When I was 35 I asked my psychiatrist for a diagnosis – but not just any diagnosis. I wanted something concrete. Something scientific. Something repeatable. She argued that a diagnosis wasn’t terribly important, and I argued for psychological testing. She referred me to Examiner X. This was the result.
Name of Client: Patient X
Date of Birth: xx-xx-xxxx
Dates of Testing: April 5 & 12, 2002
Examiner: Examiner X
Identifying Information & Reasons for Referral:
Patient X is a 35 year old single white female who was referred by her psychiatrist, Dr. X, M.D. for psychological evaluation in order to help determine the following: 1) the degree of the patient’s psychopathology: how much of her symptoms are characterological in nature versus stress-related; 2) help with understanding the origins and nature of her apparent psychotic symptoms; 3) determining whether the client suffers from either an attentional or obsessional disorder; and 4) clarifying the nature of her defenses and their impact upon her psychological functioning. During the initial interview with the client herself, Patient X’s questions for the testing included: 1) Can she trust her own perceptions? 2) Is she “paranoid” and, if so, under what circumstances? and 3) Why does she have such difficulty connecting on an interpersonal level?
Tests Administered:
Clinical Interview
Minnesota Multiphasic Personality Inventory (MMPI-2)
Rorschach Psychodiagnostics
Thematic Apperception Test (TAT)
Behavioral Observations:
At the time of the evaluation, Patient X was casually dressed and appeared fully oriented and cooperative. She seemed interested in the testing and there was no evidence of excessive guardedness. However, on two separate occasions, she got the time of the interview confused and needed to call for additional information.
Results of Testing:
MMPI:-2
Patient X’s performance on the MMPI-2 suggests that she is experiencing a significant level of distress, has markedly unconventional thinking and attitudes, and is likely to suffer from both identity diffusion and self-esteem issues that appear to be longstanding in nature. Her code patterns are consistent with persons who have a chronic and severe emotional disorder characterized by high levels of suspiciousness and anger, a tendency to be critical, blaming and argumentative, and who tend to read malevolent meaning into situation. These are persons who are very sensitive and easily hurt by criticism, and may angrily ruminate about injustices done to them. Their thinking often shows tangential or loose associations and may deteriorate into psychotic levels of distortion. Their high levels of paranoid sensitivity often contain elements of grandiosity as well. Her highest subscales were consistent with this and reflect ego-inflation, problems dealing with authority, family discord, and feeling as thought she is losing control of her mind. Neither the depression nor the mania scales were elevated which suggests that her problems are less the result of an untreated mood disorder and more characterological in nature and have as their focus problems in ideation. Persons with this code-type (4-6-8) typically come from families where there were ongoing experiences of being treated with hostility, rejection, physical abuse and cruelty–all of which form the foundation of the patient’s tendency to respond to the environment with hypervigilence and, on occasion, self-protective cruelty toward others.
Rorschach:
Cognitive Processing:
The results of Patient X’s responses on the Rorschach are in agreement with those of the MMPI-2, but elaborate further as to where the breakdown in her thinking occurs. The client tends to expend more effort than most persons when attempting to process information, but the findings suggest that her effort exceeds her current resources and is not particularly efficient. In general, there is some evidence that she may overestimate her capabilities and end up feeling disappointed in herself and her performance. In addition, she has some chronic and pervasive problems that promote perceptual inaccuracy and distortion, and thus result in significant difficulties in reality testing. It is quite clear from the testing that her internal world interferes with her accurately interpreting the external world, and that her projections cause distortions such that she tends to interpret events in a manner that is quite idiosyncratic. In particular, there are two central themes that contribute to these distortions: her sense of being damaged and abused; and her belief that the world is populated by dangerous being who are malevolent and only concerned about their own survival, regardless of the impact upon her. These themes so preoccupy her psychologically that they regularly interfere with her capacity to correctly interpret the world around her, most especially interpersonal interactions. To further compound these problems, the ways in which she thinks about issues and values is highly rigid and inflexible, making it hard for her to take in new information to change her attitudes and experience. She also has a marked style of “flight into fantasy” whereby she escapes from a world she too-frequently experiences as hostile and dangerous; this again makes it difficult for her to make lasting changes in her cognitive schemas.
