfulness, impulsivity, and lack of remorse, diagnosable only at age 18 or older and only with documented conduct disorder before age 15. Management leads with consistent limit-setting; psychotherapy has limited proven benefit, and pharmacotherapy targets comorbid depression, impulsivity, or substance use disorder rather than the personality disorder itself.

Narcissistic personality disorder is a pervasive, ego-syntonic pattern of grandiosity, need for admiration, and lack of empathy that masks a fragile self-esteem intolerant of criticism, usually present by early adulthood. Diagnosis is clinical, requiring at least 5 of 9 characteristic traits causing functional or relationship impairment; first-line management is psychotherapy that sets firm, consistent boundaries, with an antidepressant such as sertraline reserved for comorbid depressive or anxiety symptoms.

Personality disorders are enduring, pervasive, and inflexible patterns of inner experience and behavior across cognition, affect, interpersonal functioning, and impulse control that deviate markedly from cultural expectation, trace to adolescence or early adulthood, and are ego-syntonic. Diagnosis is clinical, applying a symptom-count threshold to place the patient in cluster A, B, or C. Management leads with cluster-specific psychotherapy, reserving medication for comorbid or target symptoms.

Bipolar II disorder requires at least one hypomanic episode (elevated or irritable mood for 4 or more consecutive days without marked impairment, psychosis, or hospitalization) plus at least one major depressive episode, and no lifetime history of a full manic episode; first-line treatment is lithium with careful avoidance of unopposed antidepressants.

Bipolar I disorder is a chronic mood disorder defined by at least one manic episode lasting a week or requiring hospitalization, with three or more DIG FAST symptoms causing marked impairment. Diagnosis is clinical after substances and medical mimics are excluded. Acute mania is treated with lithium or valproate, often with an atypical antipsychotic, and most patients need lifelong mood-stabilizer maintenance.

Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence, producing intrusive re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal that persist beyond 1 month with significant distress or impairment. First-line treatment is trauma-focused cognitive behavioral therapy combined with an SSRI or SNRI, with prazosin added for persistent nightmares.

Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.

Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.

Suicidal ideation ranges from passive thoughts of death to an active plan with intent and access to lethal means, and suicide accounts for about 45,000 deaths a year in the United States. Diagnosis is clinical, built on directly asking about intent, plan, and means. A patient with a plan, intent, and access requires emergent hospitalization, involuntary if needed; a patient without intent and with support can be managed as an outpatient with means restriction, close follow-up, and first-line SSRI antidepressant therapy for the driving disorder.