Psychological assessment, psychiatric diagnosis & treatment planning 9781315825847, 1315825848, 0876306075

Table of contents :
Content: Section 1. Asix I disorders --
section 2. Axis II disorders.

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■ Psychological Assessment ■ Psychiatric Diagnosis ■ Treatment Planning ■ Stephen W. Hurt, Ph.D. ■ Marvin Reznikoff, Ph.D. ■John F. Clarkin, Ph.D.

Psychological Assessment, Psychiatric Diagnosis, & Treatment Planning

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PSYCHOLOGICAL ASSESSMENT, PSYCHIATRIC DIAGNOSIS, & TREATMENT PLANNING Stephen W. Hurt, Ph.D. Marvin Reznikoff, Ph.D. and John F. Clarkin, Ph.D.

I ) Routledge

Taylor&FrancisCroup

NEW YORK AND LONDON

Library o f Congress Cataloging-in-Publication Data H urt, Stephen W. Psychological assessment, psychiatric diagnosis & treatm ent planning / by Stephen W. H urt, Marvin Reznikoff, John F. Clarkin. p. cm. Includes bibliographical references and index. ISBN 0-87630-607-5 1. Psychological tests. 2. Mental illness— Diagnosis. 3. Mental illness—Treatment. I. Reznikoff, Marvin. II. Clarkin, John F. I I I . T itle .

[DNI.M: 1. Mental Disorders—diagnosis. 3. Psychological Tests. WM 141 H967p] RC473.P79H87 1990 616.89'075—dc20 DNLM/DI.C for Library o f Congress

2. Patient Care Planning.

90-15146 CIP

Copyright © 1991 by Stephen W Hurt, Marvin ReznikofJ, and John F. Clarkin All rights reserved. No part o f this book may be reproduced by any process whatsoever without written permission o f the copyright owners. Firsl published by Brunner/M azel. Inc. 19 U nion Square New York, New York 10003 This edition published 2012 by Psychology Press Routledge Taylor & Francis Group 711 T h ird A venue N ew Y ork. N Y 10017

Routledge Taylor & Francis Group 27 C h u rc h R o a d H ove E a s t S u s s e x B N 3 2F A

Designed by '1ère LoPrete Manufactured in the United Stales of America 10

9 8 7 6 5 4 3 2

1

Contents

Fo r e w o r d

By C h a r l e s D. S p i k i .b erc . k r , P i i .D

P r kface

vii ix

Chapter 1: Psychological Testingand Psychiatric Diagnosis H istory o f Psychological Testing and Assessm ent D iagnostic and Statistical M anuals (DSM) DSMs, Psychological Testing, an d T reatm en t P lanning

1 2 14 23

Section I: Axis I Disorders

27

Chapter 2: Disorders Usually First Evident in Infancy, Childhood, or Adolescence

29

A. E ating D isorders: A norexia Nervosa an d B ulim ia Nervosa B. C onduct D isorders: G roup an d U ndifferentiated Types

29 64

Chapter 3: Schizophrenias

100

A. U ndifferentiated an d P aranoid C hronic Schizophrenia B. Schizoaffective B ipolar an d Depressive Types

100 137

Chapter 4: Major Affective Disorders

183

A. M ajor Depression with M elancholia an d with Psychosis B. B ipolar M ania: Prior To an d D u rin g a Manic Episode

183 214

Chapter 5: Anxiety Disorders

257

A. Obsessive C om pulsive D isorder with an d w ithout Personality D isorder B. Post-traum atic Stress D isorders C hronic an d Delayed

257 298

v

vi / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Chapter 6: Adjustment Disorders A djustm ent D isorder with M ixed D isturbance of Em otions and C onduct A djustm ent D isorder with D epressed M ood

330 330 350

Section II: Axis II Disorders

367

Chapter 7: Personality Disorders

369

A. P aran oid Personality D isorders B. B orderline Personality D isorders C. Narcissistic Personality D isorders

369 402 439

R e feren ces N am e I ndex

Su b j e c t I n d e x

475 481 483

Foreword

T h e critical role o f psychological assessment in treatm ent planning has been increasingly recognized in recen t years as social an d economic factors have brought about significant changes in diagnostic approaches and psychother­ apeutic intervention strategies. An adequate treatm ent plan is the necessary First step in helping clients and patients who seek assistance from m ental health service providers to alleviate their suffering, an d psychological assess­ m ent is basic to effective treatm en t p lanning. Traditionally, the m ajor goal o f psychological testing has been to describe the psychopathology a n d p e r­ sonality dynam ics o f the patient. Consequently, signiFicant questions relating to o ptim al intervention pro ced u res are o ften neglected. T his volume is unique in its dual focus on the role o f psychological assess­ m ent in clarifying diagnostic issues and the contrib u tio n o f assessm ent to treatm ent planning. In providing case examples o f comm only encountered diagnostic questions, th e au th o rs draw upo n a broad ra n g e o f psychiatric patients w ho were refe rre d for com prehensive psychological assessm ent. These case m aterials were available to the authors on the basis o f th eir long­ term association w ith a freestan d in g psychiatric hospital th a t adm its more th an a thousand patients a year. T he cases described were referred for extensive psychological assessment with traditional assessm ent in stru m en ts such as the WAIS, the M M PI, the Rorschach, the T hem atic A pperception Test, the B ender Gestalt, and Figure draw ings. T h e inclusion o f the raw d a ta o f assessm ent m akes these cases especially useful for classroom instruction and in the supervision o f clinical practicum work. P rior to the presentation o f the history, m ental status an d psychological assessment findings for individual cases, the diagnostic criteria for the DSM1II-R category for which each case is representative are reviewed by the authors. B oth sim ple an d com plex cases rep resen tin g the m ost im p o rtan t D S M -III-R diagnostic categories are evaluated an d discussed in this volume. vii