Emotional Processing:
Patient X’s responses on the Rorschach indicate that she does not have a consistent way of using emotions when making decisions: at times her emotions may overly influence her thinking, whereas at other times, she may not afford her feelings adequate consideration. Unfortunately this style leaves her more vulnerable to erratic emotional displays: in some instances her emotions will be highly controlled and modulated; at others, they may be intense, even undercontrolled. This feeling of not being able to predict how she will respond to emotional situations may be the reason that she tends to avoid affect-laden material. However, one of the notable results of her Rorschach was that her efforts to avoid having an emotions response to the blots caused her to have increased impairment in her reality testing. In other words, this client feels unsafe when confronted with emotionally impactful situations. She therefore tries to withdraw and just respond intellectually, but this does not work well; in fact, she tends to experience even more distortion in her perceptions at those times of affect avoidance. In spite of her efforts to reduce her emotional reactivity, her Rorschach summary indicates that she experiences a significant amount of emotional pain, most of which is related to longstanding wishes for attachment as well as having painful affect that she does not feel she can express and has been internalized. This is probably due to her not feeling that she has the kind of relationships that would provide her with the safety for her to openly reveal her inner world. Much of her depressive feelings probably stem from this combination of feeling that she cannot get her needs for safe attachment met, and that she does not feel safe about expressing her hurt and anger being deprived of this. Finally, there are some indications on the testing that she is experiencing an increase in stress (although the client herself did not indicate any recent new stresses) which may further impair her ability to adequately contain her emotions, and thus cause her to feel that she must back away even more from people and situations where she may find herself feeling upset. It is possible that the client is so used to feeling chaotic and upset that she cannot be an accurate observer about how she is being impacted by recent events.
Self-Perception:
Patient C’s Rorschach responses indicate that she is in serious conflict regarding self-image and self-value. She has indicators that she has an exaggerated sense of self worth and self-involvement, suggesting that she is unusually self-centered fro an adult. Yet, simultaneously, she shows evidence that she sees herself as being inadequate in comparison to others. This highly ambivalent picture of self is likely to result in both mood fluctuations (feeling quite “high” when she is in her state of self-absorption and high self-regard; feeling depressed and self-attacking when she is feeling damaged or negatively comparing herself with others) and behavioral dysfunction. This split in self-perception is evident in one of her Rorschach responses: a stuffed elephant with one eye communicating a sense of irritation and anger and the other looking scared and unsure. Most persons self-esteem and self-perception are fairly stable and only fluctuate in response to moderately large changes in how they are perceived by others; this client’s picture of self that she carries with her is highly unstable and reacts dramatically to perceived shifts in the world around her (which, more than likely are not real, but are projections of her internal world). All of this makes it hard for her to create a stable identity for herself or to be able to predict how she will feel about herself from moment to moment. It is my guess that her most “real” self-representation is that of a wounded, bleeding being who has been victimized by the aggressors around her; that her inflated ego is actually more of a defense from feeling this level of pain and vulnerability.
Interpersonal World:
As stated in the initial part of this report, Patient X’s interpersonal world is filled with scary, malevolent predators who have hostile intent and are seeking potential victims Her images on the Rorschach give a clear picture of how she interprets the human environment (“menacing mask”; “snake with emotionless, menacing expression who only purpose is survival”; “evil-looking lizard”; “bug with pinchers”, etc.). Her human images on the rorschach indicate that she has developed her beliefs about human beings less from real interactions with people and more out of “fantasy” or her own internal world. The number of aggressive responses on the test suggest that this client has learned to expect hostile interactions rather than loving or cooperative ones; the fact that this is based more on fantasy than reality means that it will be difficult to change through her treatment since she does not tend to change her attributions about the world and interpersonal reality, but rather hold onto her distorted beliefs in the face of evidence to the contrary.
