Narcissistic 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.

Borderline personality disorder is a cluster B personality disorder defined by 5 or more of 9 DSM-5 criteria spanning instability of relationships, self-image, and affect, marked impulsivity, and recurrent self-injury or suicidality; dialectical behavior therapy is the first-line treatment, with pharmacotherapy reserved as a secondary, symptom-targeted adjunct.

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 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.

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.

Cocaine use disorder is a pattern of cocaine use causing significant impairment or distress, distinct from acute intoxication, diagnosed when a patient meets at least 2 of 11 DSM-5 substance use criteria within 12 months. Acute cocaine-associated chest pain is managed first with a benzodiazepine, then nitrates or a calcium channel blocker, while beta blockade is avoided because of concern for unopposed alpha stimulation; no medication is approved for the use disorder itself, so treatment rests on psychosocial care.

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.

Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.