Case files psychiatry - part 7 pps

272 CASE FILES: PSYCHIATRY CLINICAL PEARLS Patients with pain disorder actually feel pain; it does not help to tell them that "it's all in your head." Pain disorder tends to be a chronic condition; patience, acceptance, and regular visits can promote amelioration of the intensity and frequency of complaints. The patient's therapeutic relationship with the clinician is very important in the management of this condition. REFERENCES Kaplan H, Sadock B. Synopsis of psychiatry, 9th ed. Baltimore: Lippincott Williams & Wilkins, 2003:655-658. Massie MJ, ed. Pain: what psychiatrists need to know. Review Psychiatry Series, Vol 19, no 2. 2000;89. •> CASE 33 A 42-year-old man comes to see a psychiatrist stating that his life is "crashing down around his ears." He explains that since his girlfriend of 2 months left him, he has been "inconsolable." He says that he is having trouble sleeping at night because he is mourning her loss. When asked to describe his girlfriend, the patient states, "She was the love of my life, just beautiful, beautiful." He is unable to provide any further details about her. He says that they had five dates, but that he simply knew that she was the one for him. He claims that he was often in the "depths of despair" in his life, but that he also felt "on top of the world." He denies any psychiatric history or any medical problems. On a mental status examination, the patient is dressed in a bright, tropical- pattern shirt and khaki pants. He leans over repeatedly to touch the interviewer on the arm as he speaks, and he is cooperative during the interview. He some- times sobs for a short period of time when talking directly about his girlfriend but smiles broadly during the interview when asking the interviewer questions about herself. His speech is of normal rate, although at times somewhat loud. The patient describes his mood as "horribly depressed." His affect is euthymic the majority of the time, and full-range. His thought processes and thought content are all within normal limits. • What is the most likely diagnosis? • What is the best initial treatment for this patient? 274 CASE FILES: PSYCHIATRY ANSWERS TO CASE 33: Histrionic Personality Disorder Summary: A 42-year-old man comes to a psychiatrist with complaints of a depressed mood and difficulty sleeping. His says that his girlfriend recently left him. Although he is obviously upset about the loss of the relationship, he cannot describe her in any specific detail, and they had not been going out together for long. The patient's speech and manner appear somewhat theatrical and overblown. His affect appears euthymic and full-range, and he appears to be trying to directly engage the (female) interviewer by touch- ing her and asking her direct personal questions. In this manner, he appears to be trying to draw attention to himself by being somewhat seductive. He is shown to have normal thought processes and thought content on a men- tal status examination. • Most likely diagnosis: Histrionic personality disorder. • Best initial treatment: Supportive psychotherapy while he grieves the loss of his girlfriend. Setting a strict limit on his seductive behavior needs to be implemented as well. Analysis Objectives 1. Recognize histrionic personality disorder in a patient. 2. Know the treatment recommendations for patients with this disorder who come in while experiencing some kind of psychologic crisis. Considerations This patient provides a somewhat classic presentation of histrionic person- ality disorder. Newer epidemiological evidence suggests that histrionic personality disorder is equally common in men as in women, affecting approximately 1.8% of Americans. Clues to making the diagnosis include his theatrical and overblown speech and his seductive manner. Other clues include the fact that although he describes himself as being deeply depressed about the loss of his girlfriend, he is unable to describe her other than superficially, and his affect appears euthymic. His case is not unusual because patients with this disorder come to a psychiatrist with a depressed mood but rarely with the thought that their difficulties in functioning in daily life and work are secondary to their own maladaptive behaviors. 275 CLINICAL CASES APPROACH TO HISTRIONIC PERSONALITY DISORDER Definitions Dissociation: A defense mechanism by which an individual deals with emotional conflict or stressors with a breakdown in the usually inte- grated functions of consciousness, memory, perception of self or the environment, or sensory/motor behavior. For example, a woman who has just been told that her child was killed in an automobile accident suddenly feels as if she is not herself but rather is hearing the events unfold as if they are being told to "someone else." Limit setting: An activity by which a physician clearly tells a patient what is, and what is not. appropriate behavior in a given circumstance. For example, a physician can set limits on how many times a patient can telephone the physician in a week. Repression: A defense mechanism by which individuals deal with emo- tional conflict or stressors by expelling disturbing wishes, thoughts, or experiences from their conscious awareness. For example, a patient is told that she has breast cancer and