Psychotherapeutic approaches (DBT, MBT) — MCQs

A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?

A 23-year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits to a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous 2 weeks. On morning rounds, the patient reports that the nurses are incompetent but the doctors are some of the best in the world. The patient's vitals are stable and her wrist lacerations are very superficial requiring only simple dressings without sutures. The patient is discharged a few days later and she feels well. Which of the following is the most appropriate initial treatment for this patient?

A 25-year-old woman is brought to the emergency department by her boyfriend after she cut her forearms with a knife. She has had multiple visits to the emergency department in the past few months for self-inflicted wounds. She claims that her boyfriend is the worst person in the world. She and her boyfriend have broken up 20 times in the past 6 months. She says she cut herself not because she wants to kill herself; she feels alone and empty and wants her boyfriend to take care of her. Her boyfriend claims that she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and vary from states of exuberance and self-confidence to states of self-doubt and melancholy. On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?

A 35-year-old man comes to the Veterans Affairs hospital because of a 2-month history of anxiety. He recently returned from his third deployment to Iraq, where he served as a combat medic. He has had difficulty readjusting to civilian life. He works as a taxi driver but had to take a leave of absence because of difficulties with driving. Last week, he hit a stop sign because he swerved out of the way of a grocery bag that was in the street. He has difficulty sleeping because of nightmares about the deaths of some of the other soldiers in his unit and states, “it's my fault, I could have saved them. Please help me.” Mental status examination shows a depressed mood and a restricted affect. There is no evidence of suicidal ideation. Which of the following is the most appropriate initial step in treatment?

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 33-year-old man with documented antisocial personality disorder and substance use disorder is convicted of assault. The defense attorney requests psychiatric testimony that the defendant's personality disorder diminished his capacity to conform his conduct to the law. His history includes multiple prior convictions, repeated lying, failure to sustain employment, lack of remorse, and disregard for others' safety. However, he understood the wrongfulness of his actions and planned the assault in advance. Evaluate the relationship between antisocial personality disorder and criminal responsibility.

A 26-year-old woman presents requesting cosmetic surgery consultation. She is preoccupied with achieving the 'perfect' appearance, has undergone multiple procedures, and expresses disappointment with each result. She describes herself as special and destined for greatness, becomes enraged when her primary care physician suggested psychiatric evaluation, and states she will report him for 'not understanding her needs.' She expects special treatment in the clinic and becomes irritated when kept waiting. On mental status exam, she shows intact reality testing. Analyze the most likely underlying personality structure.

A 50-year-old man is brought for evaluation by his wife who reports 25 years of strange behavior. He has no close friends, prefers solitary activities, shows little emotion even at family events, and appears indifferent to praise or criticism. He works as a night security guard and has never desired a romantic relationship beyond the marriage his family arranged. He denies hallucinations or paranoia. On exam, he shows restricted affect but is cooperative and logical. What distinguishes this presentation from schizoid personality disorder with comorbid depression?

A 29-year-old woman with borderline personality disorder presents to the emergency department after superficial self-cutting following an argument with her boyfriend. She demands admission, stating 'I'll kill myself if you send me home.' She has had 15 psychiatric hospitalizations in the past 3 years, typically lasting 2-3 days. Her outpatient therapist reports she is engaged in DBT and makes these threats regularly to avoid distress. She denies intent or plan for suicide, vital signs are stable, cuts are superficial. What is the most therapeutic management approach?

A 38-year-old man with antisocial personality disorder is admitted to the medical service for endocarditis from IV drug use. He is charming with nurses but becomes hostile when confronted about treatment non-adherence. He was found attempting to obtain opioids by feigning pain severity. The team is divided: some staff want to discharge him for manipulative behavior, while others advocate for continued treatment. He has violated unit rules multiple times. As the consulting psychiatrist, what is the most appropriate recommendation?