Analysis
of Case Characteristics, Theory and Treatment Plan
Angel Littleton is a 19-year-old
female, who arrived at the E.R. via ambulance for an attempted suicide. The
patient ingested a bottle of prescription drugs and was then found wandering
the train tracks near her home. Presenting depressed and clearly suicidal,
disoriented about the date and time, the patient reports being sexually
assaulted, however, she is unclear when. Hospital medical records
reveal the patient came into the hospital two weeks ago. The patient was seen and
treated for a severally sprained left ankle, abrasions on the toes. The toenail
of the large toe was removed because it had lifted from the toe during the
injury and was causing her pain. The patient had some other minor abrasions on her
elbows but refused to reveal how she had been injured. The patient left the
hospital prematurely against the advice of professionals after hearing from the
nurse that the X-ray had come back negative for a break or fracture. Exactly
one week before her latest suicide attempt, the patient came into the E.R. and
started the admission process and told a nurse she wanted to speak with
someone. However, shortly after she started talking she requested to use the
bathroom and left the hospital preadmission.
When asked about these incidences
the patient remembers coming to the hospital but is unclear about the events
surrounding her leaving the hospital. Patient presents at the hospital with
alternating periods of extreme discomposure with expressions of sadness and
despair, crying at times uncontrollably and muttering incoherently and then
suddenly alert, intellectual, ridge, and coherent reporting no symptoms needing
treatment and wanting to leave the hospital. The patient has an alternating perception
of the staff at times displaying trust and other times suspicion. Patient had
poor eye contact during periods of distress she chooses to look down or away,
while in periods of composure and coherent conversation about why she is in the
hospital and events surrounding her arrival she makes brief eye contact, but
then appears to gaze through you as if in a trance. Patient had fragmentary
recall about episodic or autobiographical memory and memories recalled
were lacking proper effect and emotional congruency. Patient reports a
the lifelong enduring pattern of symptoms including a feeling disconnected from her
body, a cloudy mind, tunnel vision, racing heart, periods of insomnia,
nightmares, flashbacks, blackouts, auditory hallucinations and dreamlike
states- where she questions if the world around her is real or is she dreaming.
The patient reports a history of compulsive skin washing since age 6 and compulsive
skin picking since age 8, as well as, other mixed compulsive checking and
ritualistic behaviors. The patient has self-mutilated in the form of cigarette burns
twice on her forearms, claims to have the ability to control pain.
The patient reports she has been
staying with friends since the argument with her family that prompted her
departure from her home, she is effectively homeless. Patient reports leaving
home after an argument with her mother about her brother stealing from her and
her sister having intimate relations with her fiancé. While reporting an
ambivalent attachment with the mother, the patient reports a strong attachment
with the father, and extremely despaired of the recent betrayal of her fiancé.
The fiancé is seven years older than the client and she maintains she entered a
sexual relationship with him when she 14. The patient has had some meaningful
communication with her father whom she intendeds the hospital after
discharge. However, she reports he is an active alcoholic, who lives with a new
wife almost an hour away. Patient reports no communication with her ex-fiancé
or other family members including siblings in six months. The patient is unable
to maintain work due to a high level of interpersonal problems and reports no
other viable healthy relationships or attachments. Although the problem is
severe and appears to interfere with the person’s family, work, friendships,
leisure activities, and relationships it also appears that the level of
interpersonal dysfunction in the family and untreated trauma reported would
make it hard for anyone to function normally.
Hospitals records reveal two
other suicide attempts, at ages 14 and 16, both with prescription drugs also
requiring a gastric lavage with charcoal. The patient reports adamantly and
convincingly no memory of intent to attempt suicide, rather reporting she had a
migraine both times and could not remember clearly what had happened. In all
suicide attempts, after 24 hours patient became coherent, lacking
symptoms of depression, insistent she was not trying to harm herself and was
later released to a parent. Early childhood onset of mixed symptoms key areas
is attention, memory, impulsivity, with mixed obsessive-compulsive symptoms
as early as age 6. The patient has a history of migraines, no other serious
organic illness, yet the patients report a history of somatic symptoms
including gastrointestinal symptoms, pelvic pain, fatigue, migraines, and
various areas of generalized pain. Somatic and psychiatric symptoms appear to
wax and wane in severity and duration-however, no clear indication to her as of
yet to what triggers them. After both suicide attempts, the patient reports her
mother bringing her to seeing psychiatrist no more than once and no
prescription drugs were ever prescribed to manage symptoms. Other than the
suicide attempts the patient medical history reveals only one significant other
hospitalization for wisdom teeth removal.
