A 45-year-old man comes to the office for a routine maintenance evaluation. The patient has no prior medical or surgical history and takes no medication. He moved to the area 3 weeks ago to work as a newscaster at a local television station. He says, "I quit my last job while we were on-air. I had my own show before, but then the station hired a coanchor. There was no room for me there." He became "extremely upset" last week when he saw an unflattering photograph of himself still featured on the station's website. The patient then crosses his arms dramatically and describes how he had previously quit another television job abruptly after his boss told him that he was difficult to work with because he was always trying to take over meetings. He bursts into tears and says, "I thought that he was my friend, but real friends don't stab you in the back like that." On mental status examination, speech is loud and not pressured; facial expressions and hand gestures appear exaggerated. Which of the following is the most likely diagnosis in this patient?

Question

A 45-year-old man comes to the office for a routine maintenance evaluation.  The patient has no prior medical or surgical history and takes no medication.  He moved to the area 3 weeks ago to work as a newscaster at a local television station.  He says, "I quit my last job while we were on-air.  I had my own show before, but then the station hired a coanchor.  There was no room for me there."  He became "extremely upset" last week when he saw an unflattering photograph of himself still featured on the station's website.  The patient then crosses his arms dramatically and describes how he had previously quit another television job abruptly after his boss told him that he was difficult to work with because he was always trying to take over meetings.  He bursts into tears and says, "I thought that he was my friend, but real friends don't stab you in the back like that."  On mental status examination, speech is loud and not pressured; facial expressions and hand gestures appear exaggerated.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7e8_1234_bc81_033a88892a65_MD0003_00 This patient's intense need to be the center of attention, preoccupation with physical attractiveness, and dramatic emotional displays are consistent with a diagnosis of histrionic personality disorder. Patients with histrionic personality disorder become distressed in situations where they are not the center of attention, frequently use physical appearance to attract attention, and often behave in a sexually seductive or provocative manner. They have an overly dramatic communication style (eg, crossing arms dramatically, exaggerated facial expressions and hand gestures) with rapidly shifting emotions (eg, easily becoming "extremely upset," bursting into tears) and impressionistic speech (eg, "real friends don't stab you in the back like that"); they also frequently perceive personal relationships to be more intimate than they may be in reality (eg, "I thought he was my friend"). As with all personality disorders, a diagnosis of histrionic personality disorder requires that the patient demonstrate a persistent pattern of problematic behavior since early adulthood and across multiple contexts. The differential diagnosis includes other personality disorders, mood disorders, and other psychiatric disorders that may present with intense and excessive emotions. Although patients with narcissistic personality disorder (NPD) also need to be the center of attention, they typically do not exhibit the dramatic emotional displays (seen in this patient) that are a key feature of histrionic personality disorder. Other features of NPD not seen here include a lack of empathy and interpersonal exploitation (Choice F). (Choice A) Antisocial personality disorder can explain impulsivity, irresponsibility (eg, failure to sustain consistent work behavior), and irritability but primarily manifests as a disregard for the safety of others (eg, hurting or stealing from others) and for social norms (eg, repeatedly performing acts that are grounds for arrest). (Choice B) Bipolar II disorder is diagnosed when a patient has a history of ≥1 hypomanic episode (eg, pressured speech) and ≥1 major depressive episode, neither of which are evident in this patient's history. (Choice C) Patients with borderline personality disorder are emotional and impulsive. However, there is no evidence that this patient has identity disturbance, fears of abandonment, or repetitive self-harm behaviors that are key features of borderline personality disorder. (Choice D) Intermittent explosive disorder presents with intermittent verbal or physical aggressive behavior that is disproportionate to the objective triggering offense. Educational objective: Histrionic personality disorder presents with attention seeking, inappropriately provocative behavior, and dramatic emotions and actions. These behaviors must be present since early adulthood and across multiple contexts. References: Histrionic personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/31194465)

A 45-Year-Old Man Comes to the Office for a Routine