TAT:
Patient X’s stories on the TAT indicate a view of the interpersonal world where she feels unimportant, lonely and unable to reach out effectively to others to get her needs met. Parents are seen as persons who are exceedingly self-involved and either unavailable to children, or more malevolently, using children to get their own narcissistic needs met. Women (mothers) are characterized as only attending to children if they are interesting or paying attention to the mother; Men (fathers) are seen as distant, and unavailable except as sexual predators who use women and then discard or aggress against them. She describes herself as disappointed in her inability to make much of her life or to follow through on difficult tasks. There is also some indication of a representation of herself as masochistic: being used repeatedly in an effort to get her needs for attachment met, but then coming back for more while knowing that the outcome is likely to be negative or harmful.
Summary and Recommendations:
This is the psychological protocol of a highly distressed and disturbed woman whose complex internal world intrudes regularly on her capacity to accurately interpret the world around her. Her level of cognitive distortion frequently reaches psychotic proportions and she is unable to discern the differences between her paranoid perceptions and reality. Although her emotions are causing her much pain, especially around issues of her unsatisfactory interpersonal attachments, she does not appear to have a primary affective disorder (e.g. unipolar or bipolar disorder), but rather her distorted perception is the central problem. This is most apparent when it comes to understanding other people: their functioning and motivations. She is likely to be at her most vulnerable to psychotic disintegration during times of interpersonal neediness and rejection, or narcissistic injury. She does not show the illogical and bizarre thinking characteristic of schizophrenia, but more the “slips” into psychotic perception that is common among persons with severe borderline character disorders. She also has some indicators (on all three tests) of the possible presence of some early trauma (quite possibly sexual in nature) that is consistent wit the development of borderline personality disorder. Her split in self-perception between an inflated self and a sense of being “damaged goods” is consistent with a narcissistic disorder that is organized at a borderline level, and thus is vulnerable to psychotic disintegration under stress.
Treatment of such a disorder is complicated by a number of factors: her distrust of authority figures is likely to make it difficult for her to reliably follow recommended treatment plans (e.g. not take medication as prescribed); her fear of being overwhelmed by dysphoric affect makes it difficult for her to withstand the intensity of treatment that would ultimately be most beneficial (probably twice weekly treatment for several years); her potential for developing a psychotic transference would need to be carefully attended to since that would certainly cause her to flee treatment. She would also have to examine the sources of her feelings of distrust and paranoia, all of which is likely to disrupt her situation with her family.
Given the above, the first step in the treatment is to get Patient X to accept her diagnosis: that she significantly distorts her experience and inaccurately attributes malevolent motives to persons around her. Although there well may have been a time in her life when she was surrounded by frightening people who did not care for her, but rather took advantage of her and harmed her, in the present she is projecting those images onto her environment. In order to deal with this, she needs to be on a regular regimen of psychiatric medications which will certainly include both an anti-psychotic and mood stabilizer. If she wants a chance at some psychological stability, she needs to take these regularly and make no changes without consultation with her entire treatment team. She also needs to find a therapist that has experience working with persons having this level of emotional disturbance, and she needs to make a commitment to stay in treatment, even during times when she is not convinced it is helping. One of my recommendations for treatment for any client who might experience a psychotic regression during the therapy which might interfere with the therapeutic alliance is to have another therapist available to consult when necessary (this might be a colleague of the primary therapist who could “cover” during vacations, etc.). At some point, Patient X would benefit from being in group therapy where she could conceivably address her beliefs about how other people operate and learn to compare those beliefs with current reality. However, this would be counterproductive prior to her being stabilized on medication and developing a strong therapeutic relationship where she could process her reactions to the group experience. It is predicated that, without the level of treatment intervention described above, this client will continue to function very erratically on an interpersonal and intrapsychic level, may continue to have disorganizing episodes of suicidal ideation or psychotic disintegration, and will keep having interpersonal difficulties that do not “make sense” to her. She definitely has the intellectual and psychological resources to do this kind of psychotherapeutic work if she chooses to do so; it could make a world of difference in the quality of her life and her ability to function effectively in the interpersonal sphere.
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