viii / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e results o f psychological testing are in teg rated w ith detailed case m aterials, including th e p atie n t’s ch ief p resenting com plaint, a history o f the present illness, an d th e results o f the m ental status exam ination. T h e tables th a t accom pany the description o f each case provide rich sum m aries o f the clinical an d psychological inform ation th a t n ot only clarify the d iag ­ nostic decision b u t also serve to provide inform ation on psychodynam ic issues, personality functioning, cognitive abilities, an d social an d environ­ m ental pressures th a t im p in g e on the patient. Since the inform ation on which an initial diagnostic form ulation is based is generally available to the psychologist prior to the assessment consultation, it provides the contextual fram ew ork for identifying the m ajor diagnostic issues and significant factors th at m ust be considered in treatm ent planning. W hile psychiatric diagnostic questions are typically th e c h ie f reason th a t m ost patients are re fe rre d for psychological testing, assessm ent d a ta not only answ er such questions, b u t may be even more im p o rtan t in the form u­ lation o f a com prehensive treatm en t plan. T h e richness o f the in terp retatio n s o f th e psychological test d a ta reflects the extensive research and clinical experience o f th e au th o rs in th e field o f psychological assessment, differential diagnosis and treatm ent planning, treatm ent in various clinical settings, an d teaching o f g rad u ate students and interns. A lthough this book will prove especially valuable for clinical psychologists a n d stu d en ts o f psychological assessm ent, it will also be highly useful for o th er m ental health professionals who are involved in providing clinical ser­ vices. Psychiatrists, social workers, nurses, an d counselors will gain a b e n ­ eficial u n d e rsta n d in g o f how the d a ta o f psychological assessm ent co n trib u te to the clarification o f diagnostic issues an d , especially, to the developm ent o f an o p tim al treatm en t plan. D. S p i e l b e r g e r , Ph.D. Graduate Research Professor of Psychology University of South Florida, Tampa C harles

Preface

O u r purpose in w riting this book was to exam ine the relationship between the psychological assessments commonly carried out by clinical psycholo­ gists and the treatm ent planning situation faced by the provider o f clinical services. We chose as o u r setting the psychiatric hospital. T his is the p rin ­ cipal setting in which psychological assessments are carried out and it is the principal setting in which m any m ental health professionals receive a significant portion o f their training early in their careers. It is to these pro­ fessionals, w hether psychologists, psychiatrists, nurses, social workers, coun­ sellors, or case m anagers, th at we address this book. T he book is intended for both practicing professionals and for those in training. T he practicing professional will derive considerable benefit, we believe, from reviewing the psychological assessment from the standpoint o f treatm ent planning. Although recent changes in the official diagnostic nom enclature o f the American Psychiatric Association have em phasized more behavioral and operational criteria for psychiatric diagnoses, practic­ ing professionals often recognize th a t form al diagnostic procedures do not per se provide sufficient inform ation for developing a treatm ent plan. The present climate o f patient advocacy, inform ed consent, and choice o f ser­ vices would serve in themselves to make the treatm ent planning process a more collaborative effort. This book is intended to illustrate the many ways in which psychological testing can contribute to th at effort for the benefit o f both the patient and the treatm ent provider. For the professional in training, the book also provides an introduction to the system o f psychiatric diagnosis and case formulation. In providing m any o f the details o f the case histories and the testing data, we hope the book will serve as a guide for those in training. In o u r form ulation o f the testing material, the student will find in our approach much that is traditionally taught in clinical psychology. T here is also much th at is relatively new. O u r emphasis on the role o f the psychological assessment in treatm ent planning and our organization and presentation o f the test­

IX

x / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning in g m aterial in light o f th e areas critical for this endeavor have novel elem ents. In selecting the cases for the book, we chose cases w here the treatm en t plannin g issues were ad dressed by th e d a ta from the psychological assess­ m ent. In o rd e r to preserve th e vitality o f the m aterial, we m ad e as few changes in the original test m aterials an d the clinical situations o f th e cases as were com patible with preserving the confidentiality o f the individuals. T h e cases are presented in th e o rd e r in which the diagnostic gro u p in g s o f D S M -III-R are presented, b eg in n in g with diso rd ers usually first evident in infancy, childhood , o r adolescence and e n d in g with the Axis II p erso n ­ ality disorders. T he cases represent a range o f D SM -III-R categories. H ie categories are those m ost frequently enco u n tered in the diagnostic situations o f th e psy­ chiatric hospital. Each d isorder is briefly introduced in term s o f its c u rren t psychiatric definition. Each d iso rd er is rep resen ted by two cases. O ne o f these cases has been chosen because it represents a comparatively clear case in w hich virtually all o f th e D SM -III-R diagnostic criteria for the d iso rd er are manifest. T h e second case has been chosen because although a sufficient n u m b e r o f diagnostic criteria are present to su p p o rt the diagnosis, some elem ents o f am biguity rem ain. Each presentation gives th e referral ques­ tions, as they arose in the context o f th e hospital treatm e n t situation, the c u rre n t status, historical m aterial, test responses, form al scoring an d tab ­ ulation o f these responses w here applicable, the psychological re p o rt an d recom m endations, as well as o th e r in form ation p e rta in in g to treatm en t. Finally, a brief, com parative discussion o f the two cases is used to explore differences and similarities in the diagnostic and treatm ent planning issues p e rtin en t to the two cases. In choosing the cases an d p rep a rin g the final m aterials for the book, we received a trem endous am ount o f help from several individuals. Case m ate­ rials which could not be found in o u r hospital files were contributed by o u r colleague, Dr. M ark Schw artz. We would like to th an k him for his c o n tri­ bution o f these m aterials. Ms. Lisa G erstein h elped to com pile an d select from am ong over 400 cases initially screened a set o f 120 cases w hich were reviewed for possible inclusion. She devoted a n en tire su m m er a n d a good p a rt o f th e fall to scoring an d tab u latin g th e m aterial from these cases so that o u r selection o f case m aterial could be as representative o f o u r hospital population as possible. Ms. Sharon Daly subsequently rescored the final case m aterial chosen for the book and helped to insure th a t all relevant m aterials were p rep ared with equal care an d attention to detail. T hese are timeconsum ing tasks an d we are gratefu l to both Ms. G erstein an d Ms. Daly for th e ir attention to these m atters. Ms. N ina H uza an d Ms. Jan e D renga prep ared the initial typ ed d ra fts o f m uch o f the case m aterial. T h e ir m any

