A 21-year-old woman is brought to the emergency room 1 hour after she ingested 12 pills of acetaminophen. She had a fight with her boyfriend immediately prior to the ingestion, during which she threatened to kill herself if he broke up with her. She has been hospitalized 4 times for overdoses in the past 3 years following breakups with her partners. On the way to the hospital, she screamed and then assaulted the paramedic who attempted to take her temperature. Physical examination shows multiple rows of well-healed scars bilaterally on the wrists. This patient is most likely to display which of the following defense mechanisms?
Q2
A 48-year-old man and his wife present to a psychologist's office for a therapy session. He was encouraged to visit the psychiatrist 6 months ago by his wife and they have been meeting with the psychologist several times a month ever since. Initially, she was concerned about behavioral changes she observed after he was passed up for a promotion at work. She felt he was taking on a new personality and was acting like his coworker, who actually did get the promotion. He would also talk about his coworker and praise his intelligence and strategic character. Over the course of several months, the patient bought new clothes that looked like the other man's clothes. He changed his hairstyle and started using phrases that were similar to his coworker. Today, they both seem well. The patient still does not seem to think there is a problem and requests to stop therapy. His wife was frustrated because her husband recently bought a new car of the exact make and model of his coworker. Which of the following defense mechanisms best describes this patient's condition?
Q3
A 45-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He reports that he recently found out that his wife had an affair with her personal trainer and that she now left him for her new partner. The patient is alone with their two children now. To be able to care for them, he had to reduce his working hours and to give up playing tennis twice a week. When asked about his feeling towards his wife and the situation, he reports that he has read several books about human emotion recently. He says, “Falling in love has neurological effects similar to those of amphetamines. I suppose, my wife was just seeking stimulation.” Which of the following defense mechanisms best describes this patient's reaction?
Q4
A parent-teacher conference is called to discuss the behavior of a 9-year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. He is performing poorly in school and has trouble focusing. He is destructive to classroom property, tore a classmate's art project, and takes other children's lunches regularly. He is avoided by his classmates. His mother reports that her son can "sometimes be difficult." Recently he placed a rubber band around the cats tail, resulting in gangrene. What is the most likely diagnosis?
Q5
A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class and frequently disrupts the other children. This behavior has been going on for about 8 months, but recently it worsened prompting his teacher to bring it to his mother’s attention. The patient’s mother was surprised to hear about these issues; however, she admits that she needs to repeat herself several times when asking her son to complete his chores. He also has trouble sitting still when doing homework. Which of the following is the most likely diagnosis in this patient?
Q6
A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a multi-colored top with bright yellow pants, and he makes broad gestures while speaking. Before the paramedics left, they told the doctor that multiple bystanders at the bar reported the patient was flirting with numerous women. He began to touch one of them inappropriately, and she shoved him away. Upset, he demanded to be taken to the ED. The doctor begins to suspect the patient has a personality disorder. Which one is most likely?
Q7
In your outpatient clinic you are seeing a 22-year-old female for her annual check-up. She has a past medical history significant for sexual abuse in her teens. Currently she has no complaints. She reports that her last menstrual period was 1 week ago. Her temperature is 98.5 deg F (36.9 deg C), pulse is 65/min, blood pressure is 110/75 mmHg, respirations are 11/min. Physical exam is notable only for dry mucous membranes with multiple dental carries and calluses on the dorsum of her right hand. Her BMI is 17. What is the most likely diagnosis?
Q8
A 19-year-old man presents to the emergency room after a suicidal gesture following a fight with his new girlfriend. He tearfully tells you that she is “definitely the one," unlike his numerous previous girlfriends, who were "all mean and selfish” and with whom he frequently fought. During this fight, his current girlfriend suggested that they spend time apart, so he opened a window and threatened to jump unless she promised to never leave him. You gather that his other relationships have ended in similar ways. He endorses impulsive behaviors and describes his moods as “intense” and rapidly changing in response to people around him. He often feels “depressed” for one day and then elated the next. You notice several superficial cuts and scars on the patient’s arms and wrists, and he admits to cutting his wrists in order to “feel something other than my emptiness.” Which of the following is the most likely diagnosis for this patient?