Prenatal development was normal,
mother was 40 at delivery, nothing noted as abnormal about the child at birth.
The patient's parents were separated at age 6, after the divorce at 9 some
typical behavioral issues arose when the house became increasingly chaotic and childcare became sporadic. Some behavioral issues in school: Memory attention,
focus, impulsivity, and withdrawal from most peer social relationships. She is
the youngest of five, has one older brother that is a half brother from the
mother's previous relationship. She now has one new step sister through the
father’s remarriage. The mother never remarried and has no new children from
other partners. Mother has cancer and has recently sold her house and moved to
New Hampshire to live with her eldest son. The mother has a major in psychology
the father is in the science field. The patient reports one brother, age 24,
has learning disabilities, bipolar, and substance abuse history, a father is
an active alcoholic and sister uses drugs recreationally.
The patient reports being molested as a child by an uncle yet is unclear of all the details. The patient reports low libido and some level of sexual dysfunction. She was sexually active before the sexual assault beginning at age 14 but has not had relations since the
recent assault. The patient admits a history of being a victim of domestic
violence, both in the childhood home and in her personal relationship. She has
never been married, though she once was engaged her engagement was recently
and traumatically called off. The patient identifies her sexual orientation as
a bi-sexual. The patient reports good grades despite skipping school and falling
asleep in class often. Ultimately, leaving after high school after an angry
outburst at a teacher who touched her shoulder and then obtaining her GED at
16. The patient has no career, however, reports many different service position,
starting at age 10, which ultimately ended because of personal reasons i.e
broken hand, lack of care, homelessness, etc. Patient reports never been arrested
or serving time in prison.
Discussion: Analysis of Case
Characteristics, Theory and Treatment Plan
Despite enmeshment in abusive
attachments to the mother, the fiancé, and siblings, the patients unhealthy
the family dynamic that have to lead her to flee from her home and attachments and
come to therapy in search of help. Her level of commitment to a healthy way of
life is demonstrated by her weekly prompt arrival in therapy since discharge
and is a positive sign of her desire to stay free of abuse and distressing
symptoms. The patient is smart and able to understand intellectually the benefits
of treatment and at least partially able to maintain composure through the use
of dissociation.
The patient was sexually
assaulted as a child and neglected then later subject to stress and abuse
during the divorce at an early developmentally sensitive age- these are the
early contributing childhood traumas that lead to her current state. The patient
started to display early behavioral adaptations of distress that were ignored
in childhood and adolescence. During adolescence (age 14) she became sexually
active and developed an attachment to an abusive older man, whom she was
engaged to marry. Within the last year, this important yet clearly
unhealthy attachment was severed by betrayal with her sister, which was further
exasperated by her mother ignoring this and the brothers theft of her
possessions. Eventually, she left home to live on the streets, where she was
sexually assaulted (age 19), which lead to the current to state of discomposure.
Patient show symptoms and reports
a history of depersonalizing and derealization, as well as, dissociation.
The patient appears to be displayed to at least two levels of awareness and
differing attitudes about the events that have surrounded her arrival in therapy.
The alternating patterns of behavior fit the description of apparently normal
personality and emotional personality, i.e. switching back and forth from
identifying herself as Angelica and then Angel with alternating patterns of
behaviors and thoughts. Her perceptions of blackouts during these alternate
periods are congruent with interruptions in cognition and memory that
are found in Dissociative Identity Disorder. Currently, the patient seems
unaware of the switching only disturbed by the other symptoms associated with
trauma and the dissociation i.e. blackouts, time-lapse, post-traumatic
memories. At some point, the patient should receive a comprehensive
clinician-administered structured interview such as the structured clinician
interview for dissociative disorders (SCI-DD) to determine the validity of a
DID diagnosis.
