1. You are treating a 35-year-old Caucasian male with
psychotherapy. During one of your clinical visits, the patient admits
to you that every time he gets into an argument with his wife he
feels the need to break something to "vent his anger." He has
been treated multiple times by orthopaedic surgeons for injuries to
his hand sustained while "punching holes in walls." Which of the
following defence mechanisms is the patient exhibiting?
A. Sublimation
B. Displacement
C. Projection
D. Reaction formation
E. Splitting
Answer: B
Explanation:
The clinical vignette above describes a case where a man causes
damage to property as a method of coping with his anger toward his
wife. This is an example of the defence mechanism known as
displacement. Displacement is one of the less mature defence
mechanisms. Displacement,a patient will redirect emotions from the
person or object that is causing the emotions, but it would be completely
unacceptable to direct those emotions toward, to a more acceptable, but
still inappropriate, person or object. In this example, it is completely
inappropriate for this patient to physically harm his wife; it is more
acceptable, though still inappropriate, to destroy property instead. Other
examples of this mechanism include harming pets when a patient is
angry at another person, or being angry with their children when a
patient is angry with a person in their workplace.
(Choice A) Sublimation is one of the mature defence mechanisms. It is
similar to displacement in that unacceptable drives or emotions are
redirected, bu.t in sublimation these unacceptable drives are redirected
toward completely acceptable targets. Examples include directing anger
toward a family member toward a hard workout at the gym or directing
aggressive impulses into a career in the military.
(Choice C) Projection is an immature defence mechanism where
unacceptable or personally disagreeable impulses or drives are
attributed to others. An example of this is a student who wants to cheat
,on a test that accuses his classmates of cheating . Another example is a
man who has homosexual desires who accuses men around him of
being "gay."
(Choice D) Reaction formation is an immature defence mechanism
where unacceptable feelings are ignored and the opposite sentiment is
adopted. An example of reaction formation would be a man who is angry
at his wife who instead compliments her on her dress.
(Choice E) Splitting is an immature defence mechanism frequently
employed by patients with borderline personality disorder where people,
events or actions are either all good or all bad. An example of this is a
woman who thinks her boyfriend is the "love of her life" until they have
their first disagreement at which point the patient decides that her
boyfriend is "the worst human being on Earth."
2. A 29-year-old woman comes to the physician complaining of
persistent fatigue overthelast4years. She has also felt unhappy during
the same interval. She describes her fatigues"not having the energy to
do anything except the bare minimum most days." When asked what
she enjoys, she replies that "everything in life is a chore" and that her life
seems hopeless. She has no suicidal thoughts, problems concentrating,
or changes in appetite or sleeping patterns. She used marijuana when
she was a teenager but not since. Detailed work-up,including urine
toxicology screen,is negative for organic causes of her symptoms.
Whichofthe following is the most likely diagnosis?
A. Major depressive disorder
B. Adjustment disorder
C. Substance induced mood disorder
D. Dysthymic disorder
E. Borderline personality disorder
Answer: D
Explanation:
Dysthymic disorder
, - Depressed mood occuring most days for at least 2 years
- Presence of at least 2 of the following:
- poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
This patient has a depressed mood, fatigue, anhedonia, and feelings of
hopelessness. These symptoms alone
donotmeetthediagnosticcriteriaformajordepressivedisorder.
However,sincetheyhavepersistedfor4 years, they do meet the criteria for
dysthymic disorder. Dysthymic disorder is a chronic, low-intensity mood
disorder that responds well to antidepressant medications.
(Choice A) Major depression is diagnosed when at least 5 of the
following symptoms are present for at least 2 weeks (must include either
depressed mood or anhedonia): depressed mood, Sleep disorder,
Interest deficit (anhedonia), Guilt (worthlessness, hopelessness, and
regret), Energy deficit, Concentration deficit, Appetite disorder,
Psychomotor retardation or agitation, Suicidality (the SIGECAP S
mnemonic).
(Choice B) Adjustment disorder occurs within 3 months after the
occurrence or onset of an identifiable psychosocial stressor. It can cause
depressed mood and/or functional impairment However, this patient has
no specific stressors.