Q9
A 38-year-old male presents for counseling by a psychologist mandated by the court. The patient explains that he does not mean to hit his wife when they are arguing, but something just comes over him that he cannot control. Upon further discussion, the patient reveals that his father was incarcerated several times for physically abusing his mother. Which of the following best describes the behavior seen in this patient?
Q10
You are a sleep physician comparing the results of several hypnograms taken in the sleep lab the prior night. You examine one chart which shows decreased REM sleep, less total time sleeping, and more frequent nocturnal awakenings. Which of these patients most likely exhibits this pattern?
Mood Disorders US Medical PG Practice Questions and MCQs
Question 1: A 21-year-old woman is brought to the emergency room 1 hour after she ingested 12 pills of acetaminophen. She had a fight with her boyfriend immediately prior to the ingestion, during which she threatened to kill herself if he broke up with her. She has been hospitalized 4 times for overdoses in the past 3 years following breakups with her partners. On the way to the hospital, she screamed and then assaulted the paramedic who attempted to take her temperature. Physical examination shows multiple rows of well-healed scars bilaterally on the wrists. This patient is most likely to display which of the following defense mechanisms?
A. Fantasy
B. Controlling
C. Displacement
D. Splitting (Correct Answer)
E. Sublimation
Explanation: ***Splitting***
- Splitting describes **inability to integrate positive and negative qualities** of self and others into a cohesive whole, leading to abrupt, alternating shifts between idealization and devaluation. This is characteristic of **borderline personality disorder (BPD)**, which is strongly suggested by the patient's history of impulsive acts (overdoses, assault, self-harm), unstable relationships, and suicidal threats.
- The patient's immediate shift from threatening suicide to assaulting a paramedic, along with the history of repeated overdoses after relationship breakups, indicates an extreme "all good" or "all bad" perception of situations and people, a hallmark of splitting.
*Fantasy*
- Fantasy involves retreating into a **private mental world** to escape uncomfortable thoughts, feelings, or situations. While the patient may use fantasy at times, it is not the primary defense mechanism explaining her overt behaviors like assault and repeated overdose threats in real-life situations.
- It often manifests as **daydreaming** or imaginatively creating alternative realities, which is not depicted as the leading defense in this scenario.
*Controlling*
- Controlling is a defense mechanism involving the **attempt to manage or regulate events or others** to minimize discomfort or anxiety. While the patient's behaviors might seem manipulative or an attempt to control her relationships, "controlling" in this context is a broader concept that is less specific than "splitting" for explaining the abrupt shifts in her perceptions and actions.
- While aspects of her behavior may appear controlling (e.g., threatening suicide to prevent a breakup), it doesn't capture the underlying psychological mechanism of idealization and devaluation as effectively as splitting does.
*Displacement*
- Displacement involves redirecting an **emotion or impulse from its original source to a safer, more acceptable target**. While assaulting the paramedic could be seen as displacement of anger from her boyfriend, the broader pattern of her behavior (repeated overdoses, suicidal threats, and the "all good"/"all bad" framework) points more strongly to splitting.
- The primary emotion (anger at her boyfriend) is redirected, but this single act doesn't explain the full spectrum of her unstable relationships and self-harm, which are characteristic of splitting.
*Sublimation*
- Sublimation is a **mature defense mechanism** where unacceptable impulses are transformed into socially acceptable and productive behaviors. This patient's actions, such as repeated overdoses, self-harm, and assault, are clearly maladaptive and destructive, not socially acceptable or constructive.
- It involves channeling urges into creative or beneficial activities, which is the opposite of the impulsive and destructive behaviors exhibited by the patient.
