Seventy-two hours after being admitted the patient develops delirium tremens.
Which one of the following statements about delirium tremens is not true?
Correct Answer B:
Delirium tremens (DT) usually occurs 3-7 days after the last drink. It is differentiated from the less severe forms of withdrawal by altered sensorium and autonomic instability. Confusion, obtundation, and delirium are the hallmarks of delirium tremens. Other findings include severe agitation, hyperpyrexia, tachycardia, hypertension, and diaphoresis. Only 5% of patients with ethanol withdrawal progress to DT.
The mortality rate for delirium tremens may be as high as 35% if untreated but is less than 5% with early recognition and treatment.
Visual hallucinations are more common than auditory hallucinations. Auditory hallucinations can be prolonged and disturbing, sometimes lasting months and no particularly responsive to antipsychotic medications.
A pattern of unstable but intense interpersonal relationships, impulsivity, inappropriately intense anger, identity disturbance, affective instability, and problems with being alone suggest a diagnosis of:
Correct Answer E:
Borderline personality is marked by unstable self-image, mood, behavior, and relationships. Affected people tend to believe they were deprived of adequate care during childhood and consequently feel empty, angry, and entitled to nurturance. As a result, they relentlessly seek care and are sensitive to its perceived absence. Their relationships tend to be intense and dramatic. When feeling cared for, they appear like lonely waifs who seek help for depression, substance abuse, eating disorders, and past mistreatments. When they fear the loss of the caring person, they frequently express inappropriate and intense anger.
These mood shifts are typically accompanied by extreme changes in their view of the world, themselves, and other people—eg, from bad to good, from hated to loved. When they feel abandoned, they dissociate or become desperately impulsive. Their concept of reality is sometimes so poor that they have brief episodes of psychotic thinking, such as paranoid delusions and hallucinations. They often become self-destructive and may cut themselves (self-mutilate) or attempt suicide. They initially tend to evoke intense, nurturing responses in caretakers, but after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, they are viewed as help-rejecting complainers.
After one of many inappropriate late-night phone calls from the same patient, you review in your mind recent problems of his that you have dealt with. You have treated him four times over the past 2 years for sexually transmitted diseases and he has been to your office three times in the past year for job-related injuries. More than once you have felt anger at the patient for manipulating you, and he caused a scene in your waiting room 2 months ago over a 10-minute delay for his appointment. He often has episodes of unexplained blues or anxiety. Six months ago you saw in the newspaper that he was arrested for shoplifting.
You have started to wonder if the patient has an unrecognized underlying psychopathology. If he does indeed have a psychiatric disorder, which one of the following diagnosis is most likely?
Borderline personality disorder (BPD) is defined in the Diagnostic and Statistical Manual of Mental Disorders as the presence of at least five out of eight criteria that include impulsivity, unstable interpersonal relationships, difficulty in regulation of anger unstable mood, a tendency towards self-damaging acts, difficulty in accepting loss, and a feeling of boredom or emptiness. While the other diagnoses listed are not excluded by the information provided, they are not directly suggested by the history.
You have recently begun caring for a 25-year-old white female who has multiple complaints. You have seen her 3 times for walk-in office visits over the past month. She has shown appreciation for your work during the encounter, but has been critical of your care when talking to office staff. At times she has been kind and charming, and at other times she has been rude and verbally abusive to your staff. She has a string of multiple relationships in the past, none of which has lasted very long. During times of intense stress, she has sometimes engaged in self-mutilation. She frequently changes jobs and living arrangements.
Which one of the following strategies would be most appropriate in the care of this patient?
Correct Answer D:
This patient demonstrates features of borderline personality disorder. These patients often demonstrate instability in interpersonal relationships and self-image, and may be impulsive. They can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self-mutilation, and alternating idealization and devaluation of their physicians. Their lives are often chaotic.
Treatment strategies include maintaining a caring but somewhat detached professional stance. In any treatment approach, you must combine elements of conflict resolution and social learning to minimize and limit aggression and impulsivity. Consultants must be readily available, and you must have access to appropriate hospitalization for periods of severe regression and heightened suicidal risk. The health provider's willingness to be constantly available by phone and to have frequent calls to monitor the patient and provide support can affect the level of safety.
→ A close personal relationships is typically not therapeutic for these patients.
→ Angry outbursts will often have to be tolerated, but limit-setting is necessary with respect to appropriate behaviors.
→ SSRIs, atypical antipsychotics, and mood stabilizers may be of help at times, but anxiolytics are often abused and may be associated with self-mutilating behaviors.
→ These patients tend to respond best to clear, simple, non-technical explanations related to their medical care.
A 25-year-old female is new to your practice. She left her last physician after 6 months because “she didn’t take me seriously”. While providing her personal history she tells you that she has been in and out of at least five “serious” relationships in the past 18 months. She attempted suicide on at least one occasion when she was angry with her parents. She started college after high school, but says she has not graduated yet because she has changed her major at least six times.
You suspect that she has which one of the following personality disorders?
This patient displays many of the characteristics associated with borderline personality disorder, including instability in interpersonal relationships, marked impulsivity, emotional instability, and mood lability. Antisocial patients display a persistent pattern of deceitfulness, impulsivity, and disregard for the rights of others. Narcissistic patients display a grandiose sense of self-importance, tend to be demanding, appear haughty and self-absorbed, and insist on special status and treatment in the physician-patient relationship. Patients with dependent personalities struggle with the self perception that they are unable to function adequately without the help of others. They have trouble with decision making, motivation, and assuming responsibility, and fear abandonment. Schizotypal patients are uncomfortable in interpersonal situations, emotionally distant, difficult to engage, and isolative, and exhibit strange or quasi-delusional beliefs.
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