(Choice C) Diagnosis of a substance-induced mood disorder requires
that the patient be actively using or withdrawing from a recreational drug
or medication. This patient's use of marijuana occurred several years
ago and does not meet the diagnostic criteria.
(Choice E) Individuals with borderline personality disorder show a
pattern of instability in relationships and marked impulsivity. They swing
wildly between scorning and idealising people, considering them wholly
good or wholly bad (a phenomenon known as "splitting"). They tend to
, be impulsive and reckless and may demonstrate suicidal or self-
mutilating behavior. Feelings of anger and chronic emptiness are
common.
3. You are caring for a 78-year-old man in the cardiac intensive care
unit. He was admitted for chest pain, and his admission cardiac
troponins are elevated. The interventional cardiologist is planning to take
the patient for emergent cardiac catheterization. While you are
discussing the diagnosis and planned treatment with the patient, he
states that he is afraid of dying during the procedure and asks you to
pray for him. Assuming your religious beliefs are different from those of
your patient, which of the following would be the most appropriate reply?
A. “ I would be happy to call our hospital chaplain, but you will have to
wait until after the procedure to visit with him”
B. “ I do personally share your religious beliefs, but i will pray to my
own God on your behalf”
C. “ I understand that you are afraid and that your beliefs are
important. I will keep you in my thoughts during your procedure”
D. “ unfortunately, we are not of the same faith, so my prayers will not
help you”
E. “Praying is fine, but it has not been scientifically shown to be
efficacious”
Answer: C
Explanation:
With respect to religious beliefs in the doctor-patient relationship,
physicians should recognize and respect the belief system of their
patients regardless of their own beliefs. Patients should be treated with
the utmost quality of care no matter if their beliefs are similar to or
different from those of the treating physician. Religion should enter the
doctor-patient relationship only at the behest of the patient, and religious
topics should not be forceduponthepatientbythephysician. The religious
beliefs of the patient are to help ease the patient's burden and are never
to be criticised or disagreed with.
In the United States, there are numerous belief systems, including those
who do not have a religion, and frequently the beliefs of the physician
and the patient are not the same. In the interests of doing no harm, the
physician should agree, at least in a generic sense, to keep the patient
in their thoughts/prayers (Choice C).
psychotherapy. During one of your clinical visits, the patient admits
to you that every time he gets into an argument with his wife he
feels the need to break something to "vent his anger." He has
been treated multiple times by orthopaedic surgeons for injuries to
his hand sustained while "punching holes in walls." Which of the
following defence mechanisms is the patient exhibiting?
A. Sublimation
B. Displacement
C. Projection
D. Reaction formation
E. Splitting
Answer: B
Explanation:
The clinical vignette above describes a case where a man causes
damage to property as a method of coping with his anger toward his
wife. This is an example of the defence mechanism known as
displacement. Displacement is one of the less mature defence
mechanisms. Displacement,a patient will redirect emotions from the
person or object that is causing the emotions, but it would be completely
unacceptable to direct those emotions toward, to a more acceptable, but
still inappropriate, person or object. In this example, it is completely
inappropriate for this patient to physically harm his wife; it is more
acceptable, though still inappropriate, to destroy property instead. Other
examples of this mechanism include harming pets when a patient is
angry at another person, or being angry with their children when a
patient is angry with a person in their workplace.
(Choice A) Sublimation is one of the mature defence mechanisms. It is
similar to displacement in that unacceptable drives or emotions are
redirected, bu.t in sublimation these unacceptable drives are redirected
toward completely acceptable targets. Examples include directing anger
toward a family member toward a hard workout at the gym or directing
aggressive impulses into a career in the military.
(Choice C) Projection is an immature defence mechanism where
unacceptable or personally disagreeable impulses or drives are
attributed to others. An example of this is a student who wants to cheat
,on a test that accuses his classmates of cheating . Another example is a
man who has homosexual desires who accuses men around him of
being "gay."
(Choice D) Reaction formation is an immature defence mechanism
where unacceptable feelings are ignored and the opposite sentiment is
adopted. An example of reaction formation would be a man who is angry
at his wife who instead compliments her on her dress.
(Choice E) Splitting is an immature defence mechanism frequently
employed by patients with borderline personality disorder where people,
events or actions are either all good or all bad. An example of this is a
woman who thinks her boyfriend is the "love of her life" until they have
their first disagreement at which point the patient decides that her
boyfriend is "the worst human being on Earth."