Preface / xi years o f experience in d ecip h e rin g the usually cryptic verbatim tran scrip ts o f the exam iners m ade the final editing o f the case materials alm ost a pleas­ an t task. T h e m aterial presen ted here has also benefited from the contributions o f several groups o f trainees in th e psychology in tern sh ip p ro g ram o f T h e New York H ospital’s W estchester Division. T hey reviewed previous d rafts o f these cases as the book was u n d e r preparation. T hey were helpful in pointing out areas that needed f u rth e r clarification and helped us to gauge the level at which the m aterial could be presented effectively. We would also like to th an k several individuals for taking th e tim e to read various sections o f the m anuscript. Mrs. R uth Heim deserves particular mention for having read the m anuscript in its entirety and providing m any helpf ul editorial suggestions. Finally, we wish to thank o u r spouses and children. They rather graciously bore with us d u rin g th e course o f this en terp rise an d th eir for­ b earance is m uch ap p reciated . In review ing the clinical an d psychological m aterial from the cases, we have focused on six areas th a t are central to treatm ent planning: sym ptom s/ diagnosis, personality factors, cognitive abilities, psychodynam ics (including defenses and motivations), therapeutic enabling factors, and environm ental d em an d and social ad ju stm en t. For each clinical case, we sum m arize the inform ation for these six areas as o btained from the clinical w orkup an d the psychological testing. By exam ining these tables across the patients pre­ sented here, one can come to some conclusions as to the n atu re and am ount o f inform ation that is ordinarily obtained from the clinical workup and psy­ chological assessm ent. T h e process o f w riting this book was an in -d ep th exploration for the authors o f exam ining , with actual cases, how the test findings overlapped the clinical d ata, eith e r c o n firm in g o r d ifferin g with it, as well as the com ­ plem entary relationship betw een test an d clinical d ata in a rriv in g at a com ­ prehensive clinical form ulation. H aving com pleted o u r work, we can m ake some generalizations. 1) R eferrals for diagnostic consultations still constitute th e ch ie f reason for psychological testing referrals, despite the relatively clear and o p e ra ­ tional criteria o f D SM -III and DSM -III-R. A m ong the more frequent ques­ tions are those concerning th e presence o r absence o f th o u g h t d iso rd er in patients w ho do not evidence pathological th in k in g in clinical interviews but who are suspected o f bein g m ore d istu rb ed . Q uestions also arise as to the presence o f affective sym ptom s such as depression with patients who deny any direct experience o f such a n affect. 2) C ognitive and intellectual functioning is quite relevant for p lan n in g treatm en t interventions, especially with reg ard to verbal therapies th a t d ep en d upon m aking abstractions about one’s motivations an d behaviors.

xii / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T he clinical interview and the mental status examination, in particular, yield some critical inform ation about this area o f functioning. However, the use o f structured tests with their sets o f standardized stimuli, formal scoring procedures, and norms provide an accurate picture o f the relative strengths and weaknesses o f the patient’s intellectual abilities. 3) T he same surface behaviors and/or sym ptom s may be accom panied by quite different constellations o f cognitions and motivations in different patients. This is an area in which tests are extremely helpful. Projective tests are particularly effective in circum venting a p atient’s conscious defensive operations and providing d ata on the possible underlying conflicts which motivate seem ingly contradictory aspects o f a patient’s behavior. 4) T he ability and motivation o f the patient to establish a positive th e r­ apeutic alliance can be effectively evaluated in the testing situation. T h e tests, particularly the TAT, are extremely useful in assessing the patien t’s attitudes, self-concept and interpersonal relationship style. This information can play a crucial role in developing a treatm ent plan in situations in which a choice o f several equally successful treatm ent strategies is possible. 5) T he role o f the psychological exam ination and the m an n er in which information gathered du rin g the examination is explained to the referring source and to the patient provide an excellent o p portunity to help prepare the way for a successful treatm ent intervention. T reatm ent planning is, at its best, a collaborative effort. T he information gathered d u rin g the course o f a psychological assessment can provide an opportu n ity to effect this col­ laboration by helping to place the referring questions in a treatm ent context and by providing a comm on fram e o f reference for both the referring source and the patient. In m aking these generalizations, we wish to em phasize the value o f psy­ chological testing to the treatm ent planning process. Although we have come away from this enterprise firmly convinced th a t psychological assessment indeed can serve to enhance the collaborative efforts required for successful treatm ent interventions, we must finally leave it to the read er to ju d g e the success o f o u r efforts.