Question 2: A 48-year-old man and his wife present to a psychologist's office for a therapy session. He was encouraged to visit the psychiatrist 6 months ago by his wife and they have been meeting with the psychologist several times a month ever since. Initially, she was concerned about behavioral changes she observed after he was passed up for a promotion at work. She felt he was taking on a new personality and was acting like his coworker, who actually did get the promotion. He would also talk about his coworker and praise his intelligence and strategic character. Over the course of several months, the patient bought new clothes that looked like the other man's clothes. He changed his hairstyle and started using phrases that were similar to his coworker. Today, they both seem well. The patient still does not seem to think there is a problem and requests to stop therapy. His wife was frustrated because her husband recently bought a new car of the exact make and model of his coworker. Which of the following defense mechanisms best describes this patient's condition?
A. Sublimation
B. Conversion
C. Regression
D. Splitting
E. Introjection (Correct Answer)
Explanation: ***Introjection***
- **Introjection** (also known as identification in some classification systems) is a defense mechanism where an individual unconsciously adopts the characteristics, attitudes, or behaviors of another person, particularly someone perceived as successful or threatening.
- In this case, the patient responds to feelings of inadequacy after being passed over for promotion by adopting his coworker's external characteristics—clothes, hairstyle, speech patterns, and even purchasing the same car model.
- This represents an attempt to cope with envy and feelings of inferiority by incorporating the perceived superior qualities of the coworker into his own identity.
- **Clinical note**: Some classification systems distinguish between "identification" (behavioral imitation) and "introjection" (deeper internalization of values), though these terms are often used interchangeably in defense mechanism literature.
*Sublimation*
- **Sublimation** is a mature defense mechanism where unacceptable impulses or feelings are redirected into socially acceptable and productive behaviors (e.g., channeling aggressive urges into competitive sports).
- The patient's behavior does not involve transforming an unacceptable urge into a constructive outlet; rather, it involves adopting another person's characteristics.
*Conversion*
- **Conversion disorder** (Functional Neurological Symptom Disorder) involves psychological distress manifesting as neurological symptoms without an identifiable medical cause, such as paralysis, blindness, or seizures.
- The patient's presentation involves behavioral and personality changes, not the development of physical or neurological symptoms.
*Regression*
- **Regression** is a defense mechanism where an individual reverts to behaviors characteristic of an earlier developmental stage in response to stress (e.g., thumb-sucking, tantrums, excessive dependence).
- The patient's behavior does not represent a return to childhood patterns but rather emulation of another successful adult.
*Splitting*
- **Splitting** is a primitive defense mechanism, commonly seen in borderline personality disorder, where individuals view people or situations as entirely good or entirely bad, unable to integrate both positive and negative qualities.
- The patient's actions do not involve dichotomous thinking about people but rather an attempt to model himself after someone he perceives as successful.
Question 3: A 45-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He reports that he recently found out that his wife had an affair with her personal trainer and that she now left him for her new partner. The patient is alone with their two children now. To be able to care for them, he had to reduce his working hours and to give up playing tennis twice a week. When asked about his feeling towards his wife and the situation, he reports that he has read several books about human emotion recently. He says, “Falling in love has neurological effects similar to those of amphetamines. I suppose, my wife was just seeking stimulation.” Which of the following defense mechanisms best describes this patient's reaction?
A. Sublimation
B. Intellectualization (Correct Answer)
C. Rationalization
D. Humor
E. Externalization
Explanation: ***Intellectualization***
- The patient demonstrates **intellectualization** by focusing on the abstract, theoretical aspects of his personal crisis, discussing neurology and human emotions rather than expressing his feelings of loss or betrayal.
- This defense mechanism allows him to avoid confronting the painful emotional reality of his wife leaving him by engaging in **rational, cognitive thought** about the situation.
*Sublimation*
- **Sublimation** involves channeling unacceptable impulses or emotions into socially acceptable and constructive behaviors; for instance, expressing aggression through competitive sports.
- While the patient has had to reduce his tennis playing, there is no evidence he is diverting his distress into new, positive, and productive activities sanctioned by society.
*Rationalization*
- **Rationalization** is creating logical but false explanations for one's own unacceptable feelings, behaviors, or motives to avoid self-blame or shame.
- The patient's statements about his wife seeking stimulation are more about abstractly analyzing her actions rather than fabricating an excuse for his own behavior or feelings.