clearly hears what she has been told because she can repeat the information back to the physician. However, when she returns home later, she tells her husband that the visit went well but that she cannot remember what she and the physician spoke about during the appointment. Supportive psychotherapy: Therapy designed to help patients support their existing defense mechanisms so that their functioning in the real world improves. Unlike insight-oriented psychotherapy, its goal is to maintain, not improve, a patient's intrapsychic functioning. Clinical Approach Patients with histrionic personality disorder show a pervasive pattern of excessive emotionality and attention seeking. They are uncomfortable in settings where they are not the center of attention. Their emotions are rap- idly shifting and shallow, and they often interact with others in a seductive manner. Their speech is impressionistic and lacks detail. They are dra- matic and theatrical and exaggerate their emotional expressions. They often consider relationships to be much more intimate than they really are. They are suggestible to the thoughts of others as well, often adopting other's views without thinking them through. 276 CASE FILES: PSYCHIATRY Differential Diagnosis Patients with borderline personality disorder can often appear similar to those with histrionic personality disorder, although the former make suicide attempts more often and experience more frequent (brief) episodes of psy- chosis. Patients who are manic can often be overly dramatic, attention seeking, and seductive, but symptoms of insomnia, euphoria, and psychosis are present as well. Interviewing Tips and Treatment The clinician should provide emotional support for and show interest in these patients but should not allow a personal or sexual relationship to form. Tactful confrontation about seductive behavior can help. Expressing admi- ration of the patient, without showing inappropriate behavior, can help in forming a therapeutic working alliance. The treatment of histrionic personal- ity disorder is often best attempted in a group therapy setting, where such patients, particularly if there are other patients with the same diagnosis in the group, better tolerate confrontations to avoid being rejected by other group members. Most psychotherapies require insight, which these individuals lack. Dynamic psychotherapy would likely lead to tumultuous results at best. Comprehension Questions [33.1] A 35-year-old woman with histrionic personality disorder has seen her psychotherapist once a week for the past year. During a session, the therapist tells the patient that he is going to be on vacation the follow- ing 2 weeks. When he returns from the vacation, the patient tells him that she felt he abandoned her and says, "You didn't even bother to tell me that you would be away." This lapse in memory can best be described as which defense mechanism common to patients with histri- onic personality disorder? A. Sublimation B. Splitting C. Undoing D. Repression E. Displacement [33.2] To which cluster does histrionic personality disorder belong? A. Cluster A B. Cluster B C. Cluster C D. Cluster D E Cluster E 277 CLINICAL CASES [33.3] A 20-year-old woman comes to see a psychiatrist at the insistence of her mother, who states that her daughter just "isn't herself." The patient has dressed in brightly colored clothes and worn large amounts of makeup for the past 3 weeks. She acts overtly seductive toward her col- leagues at work, is more distractible, and is easily irritated. She also sleeps less, claiming that she "no longer needs it." Which of the fol- lowing diagnoses best fits this patient's presentation? A. Histrionic personality disorder B. Borderline personality disorder C. Bipolar disorder, mania D. Narcissistic personality disorder E. Delusional disorder Answers [33.1 ] D. Repression is a common defense mechanism in patients with histri- onic personality disorder. [33.2] B. Histrionic personality disorder belongs in cluster B, the "bad" cluster (see Case 6). [33.3] C. This patient has a new onset of behavior that is unlike her usual per- sonality. It includes dressing in loud clothing and wearing lots of makeup, as well as being seductive. She is distractible, is irritable, and needs less sleep than usual. All these symptoms point to a manic episode (assuming neither a medical condition nor a substance can account for the sudden change in functioning). CLINICAL PEARLS Patients with histrionic personality disorder often appear very dra- matic and overemotional. They do not seem to have much depth in either their emotions or their relationships with others. They are uncomfortable when they are not the center of attention. Patients with histrionic personality disorder use the defense mecha- nisms of dissociation and repression most commonly. In interacting with these patients, the physician should use a low- key, friendly approach but should watch interpersonal bound- aries. He or she should not become caught up in personal or sexual relationships with such patients, who can be quite seductive. 