A 34-year-old woman presents to your clinic to establish care. When asked about her medical history, she explains that she recently moved herself into a studio apartment and that she has fallen in love with the people in her neighborhood and already has so many friends. She explains that she hasn't been to the doctor since she was in her early 20s but recently has been experiencing a cough for the past week and desires evaluation for this. Her temperature is 36.6°C (97.9°F), heart rate 64 beats/minute, blood pressure 110/64 mmHg, respirations 16/minute, and pulse oximetry 99% on room air. As the physical examination begins, she asks if she can go to the bathroom to make sure there is nothing in her teeth. She also asks for a glass of water for her hoarse voice. While in the bathroom, she can be heard singing and talking through the door to the nurse. When she comes back in the room, she stumbles slightly getting onto the exam table and falls into the physician and grabs his shoulder to catch her balance and starts laughing to herself, saying “I'm so clumsy!” Examination of the mouth reveals moist mucous membranes, no tonsillar swelling or exudate, and no erythema in the posterior oropharynx. When these findings are explained, she tells the physician “Wow you are such a smart doctor. I'm so lucky I found you!”
C) Histrionic personality disorder
Histrionic personality disorder is characterized by elevated emotion, attention-seeking behavior, preoccupation with appearance, and sometimes sexually provocative behaviors. While each individual action on its own (i.e., going to the bathroom to examine appearance, talking through the door, “stumbling” into the doctor) could be circumstantial, together they support this diagnosis over the others listed.
(Answer A) Dependent personality disorder describes a person who has an intractable need to be taken care of- often by a family member or partner. These patients are known to have low-self-confidence and tend to remain in abusive relationships. While this patient shows interest in relationships, she shows independence moving into her studio apartment and meeting new people.
(Answer B) Factitious disorder is the conscious simulation of illness for primary gain (e.g., attention from medical providers). The presentation of factitious disorder most often has a long history of utilization of the medical system and requests for extensive diagnostic workups and invasive procedures. This patient has not seen a provider for roughly a decade and has not expressed any interest in further testing for her cough.
(Answer D) Malingering is a conscious simulation of illness for secondary gain (e.g., time off work, financial benefit, obtaining controlled substances). In this patient's presentation, the patient does not request anything from the physician. Instead, she engages them for affirmation and attention.
(Answer E) Schizotypal personality disorder most often presents with patients who have an eccentric appearance and endorse “magical thinking”--ideas that are inconsistent with cultural norms and influence the patient's behavior. This patient does not demonstrate these characteristics.
Key Learning Point
Histrionic personality disorder should be considered in patients who are overly concerned about their appearance, seek attention, are sexually provocative, and have an elevated mood. Demonstration of primary and/or secondary gain is not required for diagnosis.