Psychological Assessment, Psychiatric Diagnosis, & Treatment Planning

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CHAPTER 1

Psychological Testing and Psychiatric Diagnosis

In the b ro a d e r sense, th e p u rp o se o f psychological testing is to assess individual differences on one o r m ore psychological variables. Clinical psychological testing as discussed in this book constitutes a specialized area o f psychological testing th a t focuses on d ifferen tiatin g ind iv id u ­ als in clinical in p atie n t an d o u tp atien t pop u latio n s on th e basis o f the n a tu re an d d e g re e o f psychopathology. T h e re are, o f c o u rse, m any o th e r types o f diag n o stic testin g , especially in th e fields o f m edicine a n d ed u catio n . T h e m eaningfulness o f psychodiagnostic testing is obviously based upon the prem ise that there exists a taxonomy for classifying psychopa­ thology into reliable diagnostic categories. Devising such a diagnostic classification system o r nosology, however, has proven a very form idable task. O ver a period o f 35 years, the A m erican Psychiatric Association has published four Diagnostic and Statistical Manuals (DSMs) (1952, 1968, 1980, 1987) with an additional version now in preparation. Each succes­ sive m anual has offered m ore explicit and comprehensive diagnostic cri­ teria in not always fru itfu l efforts to m ake the process o f differential diagnosis m ore reliable. In this introductory chapter, a selective history o f psychological testing will be given, including an evaluation o f its c u rre n t status. Psychological Testing (1988) by A nne A nastasi has been an invaluable source o f g u id ­ ance an d inform ation for the prep aratio n o f the first section o f this c h a p te r and is highly recom m ended as an exhaustive treatm e n t o f the subject. W ithin the framework o f the various DSM editions, an overview o f past efforts to develop reliable an d readily applicable diagnostic schem a will also be presented. /

2 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

HISTORY OF PSYCHOLOGICAL TESTIN G AND ASSESSMENT E arly Testing E fforts A nastasi (1988) defines the traditional function o f psychological tests as having been “to m easure differences between individuals o r between the reactions o f the same individuals on different occasions.” A nother leading authority on psychological testing, Cronbach (1949) states th at w hat a test entails is a “systematic procedure for com paring the behavior o f two or more persons.” C ontem porary psychological testing, perceived as the utilization o f stan­ dardized instrum ents to m easure various psychological functions, has its m ajor roots in the nineteenth century. However, it is o f interest to note that a comparatively well-developed program o f oral civil service exam inations seems to have existed in C hina more than 4,000 years ago (Wiggins, 1973). By the fourteenth century, the C hinese civil service selection program boasted a network o f local testing centers across the nation which ad m in ­ istered written examinations o f an essay type in specially constructed testing booths. T he Greeks some 3,000 years ago also employed tesdng procedures incorporating them in th eir educational system (Anastasi, 1988). T he im petus for the development o f psychological tests in the nineteenth century can be traced to the growing concern with h um ane treatm ent o f the mentally deficient and the insane. This, in tu rn , gave rise to a need to identify, differentiate between, and classify mentally im paired individuals in some sort o f systematic fashion. In France, Esquirol, for example, endeav­ ored to distinguish varying degrees o f m ental retardation by assessing lan­ guage skills. Seguin, an o th er French physician who subsequently came to America, experim ented with m ethods o f training the mentally deficient and developed a form board akin to a jigsaw puzzle which is still a p a rt o f p er­ form ance intelligence scales. T he focuses o f the experimental psychologists o f the nineteenth century were largely on m easuring sensory phenomena and developing generalized principles o f behavior. This approach is typified by W undt, who established a laboratory in Leipzig in 1879 where a n u m b er o f the early experim ental psychologists studied. W hen individual differences were observed u n d er standardized conditions, they were ordinarily ascribed to a form o f hum an error. By contrast, in the 1880s, Sir Francis Galton, the English biologist, grasped the im portance o f accurately assessing individual differences and similarities in connection with his research on heredity and, in effect, fathered contem porary psychological testing. R ather than studying mental processes exhaustively in a few people, Gal-

Psychological Testing and Psychiatric Diagnosis / 3 ton was m ore interested in less intensive investigations o f large num bers o f individuals. Furtherm ore, he did not confine his studies to simple sen­ sorimotor functions, but broadened his investigative approaches to include questionnaires and rating scales and devised statistical m ethods for analyz­ ing his findings on individual differences. Galton believed that sensory discrimination and reaction time tests could evaluate intellectual ability, a point o f view shared by the American psychol­ ogist Cattell. Cattell, stim ulated by contact with Galton, developed his own series o f simple measures for assessing individual differences in intelligence, also em phasizing in his battery sensory tasks and speed o f response which lent themselves to precise m easurem ent. For the first time in the psycho­ logical literature, Cattell employed the term “mental tests” in an article writ­ ten in 1890 describing a series o f tests adm inistered to college students to appraise intellectual functioning. In approxim ately the same period, the G erm an psychiatrist Kraepelin, who was a prim e mover in the classification o f m ental illness, devised a bat­ tery o f tests, tapping, am ong o th er factors, mem ory an d fatigue suscepti­ bility. Kraepelin was interested principally in using his tests with clinical populations. Ferrari, an Italian psychologist, was also concerned with eval­ uating psychopathology through a diverse series o f tests encom passing m otor skills, physiological m easures, an d even interpretation o f pictures. It rem ained for Binet, however, to ad d new scope and direction to testing. In an article ap p earin g in 1895, Binet and H enri criticized the intelligence tests o f the time as too simplistic, narrowly focused, and based on the dubi­ ous assum ption th at intelligence was fundam entally reducible to m otor speed and sensation. T hey asserted, additionally, th a t m ore m eaningful complex functions would no t pose m ajor m easurem ent difficulties in that there was far greater individual variability in such functions.

