A 27-year-old woman with no medical history comes to the office due to recent-onset chest pain. She gives a dramatic, vague, and nonspecific description of the pain, which she continues even when pressed for details. The patient is dressed in revealing clothing and mentions having seen the physician several times at a nearby grocery store. Physical examination, including vital signs, is unremarkable. Laboratory evaluation and an ECG are normal and suggest no medical etiology for chest pain. Despite reassurance that more serious causes of chest pain are highly unlikely, the patient insists on scheduling a follow-up appointment. On the day of the second appointment, she arrives as the office is closing and intercepts the physician in the parking lot. The patient reports that the chest pain has disappeared; however, she is very concerned about feeling fatigued. She says, "I frequently have insomnia, but it's been worse than usual lately and I am so tired." The patient insists on calling the physician by first name, apologizes profusely for being late, and requests an after-hours appointment. At the next scheduled appointment, the patient does not mention the chest pain or fatigue but reports that she has "bad headaches and feels horribly depressed and in a black hole" following a romantic breakup a week ago. She adds, "I was sure this was the person for me, but to be honest, I am thrilled to be free again. You're also single, aren't you?" The patient has difficulty describing the nature of the depression but reports that her moods go "up and down" during the day. She denies current suicidal ideation or significant disturbances in sleep and appetite. As the appointment is ending, the patient shows the physician a photograph from a recent beach vacation and then expresses disappointment when no compliments are offered. This patient's behavior is most consistent with which of the following disorders?

Question

A 27-year-old woman with no medical history comes to the office due to recent-onset chest pain.  She gives a dramatic, vague, and nonspecific description of the pain, which she continues even when pressed for details.  The patient is dressed in revealing clothing and mentions having seen the physician several times at a nearby grocery store.  Physical examination, including vital signs, is unremarkable.  Laboratory evaluation and an ECG are normal and suggest no medical etiology for chest pain.  Despite reassurance that more serious causes of chest pain are highly unlikely, the patient insists on scheduling a follow-up appointment.  On the day of the second appointment, she arrives as the office is closing and intercepts the physician in the parking lot.  The patient reports that the chest pain has disappeared; however, she is very concerned about feeling fatigued.  She says, "I frequently have insomnia, but it's been worse than usual lately and I am so tired."  The patient insists on calling the physician by first name, apologizes profusely for being late, and requests an after-hours appointment. At the next scheduled appointment, the patient does not mention the chest pain or fatigue but reports that she has "bad headaches and feels horribly depressed and in a black hole" following a romantic breakup a week ago.  She adds, "I was sure this was the person for me, but to be honest, I am thrilled to be free again.  You're also single, aren't you?"  The patient has difficulty describing the nature of the depression but reports that her moods go "up and down" during the day.  She denies current suicidal ideation or significant disturbances in sleep and appetite.  As the appointment is ending, the patient shows the physician a photograph from a recent beach vacation and then expresses disappointment when no compliments are offered.  This patient's behavior is most consistent with which of the following disorders?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ad_1951_8f63_3bac9952a6cd_MD0005_00 This patient's vague description of symptoms, use of appearance to attract attention, dramatic but shallow and shifting emotions regarding the romantic breakup, and continued inappropriate familiarity and seductive behavior toward the physician are suggestive of histrionic personality disorder. Patients with histrionic personality disorder exhibit excessive emotionality and may attempt to manipulate the physician-patient relationship through seduction and dramatic descriptions of new symptoms at each visit. This patient's eagerness to move on to more exciting romantic opportunities and disappointment after not receiving attention are also characteristic of this disorder. Histrionic personality disorder should be differentiated from borderline, dependent, and narcissistic personality disorders, but these can also co-occur. (Choice A) This patient does not describe distinct hypomanic (lasting >4 days) and depressive episodes (lasting >2 weeks) that characterize bipolar II disorder. (Choice B) Individuals with borderline personality disorder can also exhibit attention seeking, manipulative behavior, and rapidly shifting emotions. However, this patient does not exhibit self-injurious and suicidal behavior, intense anger, chronic feelings of emptiness, and identity disturbance, which would be expected in borderline personality disorder. (Choice C) Individuals with dependent personality disorder have a pervasive psychological dependence on others to meet their emotional and physical needs. They are typically submissive and clingy and lack the excessive emotionality and demands for attention seen in histrionic personality disorder. (Choice D) Factitious disorder is characterized by the purposeful falsification of symptoms to assume the sick role. There is no evidence that this patient has intentionally made up her symptoms. It is more likely that they are an expression of her personality disorder. Educational objective: Histrionic personality disorder is characterized by excessive superficial emotionality and attention seeking. Dramatic, sexually provocative behavior is common in patients with this personality disorder, and firm boundaries are required to protect the physician-patient relationship. References: Medical comorbidity of cluster B personality disorders. (http://www.ncbi.nlm.nih.gov/pubmed/22744403) Personality disorders: review and clinical application in daily practice. (http://www.ncbi.nlm.nih.gov/pubmed/22150659)

A 27-Year-Old Woman with No Medical History Comes to the Office