Sample CASC Station: Assessment of Prognosis in a Patient with OCD

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Q1 2013 October FCPS 2

Q.1 A 21-year old lady with history of chaotic Interpersonal relationships presented with history of several self-inflicted cut marks on her wrist. Her psychologist describes that she alternates between periods in which she idealises the therapist and periods of anger when she is convinced that therapist is unhelpful and the therapeutic work is worthless.

What is the likely provisional diagnosis?

Define the defense mechanisms she is using.

What is type of psychotherapy is recommended in this case and what are the different modules steps in this particular psychotherapy?

1. Personality disorder, borderline pattern (ICD11)

• 6D11.5 Borderline pattern


• Parent: 6D11 Prominent personality traits or patterns


• 6D10 Personality disorder

2. Splitting: the person sees everyone in a black and white pattern. Someone can either be good or bad. There is no inbetween. At different times, this image of someone changes.

Splitting (also called black-and-white thinking or all-or-nothing thinking) is the failure in a person's thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole. It is a common defense mechanism used by many people.[1] The individual tends to think in extremes (i.e., an individual's actions and motivations are all good or all bad with no middle ground).

The concept of splitting was developed by Ronald Fairbairn in his formulation of object relations theory; it begins as the inability of the infant to combine the fulfilling aspects of the parents (the good object) and their unresponsive aspects (the unsatisfying object) into the same individuals, instead seeing the good and bad as separate. In psychoanalytic theory this functions as a defense mechanism.

Treatment of Borderline personality disorder, Summary

1. Problem solving counselling

2. Antipsychotics and mood stabilisers (improvement in affective instability, impulsive behavioural dyscontrol, cognitive perceptual symptoms). Only for the short term.

3. Dynamic psychotherapy- difficult

4. Expressive psychotherapy- excellent results in clinical trials

5. Dialectical behavioural therapy- Reduces self haRM, very demanding, effects last for long

5. Group therapy, transference reactions are spread across the group

6. Psychoanalytically oriented psychodynamic psychotherapy, two trials, favourable