*Humor*
- **Humor** as a defense mechanism involves expressing uncomfortable feelings or thoughts in a way that is amusing or ironic, without necessarily diminishing the underlying emotion.
- The patient's statement, while analytical, does not involve any comedic or lighthearted expression of his distress.
*Externalization*
- **Externalization** (often seen in projection) attributes one's own unacceptable thoughts or feelings to another person or object.
- The patient is not projecting his own internal feelings onto his wife; rather, he is attempting to explain her actions through a detached, academic lens.
Question 4: A parent-teacher conference is called to discuss the behavior of a 9-year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. He is performing poorly in school and has trouble focusing. He is destructive to classroom property, tore a classmate's art project, and takes other children's lunches regularly. He is avoided by his classmates. His mother reports that her son can "sometimes be difficult." Recently he placed a rubber band around the cats tail, resulting in gangrene. What is the most likely diagnosis?
A. Oppositional defiant disorder
B. Conduct disorder (Correct Answer)
C. Antisocial personality disorder
D. Attention deficit disorder
E. Separation anxiety disorder
Explanation: **Conduct disorder**
- The child's behaviors, such as **aggression towards people and animals** (harming the cat), **destruction of property** (tearing art project), **deceitfulness or theft** (taking lunches), and **serious rule violations** (extreme disruptiveness), are hallmark symptoms of conduct disorder.
- The persistence and variety of these behaviors, causing significant impairment in social and academic functioning, align with the diagnostic criteria for conduct disorder, especially given the child's age.
*Oppositional defiant disorder*
- This disorder involves a pattern of **angry/irritable mood, argumentative/defiant behavior, or vindictiveness**, but typically does not include the more severe behaviors like aggression towards people or animals, destruction of property, or theft.
- The child's actions (e.g., harming the cat, stealing lunches, destroying property) go beyond mere defiance and indicate a more pervasive pattern of aggression and rule-breaking.
*Antisocial personality disorder*
- Antisocial personality disorder cannot be diagnosed before the age of 18; however, evidence often indicates the presence of **conduct disorder** with onset before age 15.
- While the symptoms described are consistent with precursors to antisocial personality disorder, the current age of the child (9 years old) makes this diagnosis inappropriate.
*Attention deficit disorder*
- While the child has trouble focusing and is disruptive, these are only some of the symptoms described; the prominent features are **aggression, destruction, and deceitfulness**, which are not core to ADHD.
- ADHD primarily involves **inattention, hyperactivity, and impulsivity**, without the deliberate harmful intent or persistent violation of others' rights seen in this case.
*Separation anxiety disorder*
- This disorder is characterized by **excessive anxiety concerning separation** from attachment figures, often manifesting as refusal to go to school, nightmares about separation, or physical symptoms when anticipating separation.
- The symptoms presented in the vignette (aggression, destruction, theft, and disruptive behavior) bear no resemblance to the diagnostic criteria for separation anxiety disorder.
Question 5: A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class and frequently disrupts the other children. This behavior has been going on for about 8 months, but recently it worsened prompting his teacher to bring it to his mother’s attention. The patient’s mother was surprised to hear about these issues; however, she admits that she needs to repeat herself several times when asking her son to complete his chores. He also has trouble sitting still when doing homework. Which of the following is the most likely diagnosis in this patient?
A. Conduct disorder
B. Antisocial personality disorder
C. Oppositional defiant disorder
D. Attention deficit hyperactivity disorder (Correct Answer)
E. Schizoid personality disorder
Explanation: ***Attention deficit hyperactivity disorder***
- The patient exhibits core symptoms of **inattention** (difficulty completing assignments, forgetting tasks, needing reminders for chores) and **hyperactivity/impulsivity** (difficulty sitting still, disrupting others).
- These symptoms are present in multiple settings (school and home), have persisted for at least 6 months, and began before age 12, fulfilling the **DSM-5 criteria for ADHD**.
*Conduct disorder*
- This is characterized by a persistent pattern of behavior that violates the **basic rights of others** or major **age-appropriate societal norms or rules**.
- Symptoms include aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations, none of which are described in this patient.
