Several months ago one of the authors (C.J.K.) was invited to be a discussant at a clinical case conference in a prestigious university hospital. The patient was a 19-year-old woman who had been hospitalized for 4 months following an acute psychotic episode. She had been found during final examinations confused and disoriented, delusional, and possibly hallucinating. There was a 2 year history of marijuana and alcohol abuse, difficulty in concentrating in school, and sexual promiscuity. Carol was considered to have an acute schizophreniform psychosis, and neuroleptics were started without much change in clinical state. After several months during which she continued to exhibit pressured speech, agitation, and insomnia, a trial of lithium was instituted. Carol's symptoms abated within days, and she was rediagnosed as having manic depressive illness as well as a borderline personality disorder.

During the interview Carol reported a long history of interpersonal problems, antisocial behavior, moodiness, and temper tantrums. She