M ental Tests D u rin g the F irst P art o f the Twentieth C entury Binet, working collaboratively with Simon, constructed an intelligence scale in 1905 which advanced the assessment o f intelligence from m easuring very delimited, specialized abilities to covering such functions as reasoning, ju d g m en t, and com prehension. T his first far b ro ad er intelligence scale, however, still included some perceptual and sensory problems am ong its 30 tasks arran g ed in o rd e r o f increasing difficulty. As a p a rt o f a 1908 m od­ ification o f this scale, the tasks were g rouped according to age levels based on a norm al sam ple o f children between th ree an d 13 years. T his gave rise to the concept o f m ental age. T here were a n um ber o f oth er revisions o f the test— the best known o f which was the 1916 Stanford-B inet developed

4 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning by T erm an at Stanford University. T his version was the first to utilize a ratio betw een m ental age an d chronological age to yield an intelligence quotient o r IQ. T h e advent o f World War I was accom panied by a practical need to eval­ u ate the intellectual level o f large n u m b ers o f recruits. T h e B inet scale, requiring individual adm inistration and a trained examiner, was clearly not a suitable instrum ent for this mass testing operation. As a consequence, con­ siderable effort was directed tow ard developing procedures w hich could be adm inistered easily an d rapidly to large groups o f individuals. T h e A rm y A lpha and Beta ultim ately pro d u ced by A rm y psychologists for large-scale testing relied to a considerable d eg ree upon Otis’s u n p u b ­ lished g ro u p intelligence test which utilized m ultiple-choice items for the first time. T h e A rm y Beta was a non-language scale specifically devised for illiterates and those with very lim ited knowledge o f English. T hese A rm y gro u p intelligence tests were ad o p te d subsequently for a variety o f civilian populations but, unfortunately, were applied indiscriminately without ade­ quate recognition o f th e ir technical crudeness an d limitations. Also developed d u rin g World W'ar I to address ano th er dim ension o f the process o f screening recruits for m ilitary service was W oodworth’s Personal Data Sheet. T his inventory was designed to identify m en who would not be suitable for the m ilitary by tallying the n u m b e r o f psychological sym p­ tom s they rep o rted abo u t themselves in response to w ritten questions. A lthough the Personal D ata Sheet was not in sufficiently finished form to be actually utilized d u rin g World War I, it was revised for civilian use and served as the pro to ty p e for subsequent personality inventories.

T h e P ro jectiv e Tests W hile the test boon o f the 1920s, which also included th e developm ent o f tests o f special ap titu d es, h ighlighted the attem p ts o f psychologists to construct more sophisticated and diverse instrum ents, psychiatrists and psy­ choanalysts were em ploying differen t m ethodologies. U sing clinical in ter­ views and observational techniques, clinicians such as Freud explored the intricacies o f personality in term s o f conscious thoughts an d em otions as well as in areas less subject to rational controls an d not w ithin the individ­ u al’s full awareness. T h ese approaches, w hich raised im p o rtan t diagnostic, therapeutic, and prognostic questions and issues, also provided an im petus for a new' kind o f test, namely, the projective technique. T his procedure was developed to tap basic personality stru c tu re an d u n d erly in g dynam ics, essentially by analyzing an individual’s in terp re tatio ns o f am biguous or u n stru c tu re d stim uli.

Psychological Testing and Psychiatric Diagnosis / 5 O ne of the earliest projective devices was a word association test devel­ o p ed by J u n g (1910), am ong others. T h ro u g h this ap p ro ach , a subject’s reactions an d associations to an em otionally-toned series o f words were exam ined from the stan d p o in ts o f speed an d content o f response, as well as for o th e r behavioral concom itants. However, the test having the greatest im pact on the fu tu re course o f clinical psychology was doubtlessly the Rorschach. Psychology is indebted to K erner for first recognizing the potential pres­ en t in inkblots for stud y in g personality. In a book entitled, Kleksographien, published in G erm an y in 1857, K erner observed th at inkblots a p p e a re d to im pose their own m eaning upon the interpreter (Klopfer & Kelly, 1942). H e d id not fully realize, however, th at significant individual differences in inkblot in terp retatio n existed and could form the basis for personality assessm ent. H erm an n R orschach, a Swiss psychiatrist, h ad a long-standing invest­ m ent in developing the diagnostic possibilities o f inkblots. For a 10-year p erio d , he ex p erim en ted with thousands o f inkblots, ad m in isterin g them to d ifferen t groups o f psychiatric patients an d also to nonpsychiatric p o p ­ ulations for purp o ses o f com parison. His goals were to select a set o f blots and develop a scoring procedure which could differentially identify various form s o f psychopathology. T he results o f R orschach’s form idable labors were published in his mono­ g rap h Psychodiagnostik in 1921 which was later tran slated and rep rin ted in English (R orschach, 1942). T h is m onograph rep ro d u ced the five a c h ro ­ m atic and five chrom atic blots, still c u rren tly in use, an d also p resented the basic R orschach scoring system which notably placed its em phasis on the form al characteristic o f th e subject’s p ercepts ra th e r th a n on the content o f the responses. A fter R orschach’s u n fo rtu n a te d eath shortly after the publication o f his m o n ograph, his close associate, O berholzer, continued his work. David Levy, an A m erican psychiatrist, stu d ied u n d e r O b erh o lzer in 1 9 2 3 -1 9 2 4 an d in tro d u ced th e R orschach to the U nited States. In flu ­ enced by Levy, Beck, th en a doctoral stu d en t at C olum bia, also sought to train w ith O berh o lzer and w rote the first A m erican dissertation on the R orschach m ethod. Klopfer, Piotrowski an d R ap a p o rt are n u m b ered am ong the m any psy­ chologists in the U nited States who subsequently m ade m ajor Rorschach contributions. More recently, H oltzm an (1968) developed a new series o f inkblots which can be ad m in istered an d evaluated u n d e r m ore controlled conditions. Also gaining prom inence has been E x n er’s (1974) co m p reh en ­ sive system which endeavors to enhance the scoring and interpretive p re­ cision an d reliability o f the R orschach technique. R orschach content