*Antisocial personality disorder*
- This diagnosis requires individuals to be at least 18 years old and exhibit a pervasive pattern of **disregard for, and violation of, the rights of others** occurring since age 15.
- The patient is only 7 years old and does not display the characteristic pattern of deceit, impulsivity, irritability, or lack of remorse associated with this disorder.
*Oppositional defiant disorder*
- Typically involves a pattern of **angry/irritable mood**, **argumentative/defiant behavior**, or **vindictiveness** directed towards authority figures.
- While the patient may have some defiant traits by not doing chores, the primary issues are inattention and hyperactivity rather than active defiance or vindictive behavior.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- There is no indication that the patient is socially isolated, prefers solitary activities, or shows a lack of interest in others, making this diagnosis unlikely.
Question 6: A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a multi-colored top with bright yellow pants, and he makes broad gestures while speaking. Before the paramedics left, they told the doctor that multiple bystanders at the bar reported the patient was flirting with numerous women. He began to touch one of them inappropriately, and she shoved him away. Upset, he demanded to be taken to the ED. The doctor begins to suspect the patient has a personality disorder. Which one is most likely?
A. Histrionic personality disorder (Correct Answer)
B. Borderline personality disorder
C. Schizotypal personality disorder
D. Narcissistic personality disorder
E. Antisocial personality disorder
Explanation: ***Histrionic personality disorder***
- Patients with **histrionic personality disorder** exhibit a pervasive pattern of excessive emotionality and attention-seeking behavior, often displayed through theatrical speech, provocative dress, and exaggerated gestures.
- The rapid shifts in mood between anger and sadness, combined with **inappropriate flirtation** and demanding behavior after being rejected, are characteristic features.
*Borderline personality disorder*
- While mood lability is present in borderline personality disorder, it is typically accompanied by a pattern of **unstable relationships**, fear of abandonment, and identity disturbance, which are not explicitly highlighted in this presentation.
- Patients with borderline personality disorder often engage in **self-harm** or suicidal gestures, which is not mentioned here.
*Schizotypal personality disorder*
- This disorder is characterized by **eccentric behavior**, peculiar thought patterns, and discomfort with close relationships, often involving magical thinking or unusual perceptual experiences.
- The patient's presentation does not describe any **paranoid ideation** or odd beliefs typical of schizotypal personality disorder.
*Narcissistic personality disorder*
- Individuals with narcissistic personality disorder display a pervasive pattern of **grandiosity**, a need for admiration, and a lack of empathy, often exploiting others for personal gain.
- While the patient might feel entitled, the primary presentation emphasizes **attention-seeking** and emotional volatility rather than an inflated sense of self-importance or exploitative behavior.
*Antisocial personality disorder*
- This disorder is marked by a pervasive pattern of **disregard for and violation of the rights of others**, often involving deceit, impulsivity, irritability, and a lack of remorse.
- Although the patient's actions led to a physical altercation, the emphasis on **emotionality** and attention-seeking rather than a consistent pattern of antisocial acts makes this less likely.
Question 7: In your outpatient clinic you are seeing a 22-year-old female for her annual check-up. She has a past medical history significant for sexual abuse in her teens. Currently she has no complaints. She reports that her last menstrual period was 1 week ago. Her temperature is 98.5 deg F (36.9 deg C), pulse is 65/min, blood pressure is 110/75 mmHg, respirations are 11/min. Physical exam is notable only for dry mucous membranes with multiple dental carries and calluses on the dorsum of her right hand. Her BMI is 17. What is the most likely diagnosis?
A. Anorexia nervosa - restrictive type
B. Obsessive compulsive disorder
C. Bulimia nervosa
D. Eating disorder not otherwise specified
E. Anorexia nervosa - purging type (Correct Answer)
Explanation: ***Anorexia nervosa - purging type***
- This patient's **low BMI (17)**, **dental caries**, and **calluses on the dorsum of her right hand** (Russell's sign) are highly suggestive of **anorexia nervosa with purging behaviors**. The history of sexual abuse is also a risk factor for eating disorders.
