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Q1: Definition & classification (2 min)
Examiner: Define a personality disorder. How does DSM-5 classify them?
Model answer. A personality disorder is an enduring, inflexible, pervasive pattern of inner experience and behaviour that deviates markedly from cultural expectations, is stable and of long onset (traceable to adolescence or early adulthood), leads to distress or impairment, and is not better explained by another mental disorder, substance, or medical condition. DSM-5 requires the general criteria (enduring pattern in cognition, affectivity, interpersonal function, or impulse control; pervasive and inflexible; distress/impairment; stable since early adulthood; not better explained) and then classifies ten specific disorders into three clusters by phenotypic resemblance: Cluster A — odd/eccentric (paranoid, schizoid, schizotypal); Cluster B — dramatic/emotional/erratic (antisocial, borderline, histrionic, narcissistic); Cluster C — anxious/fearful (avoidant, dependent, OCPD). Mnemonic: A = Mad, B = Bad, C = Sad.
Examiner follow-up: How does ICD-11 differ?
Model answer. ICD-11 abandons most categorical PDs in favour of a dimensional severity rating (personality difficulty / mild / moderate / severe) plus five trait qualifiers (negative affectivity, detachment, dissociality, disinhibition, anankastia) and an optional borderline pattern qualifier. It encourages formulation by severity first, then trait profile — a major shift from the categorical DSM-5 model. The DSM-5 alternative model (AMPD, Section III) similarly uses a level-of-personality-functioning scale plus five trait domains (negative affectivity, detachment, antagonism, disinhibition, psychoticism).
Q2: BPD criteria & diagnosis (2 min)
Examiner: Give me the DSM-5 criteria for borderline personality disorder.
Model answer. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood, present in a variety of contexts, indicated by 5 (or more) of 9: (1) frantic efforts to avoid real or imagined abandonment; (2) a pattern of unstable and intense relationships characterised by alternating idealisation and devaluation; (3) identity disturbance / markedly unstable self-image; (4) impulsivity in at least two potentially self-damaging areas (excluding suicidal/self-mutilating behaviour); (5) recurrent suicidal behaviour, gestures, threats, or self-mutilation; (6) affective instability due to marked reactivity of mood — intense, episodic dysphoria, irritability, or anxiety lasting hours, rarely more than a few days; (7) chronic feelings of emptiness; (8) inappropriate, intense anger or difficulty controlling anger; (9) transient, stress-related paranoid ideation or severe dissociation. Mnemonic: I DESPAIR.
Examiner follow-up: How do you distinguish BPD from bipolar disorder?
Model answer. By tempo and trigger. BPD mood shifts are minutes-to-hours, reactive to interpersonal events (abandonment, rejection), with rapid return to baseline; bipolar episodes are days-to-weeks, spontaneous and sustained, with normal intervals. Bipolar has a strong family history and responds to mood stabilisers; BPD responds to structured psychotherapy (DBT, MBT). The two can coexist and must each be treated.
Q3: Management (3 min)
Examiner: How would you manage a 23-year-old woman with BPD who has just taken an overdose?
Model answer. Acute: treat the medical consequences first (paracetamol level at 4 h, N-acetylcysteine per nomogram if above the line; check INR, LFT, U&E, glucose, VBG). Safe environment, remove means, observe. Structured suicide-risk assessment (C-SSRS; ideation, plan, intent, means, protective factors). Psychiatric assessment before disposition; brief, planned admission or crisis-resolution/home-treatment team; avoid benzodiazepines (disinhibition, dependence, overdose); avoid reflexive discharge and prolonged admissions. Manage splitting with a single care coordinator and team consistency.
Definitive: DBT is first-line — weekly individual therapy + weekly group skills (four modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) + phone coaching + therapist team, for 12–18 months. Alternatives with comparable evidence: MBT, schema therapy, TFP, good psychiatric management. Medication is symptom-targeted only (NICE CG78: do not use drugs for core BPD features): SSRI for affective lability/impulsivity; mood stabiliser (lamotrigine; valproate contraindicated in women of childbearing potential) for affective instability; low-dose antipsychotic (olanzapine, aripiprazole) for transient psychosis/severe anger. Treat comorbid depression, substance use, eating disorders, PTSD in their own right.
Examiner follow-up: Why are benzodiazepines avoided in BPD?
Model answer. Three reasons: (1) disinhibition and paradoxical agitation, worsening impulsivity and aggression; (2) high dependence potential in a population prone to substance misuse; (3) lethality in overdose — patients with BPD have a high suicide rate, and benzodiazepines are dangerous in overdose, especially combined with alcohol.
Q4: ASPD & OCPD pearls (2 min)
Examiner: What is the single mandatory historical element for a diagnosis of antisocial personality disorder?
Model answer. Evidence of conduct disorder before age 15. ASPD requires 3 of 7 criteria (failure to conform to law, deceitfulness, impulsivity, irritability/aggression, reckless disregard for safety, irresponsibility, lack of remorse) since age 15, plus a documented conduct-disorder history before 15. Without the childhood element, ASPD cannot be diagnosed (one may record antisocial personality traits). ASPD is commoner in men, strongly comorbid with substance use, and traits often attenuate with age ('burnout' by the 40s). Treatment evidence is limited: address comorbid substance use, cognitive-behavioural programmes, contingency management; no drug treats core traits.
Examiner follow-up: OCPD vs OCD?
Model answer. OCPD is ego-syntonic — the patient sees their perfectionism, rigidity, and control as correct and others as the problem; no true obsessions or compulsions; presents with relationship/work conflict or secondary depression. OCD is ego-dystonic — the patient recognises obsessions/compulsions as unwanted and irrational and pleads for relief; responds to SSRI + exposure-response-prevention CBT. OCPD needs longer-term psychotherapy; the trait itself rarely motivates the patient to seek help.
Q5: Prognosis & pitfalls (1 min)
Examiner: What is the long-term prognosis of BPD?
Model answer. Far better than its reputation. The McLean Study of Adult Development (Zanarini et al.) prospectively followed 290 BPD inpatients: about 50 percent achieved at least a 2-month remission by 2 years and around 88 percent over 10 years, with recurrence after sustained remission under 10 percent. Symptomatic remission (cessation of self-harm and mood instability) outpaces functional recovery (employment, relationships, independent living), which is slower. Predictors of earlier remission: younger age, absence of childhood sexual abuse, higher agreeableness, absence of comorbid substance use. The strongest negative predictor is comorbid substance use. Suicide mortality is real — around 5–8 percent in modern cohorts, peaking early in the illness — but remission is the rule with engaged, structured treatment.
Examiner follow-up: What are the main iatrogenic pitfalls?
Model answer. Over-prescribing and polypharmacy; prolonged or repeated admissions reinforcing self-harm; benzodiazepines; misdiagnosis as bipolar delaying psychotherapy; therapeutic nihilism and stigma ('heartsink', 'manipulative') denying effective treatment; and clinician burnout from unmanaged countertransference — addressed by regular supervision and team meetings.