6 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning interpretation has also been exam ined more critically (Aronow & Reznikoff, 1976; Schafer, 1954) Stim ulated by the enthusiasm that initially greeted the appearance o f the R orschach, o th e r in stru m en ts em erg ed on the projective landscape and rather quickly gained a substantial following. Noteworthy am ong these was the Thematic A p percep tio n Test (TAT) w hich was developed by M urray and his collaborators at th e H arv ard Psychological Clinic. A lthough an earlier rep o rt on th e TAT was published by M organ an d M urray (1935), it was n o t until th re e years later w hen M urray’s sem inal book, Explorations in Personality (1938), a p p e a re d an d in tegrated the TAT with a broad theory' o f personality, th at it achieved prom inence. C om pared with the Rorschach, the TAT presents pictures which are clearly more struc­ tu red than the Rorschach inkblots but, nevertheless, are sufficiently am big­ uous to be perceived (apperceived) by the individual from the stan d p o in t o f prior experience, l’he exam inee is requested to m ake u p stories to various card s in the set o f 30 black and w hite pictures d epicting su n d ry situations, plus one blank card. T h e stories are to cover w hat is tra n sp irin g in the pic­ ture, the events leading up to it, the outcom e, and the feelings and thoughts o f the characters. T hese stories are analyzed prim arily in term s o f such con­ tent variables as m ain them e, conflicts and defenses. Particularly useful n o r­ mative d a ta on TAT them es have been published by E ron (1950, 1953). M urray's TAT in its original form is still clearly the test o f choice for a variety o f population s covering a wide age range. However, over a p erio d o f tim e, th ere have been various m odifications an d extensions o f th e TAT pro posed for special groups, including an anim al form , th e C h ild ren ’s A pperception Test (CAT) for young children, and an adaptation o f the CAT desig n ated as the CAT-H, for o ld er children which depicts the sam e situ ­ ations as the anim al version b u t uses h u m an s ra th e r th a n anim als in the pictures (Beliak, 1975). T h ere are, additionally, several versions devised spe­ cifically for the elderly, w ith sets o f pictures reflecting typical problem s o f older people. T h e G erontological A ppercep tio n Test (Wolk & Wolk, 1971) an d the Senior A pp ercep tio n T echnique known as th e SAT (Beliak & Beliak, 1973) are two such them atic tests. A n o th er m ajor an d e n d u rin g projective in stru m e n t o f a very d ifferen t type w hich has retain ed a p rom inent place in the history o f testing is the B ender-G estalt Test (B en d er Visual M otor G estalt Test). T h is test, con­ stru cted by Bender, was first described in a research m onograph (Bender, 1938) an d is essentially based on the m a n n e r in which the exam inee copies nine sim ple, geom etric designs, taken one at a time. Frequently, a second recall phase o f the test is ad m in istered afte r th e copy p o rtion is com pleted. B ender selected h er designs from those used by the Gestaltist W ertheim er in his research on visual perception. In h e r original analyses o f the test,

Psychological Testing and Psychiatric Diagnosis / 7 B ender emphasized gestalt configurational principles and visual-motor m at­ uration. T here has, however, been a steady and impressive flow o f studies on the Bender-Gestalt Test since its publication, ordinarily employing the same nine designs but m odifying and expan d in g adm inistrative and in ter­ pretative approaches to em brace the detection o f organic disorders an d to provide a projective test for the diagnosis o f emotional difficulties. While most clinicians interpret organizational features o f the B ender test perform ance and distortions o f the reproductions o f the designs in an intu­ itive fashion, several objective scoring systems have been devised. For adults, the Pascal-Suttell scoring scheme (1951) is probably the best standardized and most widely known. It has proven useful in the differential diagnosis o f groups with organic pathology from both norm als and groups o f psy­ chotic patients. Koppitz (1964, 1975) focused on establishing norms for chil­ dren. In extensive standardization studies o f the Bender-Gestalt as a nonverbal developm ental scale for ages 5 to 10, Koppitz found m oderate to high correlations with stan d ard intelligence tests up until age 10. A ddi­ tionally, significant differences occurred between the scores o f normals and brain-dam aged children on h er developmental scale. A p art from her Bender-Gestalt developm ental scoring procedures, Koppitz lists 10 indica­ tors for the detection o f emotional problems in children when the projective aspects o f the tests are utilized. In contrast to the ostensible simplicity o f the copy task o f the BenderGestalt Test, draw ing o f hu m an figures, ano th er clinical tool o f long­ standing im portance, provides the opportunity for far more creativity. The least stru ctu red o f all o f the projective techniques, h u m an figure draw ing was initially used solely as a nonverbal m easure o f intellectual level in the form o f the G oodenough Draw-A-Man Test (1926). This test, tapping obser­ vational accuracy and conceptual thinking rath er th an artistic ability in depicting the h u m an figure, rem ained unrevised as an intelligence scale until 1963 when it was m odified, extended and restandardized by H arris (1963). Although Goodenough appeared to recognize the potential o f her figure draw ing test for personality as well as intellectual evaluation, it was Machover (1949) who first gave the technique projective test status. D eparting from the observation that children receiving the same IQ on the G oodenough scale were producing very different drawings, Machover devoted herself to studying the instrum ent from the vantage point o f its ability to reveal aspects o f self concept, attitudes toward people, and other personality variables. T he Draw-A-Person Test (DAP), as it is commonly known, generally requires the exam inee to draw a hu m an figure and then an individual o f the opposite sex. Associations are typically obtained to the drawings. Currently, there is no

