A 59-year-old woman comes to the office due to upper respiratory symptoms for 3 days. She arrives an hour late for her appointment and lies about the reason, blaming it on an emergency at work. The patient is angry that the physician refused to prescribe antibiotics for her over the phone, and she paces at the reception desk, insisting that the office staff work her into the schedule because "I'm very busy and must be seen immediately." She mentions that her previous physician always made time for her. The patient is a successful businesswoman and is recently divorced. During the visit, she expresses irritation at having to take time out of her busy day to come to the appointment and admits to being "under stress" at work. The patient then talks at length about feeling depressed because her children no longer want to see her even though she is a "great mother." She is upset that her daughter recently canceled plans to visit in order to help a friend who was in a near-fatal motor vehicle collision. The patient has no significant medical history, and family history is notable for major depressive disorder in her mother. Which of the following is the best explanation for this patient's behavior?

Question

A 59-year-old woman comes to the office due to upper respiratory symptoms for 3 days. She arrives an hour late for her appointment and lies about the reason, blaming it on an emergency at work.  The patient is angry that the physician refused to prescribe antibiotics for her over the phone, and she paces at the reception desk, insisting that the office staff work her into the schedule because "I'm very busy and must be seen immediately."  She mentions that her previous physician always made time for her.  The patient is a successful businesswoman and is recently divorced.  During the visit, she expresses irritation at having to take time out of her busy day to come to the appointment and admits to being "under stress" at work.  The patient then talks at length about feeling depressed because her children no longer want to see her even though she is a "great mother."  She is upset that her daughter recently canceled plans to visit in order to help a friend who was in a near-fatal motor vehicle collision.  The patient has no significant medical history, and family history is notable for major depressive disorder in her mother.  Which of the following is the best explanation for this patient's behavior?

Quizplus · Accepted Answer

11ec25c8_d7e2_e20d_bc81_47bdd0efdb50_MD0003_00 This patient's behavior is characteristic of narcissistic personality disorder, a pervasive pattern of grandiosity, need for admiration, sense of entitlement, and lack of empathy. Although these patients can often be charming and successful, their motivation is to obtain constant attention and praise. Often arrogant and boastful, they display an exaggerated sense of self-importance and frequently overestimate their abilities and accomplishments. These individuals have difficulty sustaining relationships because they are unwilling to recognize or identify with the feelings and needs of others. They are often disappointed in relationships when their needs to be admired and to be the center of attention are not met (as in this patient, who is upset that her daughter chose to help a friend rather than see her). In the medical setting, these patients may be demanding and feel entitled to special treatment (eg, being angry that the physician will not prescribe antibiotics over the phone, insisting on being seen immediately). (Choice A) An adjustment disorder occurs in response to a stressor and resolves when the stressor is no longer present. It would not explain the pattern of grandiosity, entitlement, or lack of empathy seen in this patient. (Choice B) This patient does not exhibit the disturbance of self-identity, splitting (ie, feeling herself or others to be all good or all bad), suicidal threats, and repetitive self-injury that are characteristic of borderline personality disorder (BPD). BPD would not explain this patient's sense of entitlement, grandiosity, or lack of empathy. (Choice C) Although histrionic and narcissistic personality disorders are both characterized by seeking admiration and by the need to be the center of attention, patients with histrionic personality disorder do not display emotional coldness or lack of empathy. These patients instead exhibit excessive emotionality, overestimate the closeness of relationships, and use seductive behavior to get their needs met. (Choice E) In paranoid personality disorder, patients have a pervasive suspicion or mistrust of others rather than a need for admiration. (Choice F) This patient does not have enough symptoms to diagnose persistent depressive disorder (depressed mood for ≥2 years accompanied by hopelessness, disturbance in appetite/sleep/energy/concentration, and low self-esteem). Educational objective: Narcissistic personality disorder is characterized by an exaggerated sense of self-importance, need for admiration, sense of entitlement, and lack of empathy. References: Beyond the diagnostic traits: a collaborative exploratory diagnostic process for dimensions and underpinnings of narcissistic personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25314232) Narcissistic personality disorder: an integrative review of recent empirical data and current definitions. (http://www.ncbi.nlm.nih.gov/pubmed/24633939)

A 59-Year-Old Woman Comes to the Office Due to Upper