Based on the Post Traumatic
Theory of Dissociative Identity Disorder, that presumes an origin manifesting
from a child’s attempt to cope with an overwhelming sense of hopelessness and
powerlessness in the face of repeated traumatic abuse (Butcher, 2009, p. 29) we
will consider the symptoms seen as behavioral adaptations that help the patient
cope with trauma, and label poor social and economic environments, as well as,
harmful family dynamics as contributing stressors. Given the current traumatic
experiences and the traumatic history, we will presume that many of the current
symptoms have developed as results of the memories of previous traumatic
experiences being repressed coupled with the patient’s lack of ability to cope
with the overwhelming anxiety, she feels when confronted with the memories of
the repressed traumatic experiences. Thus we will try to counter this process
by giving the patient coping skills and therapy aimed at helping her integrate
disassociated memories and identities into consciousness. The long-term
the objective is to work on dissociated mental processes throughout treatment to
help the patient work towards better integrative functioning as well as gain an
increased degree of communication and coordination among the identities and
resolution (International Society for the Study of Trauma and Dissociation,
2011, p.133).
During treatment, we will use a phase-oriented treatment plan starting with phase one establishing
safety, stabilization, and symptom reduction (International Society for the
Study of Trauma and Dissociation, 2011, p.135). Helping the patient understand,
accept, and access the alternate identities that play an active role in their
current lives will help the patient develop internal cooperation and increase
co-consciousness-which is a focus of early treatment (International Society for
the Study of Trauma and Dissociation, 2011, p.139). In phase two we will work
on confronting, working through, and integrating traumatic memories
(International Society for the Study of Trauma and Dissociation, 2011, p.135).
We will use hypnosis trauma therapy to help the patient confront the memories
of trauma, cope with the anxiety, manage symptoms and work to improve the
emotional awareness and regulation through cogitative behavioral therapy.
Lastly, we will begin working on identity integration and rehabilitation
(International Society for the Study of Trauma and Dissociation, 2011, p.135).
As she has been abused she is
suspicious and untrusting, so it is especially important to develop a trusting
relationship with the client from the start for treatment to be successful. In
addition to developing a therapeutic alliance, educating her about the
diagnosis and symptoms, explaining the process of treatment, helping the
patient cope and manage symptoms of depression, begin modulating affect,
awareness and emotional regulation, decreasing affect phobia, building distress
tolerance, reduction of behaviors like self-mutilation, and learning to
optimize effectiveness in relationships, the clinician must also advise the
patient of alternative methods to relieve stress and teach her symptom
management strategies such as grounding techniques, crisis planning, self
hypnosis to help her cope (International Society for the Study of Trauma and
Dissociation, 2011). The key phase one objectives are to teach the client to
establish control over posttraumatic and dissociative symptomatology and learn
to modulate psychophysiological arousal levels, rather than invest further into
intrusive traumatic material (International Society for the Study of Trauma and
Dissociation, 2011).
Helping the patient find
harmonious ways to take into account the wishes and needs of all identities in
making decisions and pursuing life activities, to enhance internal support
between identities is an important focus of phase one and two (International
Society for the Study of Trauma and Dissociation, 2011, p. 142). During phase
two, the focus is on remembering, tolerating, processing, integrating and
overall abreaction (International Society for the Study of Trauma and
Dissociation, 2011, p. 142). Abreaction is the process of letting strong
emotions in connection with experience or perception go and overall has been
shown to have great overall benefits for the client (International Society for
the Study of Trauma and Dissociation, 2011, p. 142). Integrating the memories
mean working to restore memories including the sequence of the events, the
associated affects, and the physiological and somatic representations of the
experience (International Society for the Study of Trauma and Dissociation,
2011, p. 142). Helping the patient come to terms with these memories should
only be done after safety, stabilization, and symptom reduction has laid the
the way for this process and during the process of integration the patient may need
intermittent help with stabilization and symptom reduction. As the process of
integration and abreaction can exasperate symptoms causing discomposure it is
vital the patient be prepared for phase two adequately.