8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning generally accepted systematic scoring procedure or interpretive approach for drawings. A m ong the draw ing characteristics which are often interpreted are com parative size an d d e ta ilin g o f the figures and th eir respective body parts, location on the page, an d line quality and shading. O ver the years, a n u m b e r o f variations o f the DAP test have been p ro ­ posed, in cluding tree an d anim al draw ings (H am m er, 1958) an d family draw ings (H ulse, 1952). N one has achieved th e p o p u larity o f the DAP. Fig­ u re draw ings share with the B ender-G estalt Test special usefulness in the personality assessm ent o f illiterate o r foreign individuals an d for th e eval­ uation o f spatial difficulties associated with b rain d am age. T h e sentence com pletion m ethod p erh a p s can be m ost accurately re g a rd e d as falling betw een a projective technique an d a questionnaire. It can appropriately be considered an extension o f the Word Association Test. R ath er th an respond in g to a single stim ulus word as in the W ord Associ­ ation Test, the exam inee com pletes a frag m en tary sentence. It has largely been a “custom ” test in th at a set o f sentence stem s are o ften designed sp e­ cifically to explore a p a rticu lar personality variable. T h u s, th ere are m any sentence com pletion forms. A m ong the e arlie r form s was one published by T endler (1930) who perceived his test as p ro b in g em otional insight. In stu d y in g language and th o u g h t processes, C am eron (1938a, 1938b) co n ­ trasted schizophrenics and senile patients with norm al groups utilizing sen­ tence completion tests. R ohde (1946) developed a sentence completion form w ith a fo rm at for scoring based on M urray’s personality theory. A d ifferen t scoring ap p ro ach is em ployed in conjunction with the widely used R otter Incom plete Sentence C om pletion Blank. T h is p articu lar S en­ tence C om pletion Test consists o f 40 stem s which can be assessed on a 7-point scale for adjustm ent-m aladjustm ent according to a m anual (Rotter & Rafferty, 1950) which provides illustrative exam ples for each scoring cat­ egory. T h e sentence com pletion, however, o ften tends to be dealt with less formally in actual clinical practice. Typically, the clinician looks for such fac­ tors as conflicted, avoidant, an d inconsistent com pletions, overly lengthy an d excessively precise responses, an d u n u su al lan g u ag e as well as behav­ ioral indicators o f tension o r discom fort accom panying certain answers.

T h e M innesota M u ltip h asic P erso n ality In v en to ry W hile projective tests were enjoying an ex tra o rd in a ry grow th sp u rt, th e self-report personality q uestionnaire was far from m o rib u n d . Some clini­ cians rem ained convinced th at inventories o f this type could provide d iag ­ nostic inform ation m ore efficiently a n d less expensively th an projectives. In the late 1930s, H athaw ay and McKinley developed the M innesota Mul-

Psychological Testing and Psychiatric Diagnosis / 9 tiphasic Personality Inventory (M M PI) an d a version o f it th en designated as the Multiphasic: Personality Schedule was published in an article on assessing depression (H athaw ay & McKinley, 1942). No test has been more influential th an the MMPI. A t this point in time, well over 5,000 references have been published a b o u t this in stru m e n t an d it has h ad a significant im pact on the grow th o f th e field o f clinical psychology b eg in n in g with World War II. T h e 550 statem ents on th e M M PI to which the exam inee can respond “tru e ,” “false,” o r “can n o t say” cover 26 d ifferen t content areas, including religious and political attitu d es, psychosom atic conditions, obsessive states, an d family and m arital affairs. T h e original test provided scores on nine scales used in trad itio n al psychiatric diagnosis based on K raepelin’s classi­ fication schem e. T hese “clinical scales” were developed em pirically a n d are com posed o f item s which differen tiated betw een specific clinical groups, m ost o f w hich were about 50 patients in size, an d a norm al control g roup o f about 700 individuals. T h e latter represented a cross section of the M in­ nesota po p u latio n an d were recru ited w hen they visited the University o f M innesota hospitals. A special aspect o f the M M PI is the inclusion o f th re e “validity” scales to check on carelessness, confusion, m alingering, an d the presence o f a response set as well as attitudes toward taking the test. Since the initial p u b ­ lication o f the M M PI, th e 550 statem ents have com prised an item pool for the developm ent o f approxim ately 300 new scales. O n e o f these, the Social Introversion Scale (Si), is now reg u larly included in the M M PI. T h ese new scales vary widely in th eir focus an d application. N u m b ered am ong them are Ego S tren g th (Es), Prejudice (Pr) an d the m ore diagnostically oriented M acA ndrew s Alcoholism Scale (1965). W hile the m ajor th ru st o f the MMPI is as an in stru m en t for differential diagnosis, clinicians have endeavored to d ro p the traditional K raepelinian psychiatric labels w hich are re g a rd e d as m eaninglessly obsolete. Literal interpretation o f elevated scores on single clinical scales is strongly discour­ aged. Rather, the em phasis is curren tly placed on score p attern s and the num erical coding o f profiles. Several books have been published to system­ atize an d sim plify M M PI diagnostic in terp retatio n th ro u g h coded profile patterns (D ahlstrom , Welsh & D ahlstrom, 1972; Hathaway & M eehl, 1951; Marks, Seem an & Haller, 1974).