- While she states her last menstrual period was 1 week ago, **amenorrhea is not a required diagnostic criterion** for anorexia nervosa in DSM-5, and purging can complicate the menstrual cycle regardless of weight.
*Anorexia nervosa - restrictive type*
- While the **low BMI** is consistent with anorexia nervosa, the presence of **dental caries** and **Russell's sign** indicates **purging behaviors**, which are not characteristic of the restrictive type.
- The restrictive type exclusively involves **restricting calorie intake**, excessive exercise, or fasting, without regular purging.
*Obsessive compulsive disorder*
- **OCD** is characterized by **obsessions and compulsions**, which might impact eating habits, but it does not directly explain the specific physical findings of **low BMI**, **dental caries**, and **Russell's sign**.
- While there can be comorbidity, the primary presentation points to an eating disorder, not OCD.
*Bulimia nervosa*
- **Bulimia nervosa** is characterized by **recurrent episodes of binge eating** followed by compensatory behaviors like purging, and it also presents with **dental caries** and **Russell's sign**.
- However, for a diagnosis of bulimia nervosa, the individual must maintain a **body weight within or above the normal range**, which contradicts this patient's **BMI of 17**.
*Eating disorder not otherwise specified*
- This category is used when symptoms cause significant distress or impairment but do not meet the full criteria for specific eating disorders.
- Given the clear presentation of **low BMI** along with **purging behaviors** and associated physical signs, the criteria for anorexia nervosa, purging type, are met, making this diagnosis more specific.
Question 8: A 19-year-old man presents to the emergency room after a suicidal gesture following a fight with his new girlfriend. He tearfully tells you that she is “definitely the one," unlike his numerous previous girlfriends, who were "all mean and selfish” and with whom he frequently fought. During this fight, his current girlfriend suggested that they spend time apart, so he opened a window and threatened to jump unless she promised to never leave him. You gather that his other relationships have ended in similar ways. He endorses impulsive behaviors and describes his moods as “intense” and rapidly changing in response to people around him. He often feels “depressed” for one day and then elated the next. You notice several superficial cuts and scars on the patient’s arms and wrists, and he admits to cutting his wrists in order to “feel something other than my emptiness.” Which of the following is the most likely diagnosis for this patient?
A. Bipolar I disorder
B. Major depressive disorder
C. Borderline personality disorder (Correct Answer)
D. Bipolar II disorder
E. Histrionic personality disorder
Explanation: ***Borderline personality disorder***
- This patient exhibits characteristic features of **borderline personality disorder (BPD)**, including a pattern of **unstable relationships** marked by idealization ("definitely the one") and devaluation ("all mean and selfish").
- Other key features are **impulsivity** (suicidal gesture, cutting), **affective instability** ("intense" and rapidly changing moods), chronic feelings of **emptiness**, and a history of **self-harm** (superficial cuts and scars).
*Bipolar I disorder*
- While the patient describes rapidly changing and "intense" moods, the rapid shifts over days and reactivity to others are more characteristic of **mood lability** in BPD than distinct **manic or hypomanic episodes** lasting several days or longer, which define bipolar disorder.
- The suicidal gesture stemming from interpersonal conflict and fear of abandonment, combined with chronic self-harm, points strongly away from a primary mood disorder.
*Major depressive disorder*
- Although the patient reports feeling "depressed," the predominant features are not a persistent depressed mood or anhedonia but rather **unstable relationships**, **impulsivity**, and **affective dysregulation** beyond typical depressive symptoms.
- The "elated" periods described are also inconsistent with unipolar depression.
*Bipolar II disorder*
- This diagnosis requires a history of at least one **major depressive episode** and at least one **hypomanic episode**. While the patient describes mood shifts, they are described as "rapidly changing in response to people around him" and lasting for a day, which is more consistent with **affective instability** seen in BPD rather than sustained hypomanic episodes.
- The prominent features of self-harm and unstable relationships are not central to Bipolar II disorder.
*Histrionic personality disorder*
- Patients with **histrionic personality disorder** typically display excessive emotionality and attention-seeking behavior, often with a theatrical presentation.
