A nurse greets a patient who had been experiencing delusions of prosecution and auditory hallucinations by saying, "Good evening. How are you?" The patient, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?

1. A

   Dissociation

2. B

   Transference

3. C

   Displacement

4. D

   Identification

Appeared in: ISRO 2024

Explanation

• The patient's statement, "The man is bad," demonstrates a split between his sense of self and his feelings, a phenomenon known as dissociation.
• Specifically, this is a form of depersonalization, where one feels detached from one's own mental processes or body.
• Referring to oneself in the third person is a classic clinical manifestation of dissociative alterations in identity.
• This mechanism allows the patient to distance himself from distressing thoughts and feelings associated with his psychotic symptoms.

Why Other Options Were Wrong

• Option B: Transference involves redirecting feelings from a past relationship onto a current person, such as the nurse. The patient is talking about himself, not projecting feelings onto the nurse.
• Option C: Displacement is the act of shifting emotions from an original, threatening source to a less threatening one. The patient is expressing a feeling about himself, not redirecting it elsewhere.
• Option D: Identification is the process of adopting the traits or behaviors of another person. The patient is doing the opposite; he is detaching from his own identity.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Psychiatric symptoms and defense mechanisms to guide bedside assessment, documentation, and the next nursing action.
• Nurses must recognize third-person self-reference as a potential sign of severe psychological distress, depersonalization, or a psychotic process. It is not just a quirk of speech.
• Documenting this type of speech verbatim is crucial for accurate psychiatric assessment and diagnosis by the healthcare team.
• What if the patient had said, "That nurse is bad"? This could be a simple statement of opinion, or it could be a sign of paranoia or displacement, depending on the context. The nurse's next step would be to explore the patient's reasoning without being defensive.

How to Approach the Question

• First, analyze the core behavior in the clinical scenario. The patient is referring to himself in the third person ('the man').
• Next, review the definitions of the four options provided.
• Evaluate 'Dissociation': This involves a disconnection from self or reality. Third-person self-reference is a form of depersonalization, which is a dissociative symptom. This is a strong match.
• Evaluate 'Transference': This involves redirecting feelings about a past figure onto a current one (e.g., the nurse). The patient is talking about himself, so this is incorrect.
• Evaluate 'Displacement': This involves shifting feelings to a safer target. The patient is expressing feelings about himself, not another target. This is incorrect.
• Evaluate 'Identification': This involves adopting another's traits. The patient is detaching from his own traits. This is incorrect.

Concept Tested & Keywords

• Concept Tested: Psychiatric symptoms and defense mechanisms
• Stem keywords: delusions of prosecution, auditory hallucinations, referring to himself, the man is bad
• Lead-in keywords: example
• Clinical cues: The patient's use of the third person ('the man') to refer to himself is the key clinical sign.

Question ID

QDr0kPo0T1oGjbJFH37C9y

Copy ID

Reference Book

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 6334-6336

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 1418-1420