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Abandonment Anxiety in Therapy — MRCPsych Paper B MCQ

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ModeratePsychotherapyAbandonment Anxiety in TherapyMRCPsych Paper B

During psychodynamic psychotherapy, a woman with borderline personality disorder reacts to her therapist's planned 2-week holiday with intense anger, repeated reassurance seeking and an abrupt shift from idealising to denigrating the therapist. She interprets the break as evidence that the therapist no longer cares about her, although her reality testing remains intact. Which underlying difficulty best accounts for this reaction?

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Correct answer: E — Insecure attachment with heightened abandonment sensitivity

The correct answer is **B: insecure attachment with heightened abandonment sensitivity**. In borderline personality disorder, a temporary separation from an important attachment figure may be experienced as rejection or impending abandonment. Within therapy, this can produce reassurance seeking, intense anger and rapid idealisation–devaluation of the therapist. NICE similarly cautions that treatment endings and transitions can evoke strong emotional reactions. Psychotic transference is less likely because reality testing remains intact; intense affect or distorted interpretation alone is not psychosis. Antisocial traits do not characteristically explain separation distress. Intellectual disability is neither established nor required for this pattern. Malingering involves conscious fabrication for external gain, for which the stem provides no evidence.

Reference: Matthies S et al. Please Don't Leave Me—Separation Anxiety and Related Traits in Borderline Personality Disorder. Current Psychiatry Reports. 2018;20:83. https://pubmed.ncbi.nlm.nih.gov/30155649/