A 27-year-old woman comes to the office due to abdominal pain. She has had intermittent "aches and cramps" in her abdomen for the past few weeks. The patient denies nausea, vomiting, or a change in appetite or bowel movements. Her stress level has been higher than normal since her boyfriend broke off their relationship a month ago. She says, "We were together for 10 years. I did everything to please him and make him happy, and he abandoned me. I don't know how to go on without him." The patient starts crying when discussing how her boyfriend managed her finances and recently helped her apply for a new job. She is unsure about switching jobs now and canceled her interviews to "avoid more confusion." She recently moved in with a friend and hopes this person can help her "sort everything out." The patient reports feeling "tired and sad" since the breakup and looks down at the ground, speaking softly during the interview. Medical history is noncontributory. Physical examination shows minimal discomfort on palpation of the abdomen with no rebound or guarding; the abdomen is soft and nondistended. Which of the following is the most likely explanation for the patient's behavior?

Question

A 27-year-old woman comes to the office due to abdominal pain.  She has had intermittent "aches and cramps" in her abdomen for the past few weeks.  The patient denies nausea, vomiting, or a change in appetite or bowel movements.  Her stress level has been higher than normal since her boyfriend broke off their relationship a month ago.  She says, "We were together for 10 years.  I did everything to please him and make him happy, and he abandoned me.  I don't know how to go on without him."  The patient starts crying when discussing how her boyfriend managed her finances and recently helped her apply for a new job.  She is unsure about switching jobs now and canceled her interviews to "avoid more confusion."  She recently moved in with a friend and hopes this person can help her "sort everything out."  The patient reports feeling "tired and sad" since the breakup and looks down at the ground, speaking softly during the interview.  Medical history is noncontributory.  Physical examination shows minimal discomfort on palpation of the abdomen with no rebound or guarding; the abdomen is soft and nondistended.  Which of the following is the most likely explanation for the patient's behavior?

Quizplus · Accepted Answer

11ec25c8_d7e3_f37e_bc81_a556bfd8a365_MD0003_00 This patient's excessive dependency on her boyfriend, indecisiveness, and fear of managing on her own are suggestive of dependent personality disorder (DPD). Individuals with DPD need excessive reassurance and advice in making decisions (eg, interviewing for a new job), and they avoid taking initiative due to feelings of inadequacy. They tend to be clingy and submissive and often acquiesce to others' demands due to fear of losing approval or support. They are fearful of being left to care for themselves (eg, canceling interviews to "avoid confusion," hoping a friend will help "sort everything out") and typically seek a new relationship as soon as one ends. Patients with DPD may experience symptoms of depressed mood or anxiety, triggered by their sense of inadequacy and concerns about managing alone when relationships end. They may seek medical attention with somatic symptoms (eg, this patient's nonspecific abdominal pain) that are an expression of their distress. (Choice A) Acute stress disorder develops within 4 weeks of a life-threatening, traumatic event and is characterized by intrusive reexperiencing and avoidance of reminders of the incident. (Choice B) An adjustment disorder would not explain this patient's long-standing dependency on her boyfriend, indecisiveness, and fear of being alone. Stressors often exacerbate the symptoms of an underlying disorder. (Choice C) Both DPD and avoidant personality disorder are characterized by feelings of inadequacy, fear of rejection, and need for reassurance. However, these characteristics lead individuals with avoidant personality disorder to avoid relationships, rather than seek them out (as in this patient). (Choice D) Although individuals with borderline personality disorder also fear abandonment, they react with rage and demanding behavior, whereas individuals with dependent personality are submissive. This patient also lacks the mood instability, impulsivity, and self-harm characteristically seen in borderline personality disorder. (Choice F) This patient's mood symptoms are insufficient to meet criteria for a major depressive episode. Patients with DPD commonly experience some degree of depression following separation from their source of support. (Choice G) Patients with somatic symptom disorder have anxiety that is caused by their symptoms. This patient's anxiety, however, is triggered not by her physical symptoms but by a fear of being alone and having to care for herself. Somatic symptoms are often an expression of anxiety or depression. Educational objective: Dependent personality disorder is characterized by excessively dependent and submissive behaviors, indecisiveness, and fear of being left to manage alone. References: Dependent personality disorder: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/24185092) Classification, assessment, prevalence, and effect of personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25706217)

A 27-Year-Old Woman Comes to the Office Due to Abdominal