2. A 29-year-old woman comes to the physician complaining of
persistent fatigue overthelast4years. She has also felt unhappy during
the same interval. She describes her fatigues"not having the energy to
do anything except the bare minimum most days." When asked what
she enjoys, she replies that "everything in life is a chore" and that her life
seems hopeless. She has no suicidal thoughts, problems concentrating,
or changes in appetite or sleeping patterns. She used marijuana when
she was a teenager but not since. Detailed work-up,including urine
toxicology screen,is negative for organic causes of her symptoms.
Whichofthe following is the most likely diagnosis?
A. Major depressive disorder
B. Adjustment disorder
C. Substance induced mood disorder
D. Dysthymic disorder
E. Borderline personality disorder
Answer: D
Explanation:
Dysthymic disorder
, - Depressed mood occuring most days for at least 2 years
- Presence of at least 2 of the following:
- poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
This patient has a depressed mood, fatigue, anhedonia, and feelings of
hopelessness. These symptoms alone
donotmeetthediagnosticcriteriaformajordepressivedisorder.
However,sincetheyhavepersistedfor4 years, they do meet the criteria for
dysthymic disorder. Dysthymic disorder is a chronic, low-intensity mood
disorder that responds well to antidepressant medications.
(Choice A) Major depression is diagnosed when at least 5 of the
following symptoms are present for at least 2 weeks (must include either
depressed mood or anhedonia): depressed mood, Sleep disorder,
Interest deficit (anhedonia), Guilt (worthlessness, hopelessness, and
regret), Energy deficit, Concentration deficit, Appetite disorder,
Psychomotor retardation or agitation, Suicidality (the SIGECAP S
mnemonic).
(Choice B) Adjustment disorder occurs within 3 months after the
occurrence or onset of an identifiable psychosocial stressor. It can cause
depressed mood and/or functional impairment However, this patient has
no specific stressors.
(Choice C) Diagnosis of a substance-induced mood disorder requires
that the patient be actively using or withdrawing from a recreational drug
or medication. This patient's use of marijuana occurred several years
ago and does not meet the diagnostic criteria.
(Choice E) Individuals with borderline personality disorder show a
pattern of instability in relationships and marked impulsivity. They swing
wildly between scorning and idealising people, considering them wholly
good or wholly bad (a phenomenon known as "splitting"). They tend to
, be impulsive and reckless and may demonstrate suicidal or self-
mutilating behavior. Feelings of anger and chronic emptiness are
common.
3. You are caring for a 78-year-old man in the cardiac intensive care
unit. He was admitted for chest pain, and his admission cardiac
troponins are elevated. The interventional cardiologist is planning to take
the patient for emergent cardiac catheterization. While you are
discussing the diagnosis and planned treatment with the patient, he
states that he is afraid of dying during the procedure and asks you to
pray for him. Assuming your religious beliefs are different from those of
your patient, which of the following would be the most appropriate reply?
A. “ I would be happy to call our hospital chaplain, but you will have to
wait until after the procedure to visit with him”
B. “ I do personally share your religious beliefs, but i will pray to my
own God on your behalf”
C. “ I understand that you are afraid and that your beliefs are
important. I will keep you in my thoughts during your procedure”
D. “ unfortunately, we are not of the same faith, so my prayers will not
help you”
E. “Praying is fine, but it has not been scientifically shown to be
efficacious”
Answer: C
Explanation:
With respect to religious beliefs in the doctor-patient relationship,
physicians should recognize and respect the belief system of their
patients regardless of their own beliefs. Patients should be treated with
the utmost quality of care no matter if their beliefs are similar to or
different from those of the treating physician. Religion should enter the
doctor-patient relationship only at the behest of the patient, and religious
topics should not be forceduponthepatientbythephysician. The religious
beliefs of the patient are to help ease the patient's burden and are never
to be criticised or disagreed with.
In the United States, there are numerous belief systems, including those
who do not have a religion, and frequently the beliefs of the physician
and the patient are not the same. In the interests of doing no harm, the
physician should agree, at least in a generic sense, to keep the patient
in their thoughts/prayers (Choice C).
