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.Thephysician should use a low-key, technical approach (not a  warm and fuzzyone) when dealing with these patients.96 CASE FILES: PsychiatryComprehension Questions6.1 A 48-year-old woman presents to a psychotherapist.The patient livesa very secluded life, largely consumed by working nights as a securityguard, and taking care of her elderly mother.She complains of feelinglonely, and is aware that she has a great deal of difficulty relating toother people.Which of the following conditions would most distin-guish her issues from a person with schizoid personality disorder?A.Family history of a cousin with schizophrenia.B.A desire to engage in interpersonal relationships.C.Lack of hallucinations or delusional thinking.D.Her gender.E.A history of abstinence from alcohol.6.2 A patient with schizoid personality disorder comes to his primary carephysician with chief complaints of polyuria and polydipsia.He isfound to have insulin-dependent diabetes.Which of the followinginterventions by the physician is likely to be most well received by thispatient?A.Asking the patient to bring in a relative so that he can describe thetreatment regimen to both of them at the same time.B.Referring the patient to a therapist so that he can talk about thedifficult nature of the diagnosis.C.Giving the patient detailed written information about the diseaseand telling him, the physician will be available to answer anyquestions.D.Referring the patient to a group that helps its members learn aboutdiabetes and to better deal with their illness.E.Scheduling frequent appointments with the patient so that all thetreatment details can be explained on a one-to-one basis.6.3 A woman with schizoid personality disorder was involved in a motorvehicle accident in which she was rear-ended by another car.Thedriver of the other car refused to take responsibility for the accidentand hired a lawyer to provide his defense.The woman spends hourseach day thinking about the specifics of the accident, including suchdetails as the color of the cars involved and what each party to theaccident was wearing.Which of the following defense mechanisms,common to patients with schizoid personality disorder, is the womanusing?A.SublimationB.UndoingC.ProjectionD.IntellectualizationE.IntrojectionCLINICAL CASES 97ANSWERS6.1 B.The hallmark of schizoid personality disorder is a detachment anddisinterest in social relationships.This patient is clearly distressed byher lack of social relationships.6.2 C.Patients with schizoid personality disorder generally prefer tokeep social interaction to a minimum.They do well with technicalinformation.6.3 D.Intellectualization is characterized by rehashing events over andover.Clinical Pearls¤' Patients with schizoid personality disorder show a pervasive, stable pat-tern of disinterest in interpersonal relationships, coupled with a rich fan-tasy life.They appear emotionally detached.¤' Schizoid personality disorder belongs in cluster A, the  mad cluster.¤' Patients with this disorder can be differentiated from patients withavoidant personality disorder by their utter lack of interest in interpersonalrelationships.Patients with avoidant personality disorder wish to engagein interpersonal relationships, but find this distressing and confusing.¤' Patients with schizoid personality disorder can be differentiated frompatients with schizotypal personality disorder by the former s lack of afamily history of schizophrenia, absence of magical thinking, and theiroften successful (if isolated) work careers.Patients with schizotypal per-sonality disorder exhibit more flamboyantly odd behavior, such as immer-sion in the occult, witchcraft, and the paranormal.¤' Physicians do well in dealing with such patients when they use a low-key,technical approach.¤' Therapy does not tend to work well with these patients, as they are notmotivated to undergo treatment.Their disorder is ego-syntonic, as are allpersonality disorders.REFERENCESEbert M, Loosen P, Nurcombe B, eds.Current Diagnosis and Treatment in Psychiatry.New York: McGraw-Hill; 2008:456-457.Grant BF, Hasin DS, Stinson FS, et al.Prevalence, correlates, and disability of personalitydisorders in the United States: Results from the national epidemiologic survey onalcohol and related conditions.J Clin Psychiatry.2004;65(1):948-958.Sadock BJ, Sadock VA.Kaplan and Sadock s Synopsis of Psychiatry.10th ed.Baltimore,MD: Lippincott Williams & Wilkins; 2007:1121-1125.This page intentionally left blankCase 7A 79-year-old man is brought to the emergency department by his fam-ily.Although the patient is essentially mute, his family members reportthat he has had a history of numerous episodes of depression, the lastoccurring 6 years ago.At that time, he was hospitalized and treated withsertraline.He has been hospitalized a total of four times for depression,but the family denies that he has ever been treated for mania.Thepatient s only current medication is hydrochlorothiazide, although hehas refused to take it for the past 2 days.This current episode of depression, similar to previous ones, began3 weeks prior to the emergency department visit.The patient has hadfrequent crying episodes and has complained of a decrease in energy.Hehas lost at least 15 lb in the 3 weeks and for the past 2 days has refusedto eat anything at all.Three days ago, the patient told his family that hewas  sorry for all the pain and suffering I have caused you and that  itwould be better if I were not around any more. Two days ago, hestopped speaking and eating, and for the past 24 hours he has refused totake anything by mouth, even water.After rehydration in the emer-gency department, the patient was admitted to the psychiatry service.The results of his physical examination were essentially normal,although his blood pressure was 150/92 mm Hg, and he exhibited psy-chomotor slowing.The patient refused all attempts to feed him bymouth.When asked if he was suicidal, he nodded his assent, as well asnodding to the question,  Are you hearing voices?¤' What is the most likely diagnosis?¤' What is the best plan of action for this patient?100 CASE FILES: PsychiatryANSWERS TO CASE 7:Major Depression in Elderly PatientsSummary: A 79-year-old man is brought in by his family after refusing to drinkfluids for 24 hours.For the past 3 weeks, the patient has shown worseningsigns and symptoms of major depression (decreased energy, crying spells, sui-cidal ideation, anorexia with weight loss, and guilt), culminating in a refusalto eat or drink.He continues to refuse to eat or drink, is suicidal, and is prob-ably experiencing auditory hallucinations.He has had episodes similar to thisone in the past, although no episodes of mania have been described.¤' Most likely diagnosis: Recurrent major depression with psychotic features.¤' Best plan of action: Close observation in the hospital, intravenous hydra-tion, and consideration of electroconvulsive therapy (ECT) because of theseverity and urgency associated with this episode of depression.ANALYSISObjectives1 [ Pobierz caÅ‚ość w formacie PDF ]