[ Pobierz całość w formacie PDF ]
.Group therapy is helpful only if thetherapist can make the inevitable confrontation by group members somehowpalatable to the patient.Psychotherapy with these individuals is challenging,and the patient often terminates treatment when confrontation is attempted.Psychopharmacology can be employed to treat symptoms associated with nar-cissistic personality disorder (eg, lithium for the affective lability, selectiveserotonin reuptake inhibitors [SSRIs] for depressive symptoms).Comprehension Questions41.1 A 22-year-old, single graduate student with narcissistic personality dis-order is admitted to a hospital after a car accident in which his rightfemur is fractured.A medical student has been assigned to follow thepatient, but when she enters the room and introduces herself as a medicalstudent, the patient states, Oh, I wouldn t let a medical student touchme I need someone with much more experience than you. Whichof the following statements by the medical student is most likely tolead to a successful interview with this patient?A.I know this will be boring for you, but it s just one of the thingsthat you will have to put up with in the hospital.B.I know you must be scared to be in the hospital, but you will besafe here.C.I m told that you are a very articulate person, and so I m hopingyou ll teach me what I need to know.D.I understand that you think you deserve only the best, but I havebeen assigned to you.E.Please don t make this difficult, I have to interview you as part ofmy job. CLINICAL CASES 34141.2 The patient in question 41.1 would be most likely to becomedepressed after which of the following life occurrences?A.AgingB.GraduationC.Job changeD.MarriageE.Moving to a new city41.3 A 36-year-old man with narcissistic personality disorder calls youroffice asking for an appointment with the best therapist in the clinic. One of his complaints is difficulties in his relationships with his col-leagues.The patient states They are not giving him the credit hedeserves for his accomplishments at the law firm. What is the mostlikely reason the patient is seeking treatment?A.AngerB.AnxietyC.Attempting to identify with othersD.Grandiose thinkingE.Seeking medication41.4 The patient in question 41.3 has now been seeing a therapist twice weeklyfor the last year.The therapist and the patient have a good workingalliance.During one therapy session, the therapist comes to the session4 minutes late.He apologizes to the patient, stating that he had an emer-gency involving another patient.During the session, the patient notes thatthe therapist isn t as sharp as some of the therapists I hear on the talkshows. Which of the following defense mechanisms is the patient using?A.DenialB.DevaluationC.Isolation of affectD.RationalizationE.SplittingANSWERS41.1 C.Appealing to the patient s narcissism by being admiring most oftendeescalates the patient as well as improves the therapeutic alliance inthese cases.41.2 A.Patients with narcissistic personality disorder do not handle agingwell because beauty, strength, and youth are often highly valued.Anyblow to their fragile (but covert) self-esteem can raise their feelings ofenvy, anger, and subsequently lead to depression.All the other lifeoccurrences represent changes which may be stressful to people, but donot affect those with personality disorders any differently than thegeneral population.(Other than personality disordered patients donot handle any kind of stressors well in general.) 342 CASE FILES: Psychiatry41.3 A.Patients with narcissistic personality disorder rarely seek treatmentand tend to have little insight into their grandiosity.When these indi-viduals do present for treatment it is usually due to underlying angeror depression resulting from being belittled or not receiving the admi-ration to which they feel entitled.41.4 B.The patient defends against his feelings of hurt and anger towardthe therapist by using devaluation.Devaluation, along with idealiza-tion and denial are considered primitive (lower-functioning) defensemechanisms used by patients with personality disorders such as narcis-sistic and borderline.Clinical Pearls¤' Patients with narcissistic personality disorder show a pervasive sense ofgrandiosity and entitlement in their thoughts and behavior.They are veryseldom capable of true empathy with others and often manipulate themfor personal gain.¤' Clinicians should try to maintain an admiring stance with these patients.Tact is important as well, as these individuals handle criticism poorly.¤' Defense mechanisms in patients with narcissistic personality disorderinclude denial, devaluation, and idealization.REFERENCESAndreasen N, Black D.Introductory Textbook of Psychiatry.4th ed.Arlington, VA:American Psychiatric Publishing; 2006:296-298.Gabbard GO.Gabbard s Treatments of Psychaitric Disorders.4th ed.Washinton, DC:American Psychiatric Publishing, Inc.; 2007:791-801. Case 42A 7-year-old boy in second grade is brought to a pediatrician by his parentsfor an evaluation of his eyes.They state that he blinks them repeatedly,and that this behavior seems to be worsening.They first noticed it a yearor more ago, but it became very obvious in the past several weeks.Theynote that their son cannot control the blinking, and that it appearsworse at some times of the day compared to others.The boy s teacherreports that other children tease him because of his rapid eye blinking.The pediatrician observes that in addition to blinking, the child seemsto clear his throat frequently, although his nose and throat appear normalon physical examination.The parents report that this behavior occursseveral times daily as well.The patient is doing well at school, althoughhe sometimes has trouble completing his homework.The patient s fatherhas a history of obsessive-compulsive disorder.¤' What is the most likely diagnosis?¤' What is the best therapy for this condition? 344 CASE FILES: PsychiatryANSWERS TO CASE 42:Tourette DisorderSummary: A 7-year-old boy presents to a pediatrician with a year-long historyof uncontrollable blinking, which has worsened over the past several weeks.The blinking is worse at some times than at others, and the boy is teased atschool because of it.The child also clears his throat repeatedly, althoughnothing physically wrong can be found.He is doing well at school althoughhe sometimes has trouble completing his homework.The patient has a paternalhistory of attention-deficit/hyperactivity disorder (ADHD).¤' Most likely diagnosis: Tourette disorder.¤' Best treatment: The first-line of treatment should be an alpha-adrenergicmedication such as clonidine or guanfacine.If ineffective the atypicalantipsychotics would be the next class of medications to try.ANALYSISObjectives1.Recognize Tourette disorder in a patient (see Table 42 1 for diagnosticcriteria).2.Describe the basic evaluation and treatment of this disorder.ConsiderationsA 7-year-old boy shows signs of a motor tic in the form of eye blinking.This behavior has been present to some degree for more than a year andhas recently worsened
[ Pobierz całość w formacie PDF ]