A 45-year-old business executive with advanced cirrhosis of the liver and a history of alcohol abuse claims that he does not have a problem with drinking and can quit any time he wants to. Eventually he quits drinking but continues to have the symptoms of advanced cirrhosis of the liver. Despite the obvious discomfort caused by his illness, he tells everyone how happy he is to have cirrhosis because it has led to the cessation of his drinking.
The defense mechanism he is using is best identified as:
Correct Answer D:
Reaction formation involves going to the opposite extreme; overcompensation for unacceptable impulses. Examples include: a man violently dislikes an employee; without being aware of doing so, he "bends overbackwards" to not criticize the employee and gives him special privileges and advances. Another example is a married woman who is disturbed by feeling attracted to one of her husband's friends treats him rudely.
Intentional efforts to compensate for conscious dislikes and prejudices are sometimes analogous to this mechanism.
A 45-year-old business executive with advanced cirrhosis of the liver and a history of alcohol abuse says that he drinks only because of the constant nagging of his wife.
This is an example of which of the following defense mechanisms?
Correct Answer A:
Offering a socially acceptable and apparently more or less logical explanation for an act or decision actually produced by unconscious impulses. The person rationalizing is not intentionally inventing a story to fool someone else, but instead is misleading self as well as the listener. Examples: a man buys a new car, having convinced himself that his older car won't make it through the winter. A woman with a closet full of dresses buys a new one because she doesn't have anything to wear.
A 32-year-old man is in twice-weekly insight-oriented psychotherapy with a psychiatrist. Recently, the patient has been exploring his thoughts and feelings around his wife's complaint that he is too restricted and inhibited in their sexual activity. The patient admits that he wishes to be more sexually available for his wife, but finds himself maintaining a restricted stance.
Which of the following defense mechanisms would best describe this patient's tendency in his sexual relationship with his wife?
Correct Answer B:
Reaction formation, often seen in obsessional characters, is the term for the defense mechanism in which an unacceptable impulse is transformed into its opposite. In this case, during insight-oriented psychotherapy, the patient realizes his wish to be freer in his sexual relationship with his wife (an impulse which he finds unacceptable on some level) but finds himself responding in the opposite way (maintaining a restricted stance). Inhibition may also partly account for this man's difficulty, in that a renunciation is used to evade anxiety arising out of impulses.
A psychiatrist is consulted to see a 29-year-old woman who is being treated in an ICU for complications resulting from her intentionally overdosing on her medication. This is her fourteenth overdose in the past five years. All of them have been desperate attempts to stop various boyfriends from leaving her. Several of the ICU nurses complain that she is being mistreated by other nurses. They accuse these nurses of labeling her a “problem patient” despite her “sweet and vulnerable nature,” and of punishing her by ignoring many of her requests for care, and otherwise being rude to her. The accused nurses admit that she is indeed a difficult patient, but that despite her constant verbal abuse and hostility toward them, they have at all times been very polite to her.
What would be the most appropriate management of the situation?
Splitting, a primitive defense mechanism where external objects are divided into categories of “all good” or “all bad”, is characteristically employed by patients with borderline personality disorder. When hospital staff are unwittingly co opted into these patients’ defensive strategies, they may become divided against each other. The ICU nurses should be advised regarding the psychological dynamics of the patient, and on how to manage the countertransference (i.e., the feelings toward her) she provokes.
A. Most nurses do not receive much training regarding psychological defense mechanisms; thus, this situation does not reflect on their professionalism.
B. Refusing emergency treatment would be inappropriate and would violate federal EMTALA regulations.
C & E. These more elaborate options might be appropriate if the dispute still continued after full education regarding the psychological dynamics of the patient and advice on how to manage transference and countertransference.
A 45-year-old woman who is well controlled on lithium for bipolar disorder becomes hypothyroid (confirmed by labs).
What is the appropriate intervention?
It is well established that lithium therapy can cause hypothyroidism in about 2-3 % of patients. Once hypothyroidism is diagnosed, treatment of the condition should be initiated with thyroxine.
→ Development of hypothyroidism is not a contraindication to continuing lithium.
→ Once treatment is begun, regular monitoring of TSH and FT4 will be required.
→ Suspicion of goiter upon physical examination may prompt you to order ultrasonography. In this case, unknown information should not be assumed.
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