During phase two, the providers
work will involve working with alternate identities that experience themselves
as holding the traumatic memories (International Society for the Study of
Trauma and Dissociation, 2011, p. 143). As the various elements of a traumatic
memory emerge the provider can explore them with the patient to help them
broaden the emotional depth and understanding, as well as slowly become accustomed
to the feelings associated with the memories. Eventually the material in these
memories become altered from “traumatic memory” and subjective memory into
“narrative memory” which will help the patient make sense of her past in
relation to identity (International Society for the Study of Trauma and
Dissociation, 2011, p. 143). It is thought that part of the reasons these
patients lack a coherent sense of self is because of the dissociated memories
that have not integrated into consciousness (Spring, 2011). Therefore, it is
believed by giving them the tools to cope with the feelings instead of
dissociate in the face of them (phase one) and then helping the patient
“reassociate” these dissociated memories (phase two) that patients will begin
to formulate a more cohesive sense of self (phase three).
Accordingly, by phase three the client should show marked improvements and have begun to formulate a stable
sense of self and sense of how they relate to others and to the outside world
and the clinician should continue to foster ideas of unification (International
Society for the Study of Trauma and Dissociation, 2011, p. 145). During this the phase of treatment it is important to advise the patient on how to deal with
everyday problems in a nondissociative manner to promote future healthy
functioning (International Society for the Study of Trauma and Dissociation,
2011, p. 145 ). Depending on how far the patent makes it’s into integration and
fusion there may be a need to show the patient the new pain threshold is, or
how to integrate all the dissociated ages into one chronological age
(International Society for the Study of Trauma and Dissociation, 2011, p. 145).
Integration is a broad, longitudinal process referring to all work on
dissociated mental processes throughout treatment, while fusion is when two or
more alternate identities are no longer defined as separate and the two (or
more) experience themselves as united and one (International Society for the
Study of Trauma and Dissociation, 2011, p.134). Lastly, final fusion is the point in time that the client stops seeing themselves as someone with
subjective separate identity and views themselves as one (International Society
for the Study of Trauma and Dissociation, 2011, p.134)
Often patients are highly traumatized
thus their treatment takes a long time, which is why provider commitment to
treatment is as important as client commitment. Sometimes there are
complications in the patient’s life that interfere with treatment and the provider may spend the majority of treatment trying to meet phase one goals
consequently, the goals of phase one and phase two can take so long that phase
three and final fusion may never occur (International Society for the Study of
Trauma and Dissociation, 2011, p.134). It is cautioned “chronic and serious
situational stress; avoidance of unresolved extremely painful life issues and
traumatic memories, lack of resources for treatment, comorbid medical
disorders; advanced age; significant unremitting DSM Axis I and/or Axis II
comorbidities; or significant narcissistic investment in the alternate and/or
DID itself” often are contributing factors to patients being unable to achieve
final fusion (International Society for the Study of Trauma and Dissociation,
2011, p.134). Therefore, the focus of treatment overall is to help the patient
the gain in internal cooperation, coordinated functioning, with hopes of
integration and later fusion of alter identities (International Society for the
Study of Trauma and Dissociation, 2011, p.134).
References
Butcher. (2009). Dissociative
Disorders. Abnormal Psychology, 14th Edition. Pearson Learning Solutions.
Retrieved from VitalBook file.
International Society for the
Study of Trauma and Dissociation (2011): Guidelines
for
Treating Dissociative Identity Disorder in Adults. Journal of Trauma
& Dissociation, Third Revision, 12:2, 115-187. Retrieved from
http://dx.doi.org/10.1080/15299732.2011.537247
Spring, C. (2011). A Guide to
Working with Dissociative Identity Disorder. Healthcare Counseling &
Psychotherapy Journal. Retrieved from.
http://www.tasc-online.org.uk/pods-online/briefguidetoworkingwithDissociative
Identity Disorder.pdf