- While there may be some overlap in attention-seeking aspects (suicidal gesture), the profound **instability of mood**, chronic **emptiness**, self-harm, and intense **fear of abandonment** are core to BPD and less characteristic of histrionic traits.
Question 9: A 38-year-old male presents for counseling by a psychologist mandated by the court. The patient explains that he does not mean to hit his wife when they are arguing, but something just comes over him that he cannot control. Upon further discussion, the patient reveals that his father was incarcerated several times for physically abusing his mother. Which of the following best describes the behavior seen in this patient?
A. Acting out (Correct Answer)
B. Reaction formation
C. Splitting
D. Dissociation
E. Identification
Explanation: ***Acting out***
- **Acting out** is the defense mechanism where unconscious emotional conflicts or impulses are expressed through actions rather than being consciously felt or verbalized.
- The patient's violent behavior toward his wife represents the direct expression of aggressive impulses through physical action without conscious emotional processing or reflection.
- The key phrase "something just comes over him that he cannot control" demonstrates the hallmark of acting out—expressing feelings through action rather than words or conscious awareness.
- This is a primitive defense mechanism commonly seen in individuals with poor impulse control who cannot tolerate uncomfortable feelings.
*Identification*
- **Identification** involves unconsciously adopting the characteristics, behaviors, or attitudes of another person, typically to reduce anxiety.
- While the patient has a history of witnessing his father's abuse, the question doesn't indicate he is consciously or unconsciously trying to become like his father or modeling himself after him.
- The core issue here is impulsive action (acting out), not identification with the father figure.
*Reaction formation*
- **Reaction formation** occurs when an individual replaces an unacceptable impulse with its opposite behavior.
- This is not present here, as the patient is directly expressing aggression, not replacing it with an opposite behavior like excessive kindness.
*Splitting*
- **Splitting** is viewing people or situations in extreme all-good or all-bad terms, without integrating positive and negative qualities.
- This scenario describes a behavioral pattern, not a distortion in how the patient perceives others.
*Dissociation*
- **Dissociation** involves disruption in consciousness, memory, identity, or perception, with detachment from reality.
- While the patient feels he "cannot control" himself, this describes impulsive acting out rather than true dissociation with memory gaps or detachment from identity.
Question 10: You are a sleep physician comparing the results of several hypnograms taken in the sleep lab the prior night. You examine one chart which shows decreased REM sleep, less total time sleeping, and more frequent nocturnal awakenings. Which of these patients most likely exhibits this pattern?
A. A healthy 9-month-old female
B. A healthy 40-year-old male
C. A healthy 75-year-old male (Correct Answer)
D. A healthy 3-year-old male
E. A healthy 20-year-old female
Explanation: ***A healthy 75-year-old male***
- As individuals **age**, changes in sleep architecture commonly include **decreased REM sleep**, reduced total sleep time, and more frequent **nocturnal awakenings**.
- These normative age-related changes are due to alterations in **circadian rhythm regulation** and a decrease in the intensity of sleep-promoting mechanisms.
*A healthy 9-month-old female*
- **Infants** typically have a significantly **higher proportion of REM sleep** (around 50%) and **more total sleep time** than adults.
- While they have frequent awakenings, their overall sleep pattern is not characterized by decreased REM sleep or less total sleep time.
*A healthy 40-year-old male*
- A healthy middle-aged adult generally exhibits a relatively **stable sleep architecture**, with typical percentages of REM and non-REM sleep.
- Significant decreases in REM sleep, total sleep time, and frequent awakenings are **uncommon** in healthy individuals of this age without underlying pathology.
*A healthy 3-year-old male*
- **Young children** still exhibit a relatively **high percentage of REM sleep** and require a substantial amount of total sleep.
- While night awakenings can occur, the overall sleep pattern is not usually characterized by the marked reduction in REM and total sleep seen in the described hypnogram.
*A healthy 20-year-old female*
- **Young adults** generally have a relatively **robust sleep architecture**, with a higher proportion of **slow-wave sleep** (deep sleep) and stable REM sleep percentages.
- The described pattern of decreased REM and total sleep, along with frequent awakenings, is **atypical** for a healthy young adult.
