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.In particular, she is distressed by herinability to maintain a romantic relationship with a man.During thecourse of treatment, the therapist learns that her father was alcoholic,and was physically abusive to the patient and her mother.Whichdefense mechanism best describes the patient s behavior?A.UndoingB.SplittingC.Isolation of affectD.IdealizationE.DisplacementANSWERS47.1 B.The goal of cognitive-behavioral psychotherapy in such cases is tohelp patients critically examine if their assumptions about themselvesand other people are correct.47.2 A.Option A is most consistent with avoidant personality disorder.The patient has some close relationships and seems to desire more, butdoes not feel that he can maintain such relationships.B is more con-sistent with social phobia.C is grossly paranoid, consistent with a psy-chotic disorder.D is highly suggestive of schizoid personality disorder,as the patient has a close relationship with his parent but has no inter-est in other human contact.E suggests dependent personality disorder.47.3 C.Patients with avoidant personality disorders would desperately like tohave social relationships, but they are afraid of criticism and/or rejection.47.4 E.This patient can be theorized to be using displacement to assumethat all men will act as punitively toward her as her father did.Displacement and projection are the two defense mechanisms mostcommonly utilized by patients with avoidant personality disorders.384 CASE FILES: PsychiatryClinical Pearls¤' Patients with avoidant personality disorder have a pervasive hypersensi-tivity to criticism and rejection.They avoid interpersonal relationships inevery setting because they fear criticism and rejection.Their self-esteem islow, and they usually believe that they are inferior or inadequate, especiallyin the social arena.¤' Patients with avoidant personality disorder are differentiated from thosewith schizoid personality disorder by the fact that they desperately wouldlike interpersonal relationships but are afraid of them.Individuals withschizoid personality disorders do not have relationships but do not missthem.¤' Patients with avoidant personality disorder are differentiated from thosewith dependent personality disorder by the fact that the former are afraidof rejection and criticism in relationships.Patients with dependent per-sonality disorder are afraid of being left alone to fend for themselves.¤' Physicians need to be tactful, encouraging, and accepting of thesepatients, especially regarding their fear of rejection.Confrontation andcoercion are not appropriate, as they can drive the patient away.¤' Defense mechanisms used by patients with avoidant personality disorderinclude displacement and projection.REFERENCECloninger CR, Svrakic DM.Personality disorders.In: Sadock BJ, Sadock VA, eds.Kaplan and Sadock s Comprehensive Textbook of Psychiatry.8th ed.Philadelphia, PA:Lippincott Williams & Wilkins; 2004:1723-1764.Case 48A 10-year-old boy with chronic asthma is brought to a pediatrician forhis 6-month check up.In addition, he has complained of chronicheadaches for the past 3 months, as well as increasing gastric upsets,which his family believes are caused by multiple food allergies.Thepatient also has a severe allergy to peanuts, which limits the number ofplaces he can go in public.Thus, he has been home-schooled for a yearand is doing well.A review of his history shows that he is a highly artic-ulate, thoughtful child who grossly appears to be at or above the educa-tional level of his peers.The child does not agree to be interviewedseparately from his mother, stating,  I don t go anywhere without mymother. The two of them are almost never apart.Two years ago, themother was hospitalized after a serious bout with lupus.She continuesto struggle with her disease, and despite having a thriving career beforeher illness; she can do very little now.She is home all the time, dealingwith her own recovery and the management of her illness.During herhospitalization, the patient was quite worried about her illness and evennow believes that if he is not around to monitor her condition, shemight get sick and require hospitalization again or even worse.Themother has difficulty sleeping and is most comfortable on the livingroom couch.The patient no longer uses his own room but sleeps in achair next to his mother to continue to keep an eye on her.He has veryfew friends and can be separated from his mother only briefly, and onlyif he is in the company of his brother or father.After a short period, hebecomes anxious and upset and must be reunited with his mother.¤' What is the most likely diagnosis?¤' What is the prognosis for this disorder?¤' What treatments might be helpful in this disorder?386 CASE FILES: PsychiatryANSWERS TO CASE 48:Separation Anxiety DisorderSummary: A 10-year-old, late latency/early adolescent boy exhibits extremeanxiety when not in the presence of his mother.As a result, he no longerattends school but seems quite bright and cognitively on target.His anxietysymptoms began after the mother experienced a serious, life-threatening illness.The patient believes that if he is separated from her, something terrible mighthappen to her.In addition, he reports several somatic complaints that havebeen difficult to diagnose.¤' Most likely diagnosis: Separation anxiety disorder (a childhood disorder).¤' Prognosis: Difficult to treat; the patient is possibly more likely to developdepression and psychotic disorders.¤' Best treatment: A multisystemic treatment approach is required.Selectiveserotonin reuptake inhibitors (SSRIs) can be helpful in the management ofmood symptoms and anxiety.Relaxation techniques can help, along with agradual separation program.Home schooling only reinforces the child s fearof separating from the family and should be reconsidered.ANALYSISObjectives1.Recognize the symptoms of a typical case of separation anxiety disorder.2.Understand the predisposing factors contributing to the disorder.3.Understand what other disorders the patient is at a higher risk of developing.ConsiderationsThe patient has a typical presentation for separation anxiety disorder, whichusually begins in the late latency period, 11-12 years of age (see Table 48 1).Table 48 1 DIAGNOSTIC CRITERIA FOR SEPARATION ANXIETY DISORDERDevelopmentally inappropriate anxiety about separation from home or from the caretaker to which an individual is attached.Duration of the illness must be at least 4 weeks.Onset of the illness should be prior to 18 years of age.The disturbance should cause clinically significant impairment in important areasof functioning.CLINICAL CASES 387It is often precipitated by the life-threatening disease of a parent mosttypically the mother or primary caretaker.Patients become extremely anxiousand worried when they are physically separated from the parent.They worrythat the parent will die if they are separated and thus are very difficult to con-sole during these periods.Their beliefs can be quite strong and are minimallyamenable to reason or reassurance [ Pobierz caÅ‚ość w formacie PDF ]