Examkin

Soru

Zorluk: OrtaPersonality Disorders

A 42-year-old man is admitted to the cardiac telemetry unit for observation following an episode of unstable angina. On hospital day 2, the cardiology team requests a psychiatric consultation due to disruptive behavior. The nursing staff reports that the patient frequently presses the call button and becomes irate if not answered immediately, accusing the nurses of "deliberately ignoring" him. However, when the attending cardiologist rounds, the patient is highly complimentary, describing the attending as "the only competent doctor in this entire hospital" and stating that the rest of the staff are "idiots who are going to kill me." Later that afternoon, after a resident physician informs him that he cannot have an extra portion of dessert on his cardiac-restricted diet, the patient becomes tearful, threatens to leave against medical advice, and screams that nobody cares if he starves to death. Which of the following is the most appropriate recommendation for the medical team in managing this patient?

  1. Establish clear, consistent limit-setting and ensure the entire healthcare team communicates a unified care planCevap
  2. B
    Initiate fluoxetine to manage the acute onset of severe emotional lability and tearfulness
  3. C
    Begin treatment with a long-acting injectable antipsychotic for chronic persecutory delusions
  4. D
    Investigate the nursing staff for potential neglect and reprimand those who delayed answering his call button
  5. E
    Immediately administer intravenous haloperidol and apply physical restraints to prevent departure against medical advice

Cevap

The most appropriate recommendation is to establish clear, consistent limit-setting and ensure the entire healthcare team communicates a unified care plan.
This patient's presentation is highly characteristic of borderline personality disorder (BPD). In the medical setting, patients with BPD frequently utilize splitting—an unconscious defense mechanism where individuals are viewed as entirely good (idealized) or entirely bad (devalued). The patient idealizes the attending cardiologist while devaluing the nursing staff and residents. He also demonstrates severe affective instability and an intense reaction to perceived rejection or abandonment (being denied extra dessert). The most critical management step for the medical team is to recognize this behavior, maintain strict professional boundaries, hold frequent team meetings to ensure all members are on the same page, and communicate a unified care plan to the patient. This prevents the patient from manipulating staff and causing interpersonal conflict on the ward.

Adım Adım Çözüm

1
Analyze the patient's interpersonal behavior on the medical ward.
The patient idealizes the attending physician ('only competent doctor') while severely devaluing the nurses and residents ('idiots', 'deliberately ignoring' him).
Identifying patterns of idealization and devaluation is key to recognizing the defense mechanism of splitting.
2
Evaluate the patient's emotional reaction to being denied dessert.
The patient exhibits extreme affective instability and intense fear of abandonment (screaming that nobody cares if he starves) in response to a minor boundary.
This confirms a cluster B personality disorder presentation, specifically borderline personality disorder.
3
Determine the optimal management strategy for this behavior in a hospital setting.
The treatment team must communicate closely, set firm boundaries, and present a united front to the patient.
A unified approach prevents the patient from successfully pitting providers against one another and ensures consistent medical care.

Anahtar Kavram

Management of Borderline Personality Disorder and Splitting in the Medical Setting
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Konular

Personality Disorders

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