278 CASE FILES: PSYCHIATRY Patients with histrionic personality disorder can be differentiated from I those with mania because the latter often develop dramatic, seduc- tive symptoms as new-onset behavior, not as a pervasive pattern. Patients with mania commonly also have vegetative symptoms, such as a decreased need for sleep, and psychotic symptoms as well. REFERENCES Ebert M, Loosen P. Nurcombe B. eds. Current diagnosis and treatment in psychiatry. New York: McGraw-Hill. 2000:477-479. Grant BF. Hasin DS, Stinson FS, et al. Prevalence correlates and disability of per- sonality disorders in the United Slates: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2004;65(7):948-958 Kaplan H, Sadock B. Synopsis of psychiatry, 8th ed. Baltimore: Lippincott Williams & Wilkins, 1998:220-221. <• CASE 34 A 9-year-old girl is brought to her pediatrician by her mother because of fre- quent complaints of headaches and stomachaches for the past 3 to 4 weeks. The mother tells you that she has also been doing worse in school during this same time period and believes it is a result of the chronic aches. She has already taken her to the optometrist, and her vision is not a problem. On fur- ther questioning by the medical student, we find out that the child's father is part of the army reserve and left for a 6-month assignment in Iraq 5 weeks ago. He e-mails her almost daily, but his daughter notes how much she worries about him and whether he is safe or not. When interviewed, the girl also notes that in addition to her worries about her father, she also sometimes cries about it and feels better when she talks to her friends. She occasionally has a bad dream about her father and feels she sleeps more uneasily as a result. • What is the most likely diagnosis for this patient? • What is the treatment of choice for this disorder? 280 CASE FILES: PSYCHIATRY ANSWERS TO CASE 34: Adjustment Disorder Summary: A 9-year-old girl presents to her pediatrician with a number of short-term (3-4 weeks) somatic complaints. In addition, she also has some mild symptoms related to mood as well as anxiety as a result of her father's army commitment. She is able to maintain general functioning, but there does seem to be some decline. She shows evidence of good strengths in that she can express these feelings to others and feels better as a result. + Most likely diagnosis: Adjustment disorder with mixed anxiety and depressed mood • Treatment of choice: Psychotherapy (supportive) Analysis Objectives 1. Recognize adjustment disorder in a patient. 2. Understand the best treatment recommendation for patients wilh this disorder. Considerations A few weeks after her father was sent overseas to fulfill an armed-service obli- gation. his daughter begins to have some difficulties noted by her modier. These seem to show up first in terms of somatic complaints. This is a common presen- tation for anxious or depressed feelings in children. These should be worked up to reassure both the parents and the patients that there is nothing physically seri- ously wrong. When further investigated, we find that she has additional, more classically psychiatric symptoms in the areas of mood and worries. She is func- tioning adequately, but there does seem to be a mild decline. The symptoms have been short in duration (less than 6 months) and occurred within 4 months of the stressor (father going overseas). Her prognosis is good, given her supportive environment and responsiveness to talking about her feelings. (See the diagnos- tic criteria in Table 34—1.) Supportive therapy would be indicated in this situation as well as an evaluation of the mother to see how she is managing. APPROACH TO ADJUSTMENT DISORDER Definitions Clinically significant symptoms: Distress in excess of what might be expected in response to the particular stressor in question. To be consid- ered clinically significant, these symptoms must include a marked impact on functioning in a variety of settings. 281 CLINICAL CASES Table 34-1 DIAGNOSTIC CRITERIA FOR ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD 1. Development of an emotional response to a specific stressor within 3 months of the onset of that stressor. 2. Clinically significant symptoms developed as a response to the stressor. ,v The symptoms do not persist longer than 6 months alter the stressor is resolved. 4. Five different subtypes of adjustment disorder are recognized, each characterized by a specific set of moods and/or behavior: With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Conduct: When used clinically, this term relates to the psychopathology associated with a conduct disorder. The hallmark of this disorder includes violation of the rights of others. Supportive psychotherapy: A type of therapy in which individuals are taught how to confront issues such as phobias and stressors. Clinical Approach Differential Diagnosis The largest concern in the differential diagnosis for patients with adjustment disorder is major depression. The difference between the two is a matter of degree. Patients with major depression can see its onset following the onset of a stressor, although even after the stressor is removed, the major depression continues. Also, in major depression, marked difficulties involving sleep, appetite, concentration, and energy level are noted, and suicidal ideation (not just transient) and psychotic symptoms can occur. In children or adolescents, irritable mood is often seen rather than the classic depressed mood seen in adults. Mood disorders arising secondary to the u.se of a substance or a general medical condition must always be ruled out. Clinicians should exclude any symptom complexes characteristic of other stress-induced disorders as well (such as in acute stress disorder or posttraumatic stress disorder [PTSD]) before diagnosing adjustment disorder. With PTSD. the stressor is usually actual or threatened death or serious injury. Finally, normal grief reactions or bereavement can be difficult to differentiate from adjustment disorders, but if the stressor is within expected and/or culturally acceptable ranges, adjustment disorder should generally not be diagnosed. [...]... enuresis 294 CASE FILES: PSYCHIATRY A Snoring sounds Nasal/oral airflow »>• •HH-» >-* - —*-rHH»»« • -" -tf+rHr *-* •' ^ 1MJU MM, ^AMA/ Respiratory effort 9598 979 69593 „ " » " 95 94 „ _ Arterial 0? saturation 9493 ~90 89 91 90« 97 " 9 8 " 95 93 90 1 30 s 88 86 ^ 1 B EEG H H>m4»"»il»*tiMIW#*>i' Chin EMG Heart rate RAT EMG « L.A.T EMG i-30 SH Figure 3 6-1 The parameters... comprehensive textbook of psychiatry, 7th ed Philadelphia: Lippincott Williams & Wilkins, 2000: 272 0-2 72 8 Moore CA, Williams RL Hirshkowitz M Sleep disorders In: Sadock BJ Sadock VA, eds Kaplan and Sadock's comprehensive textbook of psychiatry 7th ed Philadelphia: Lippincott Williams & Wilkins, 2000:1 67 7- 1 70 0 •> CASE 37 A 28-year-old woman comes to her primary care physician with a chief com­ plaint of not getting... diagnosis and treatment in psychiatry New York: McGraw-Hill, 2000: 37 8-3 83 Kaplan H, Sadoek B Synopsis of psychiatry, 9th ed Baltimore: Lippincott Williams & Wilkins, 2003:84 3-8 46 •> CASE 36 The 2'/2-year-old, first-born son of married parents is brought to a pediatri­ cian's office by his father Before this visit, the patient visited the pediatrician only for regular well-child checks and for treatment... somatic intervention REFERENCES Ebert M Loosen P Nurcombe B eds Current diagnosis and treatment in psychiatry New York: McGraw-Hill 2000:46 0-4 66 Kaplan H, Sadock B Synopsis of psychiatry, 9th ed Baltimore: Lippincott Williams & Wilkins, 2003:111 1-1 112 •> CASE 35 A 41-year-old nurse presents to the emergency department with concerns that she has hypoglycemia from an insulinoma She reports repeated episodes... the bell-and-pad method desmopressin, and imipramine REFERENCES Gillin JC Seifrilz E, Zoltoski RK, Salin-Pascual RJ Basic science of sleep In: Saddock BJ Saddock VA, eds Comprehensive textbook of psychiatry, 7th ed Philadelphia: Lippincott Williams & Wilkins 2000:19 9-2 09 Mikkelsen EJ Elimination disorders In: Sadock BJ, Sadock VA, eds Kaplan and Sadock's comprehensive textbook of psychiatry, 7th ed... developing a severe behavioral problem • What is the most likely diagnosis for this child? • What treatments would you recommend for this child? 292 CASE FILES: PSYCHIATRY ANSWERS TO CASE 36: Sleep Terror Disorder Summary: The patient is a 272 -year-old boy with new-onset sleep problems who has no significant other history He wakes at night, screaming with auto­ nomic hyperarousal, and his parents are unable... and L-tryptophan do not have proven benefit Deconditioning, relaxation training, and sleep hygiene training can be useful in helping patients with primary insomnia sleep REFERENCES Ebert M, Loosen P Nurcombe B eds Current diagnosis and treatmenl in psychia­ try New York: McGraw-Hill, 2000:4 37^ 140 Kaplan H, Sadock B Synopsis of psychiatry, 9th ed Baltimore: Lippincott Williams & Wilkins 2003 :76 3 -7 67 ... plasma C-peptide, which indicates exogenous insulin injection When she is confronted with this information, she quickly becomes angry, claims the hospital staff is incompetent, and requests that she be discharged against medical advice • What is the most likely diagnosis? • How should you best approach this patient? 286 CASE FILES: PSYCHIATRY ANSWERS TO CASE 35: Factitious Disorder Summary: A 41-year-old... sleep, such as caffeine, alcohol, nicotine, or stimulants 8 Begin a physical fitness program 9 Avoid evening stimulation—listen to the radio or read a book instead 302 CASE FILES: PSYCHIATRY Comprehension Questions [ 37. 1 ] A 33-year-old married physician presents to your primary care practice with complaints of "depression." On interview, he denies pervasive feelings of sadness or anhedonia and he... desmopressin, 70 % It was used successfully in both 296 CASE FILES: PSYCHIATRY tablet and nasal form to control enuresis in children Again, it is an effective short-term treatment for enuresis, but there is a high rate of recidivism once the medication is discontinued Another common treatment for enuresis involves medication Imipramine was an effective treatment in more than 40 double-blind studies . McGraw-Hill, 2000: 37 8-3 83. Kaplan H, Sadoek B. Synopsis of psychiatry, 9th ed. Baltimore: Lippincott Williams & Wilkins, 2003:84 3-8 46. •> CASE 36 The 2'/2-year-old, first-born. this disorder? 280 CASE FILES: PSYCHIATRY ANSWERS TO CASE 34: Adjustment Disorder Summary: A 9-year-old girl presents to her pediatrician with a number of short-term ( 3-4 weeks) somatic complaints approach this patient? 286 CASE FILES: PSYCHIATRY ANSWERS TO CASE 35: Factitious Disorder Summary: A 41-year-old female health care worker presents to the emer- gency department with symptoms typical