T he W echsler Scales A t about the sam e tim e as th e MMPI was g ain in g prom inence, a very d if­ ferent kind o f individually adm inistered intelligence scale was being added

10 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning to the psychologist’s array o f testing tools. This test, the Wechsler-Bellevue Intelligence Scale (Wechsler, 1939), was the initial version o f two subsequent Wechsler scales very sim ilar in form at to the first scale for adults, as well as two forms for children and a preschool scale, all o f which essentially p a r­ allel the adult tests. C om pared with the Stanford-Binet, a child-oriented scale, later extended to adult levels in somewhat procrustean fashion, the Wechsler tests are point rath er th an m ental age scales. Item s specially geared for either adults or children are not arranged by age levels as on the Stanford-Binet, but rather are grouped by type into subtests and ordered according to difficulty. Since the Wechsler scales are composed o f Verbal and Performance subtests, sep­ arate Verbal, Perform ance, and Full-Scale IQs can be obtained. F u rth er­ more, a p art from estim ating intelligence, study o f the subtests from the standpoints o f both intertest and intratest pattern in g can sometimes be m eaningful in the diagnosis o f various emotional disorders and brain d am ­ age. T he Wechsler scales have been the subject o f extensive clinical and research use. N um erous publications have ap p eared about these scales, including a great deal o f work on short forms (M atarazzo, 1972), the latter with the goal o f developing a quick screening instrum ent for intelligence. T he revisions o f the adult and children scales o f the Wechsler prim arily reflected an ongoing research effort to improve the representativeness o f the norm ative standardization samples and additionally to refine item content.

W orld War II an d Postw ar Testing At the start o f World War 11 and once again facing the pressing need to screen and classify large num bers o f recruits for the military, clinical psy­ chologists already had some very substantial diagnostic tools. Unfortunately, however, form al clinical psychology training program s had not yet been established. T his resulted in a d earth o f individuals am ong the approxi­ mately 1,500 psychologists in the arm ed forces who had sufficient back­ ground training to use these instrum ents in actual clinical situations. T here was no dim inished need for psychologists at the conclusion o f World War II. Rather, the opposite prevailed. T he rem arkable postw ar growth o f the Veteran’s A dm inistration (VA) clinics and hospitals decisively established a dem and and role for clinical psychologists. T raining issues were concom­ itantly addressed to a considerable degree with the inception o f the United States Public Health Service funding for graduate training program s in psy­ chology and the network o f clinical psychology internships underw ritten by the VA.

Psychological Testing and Psychiatric Diagnosis I I I T he professional activities o f the clinical psychologist o f the 1940s were mostly confined to psychodiagnostic testing. In the m iddle o f this decade, Rapaport, Gill and Schafer (1945, 1946) published their classic two-volume work on psychological testing which had a m ajor im pact on the field. R apaport and his collaborators articulated the concept o f adm inistering a battery o f tests tap p in g diverse psychological functions, in lieu o f a single test, to achieve a genuine u n d erstan d in g o f the subtleties and complexities o f the dim ensions o f personality. They endeavored to spell out the contri­ butions o f each test in a battery in the differential diagnostic process, draw­ ing on psychoanalytic ego theory. Schafer (1948, 1954) added fu rth e r dimension to differential diagnosis in two subsequent books on testing, the latter focusing explicitly on Rorschach interpretation from a psychoanalytic viewpoint. Still later, with Holt serving as editor, the R apaport, Gill and Schafer volumes (1968) on diagnostic testing were skillfully updated and condensed. A fter the enorm ous growth sp u rt o f psychodiagnostic testing in the 1940s, interest in testing began to decline somewhat in the 1950s. Reasons for this decline have been offered from many diverse quarters (for example, G arfield, 1983; Goldstein 8c H ersen, 1984; Holt, 1967). Essentially, conse­ quences o f overselling the value o f a very tim e-consum ing activity were being felt. Furtherm ore, in the attem p t to m eet the inordinate dem and for testers, a num ber o f psychologists had received somewhat perfunctory training and experienced considerable uncertainty about their own testing com petence. Test reports often contained a plethora o f unw arranted spec­ ulations raising serious question about the reliability and validity o f psycho­ diagnostic instruments. Meehl (1954), in an influential book on prediction, even argued that statistical or actuarial m ethods were superior to the ju d g ­ m ental processes employed by the clinician— a shocking assertion at the time. Perhaps central to the lessened involvement in psychological testing, how­ ever, was the fact th at testing was bound to a psychiatric taxonomy, in itself dem onstrated, at the time, to be highly unreliable (Schmidt & Fonda, 1956; Zubin, 1967). In addition, it was a commonly held view am ong psychologists th at testing, p e r se, was very restrictive and comparatively unrew arding, with typically no feedback on the usefulness o f psychological reports from their recipients. T hus, psychologists successfully sought to expand their professional roles to include such activities as psychotherapy and community consultation which, in turn , fu rth er underlined the limited satisfactions that could be derived from testing. Furthermore, in the treatm ent sphere, behav­ ioral therapy approaches were em erging, em phasizing coping with various behavioral problem s ra th e r than probing underlying conflicts, the dom ain o f traditional psychodiagnostic testing.

12 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning A lthough testing activities were in some disarray, virtually every g raduate pro g ram in clinical psychology retained th eir req u ired courses in psycho­ logical testing. Also, assessm ent continued to be re g a rd e d as a relatively im p o rtan t activity to which clinical psychologists clearly devoted substantial time in their actual professional work (Garfield 8c K urtz, 1976). Noteworthy, as well, was the rem arkable stability o f p atte rn s o f test usage over tim e (L ubin, L arsen 8c M atarazzo, 1984). In o rd e r o f overall frequency o f use across various clinical settings, the most p o p u lar instrum ents in a 1982 su r­ vey were: the M M PI, WAIS, B ender-G estalt, Rorschach, W ISC, Sentence C om pletion, TAT and DAP (L ubin, L arsen, M atarazzo 8c Seever, 1985).

C u rre n t T esting T rends Recently, the indications are th a t not only is testing hold in g its own bu t, in fact, may be gaining an increasingly im p o rtan t role in the clinical psy­ chologist’s array o f skills. T his resurgence ap p e ars to be sp e a rh e a d e d by developm ents principally in two areas, namely, neuropsychological testing an d com puter-based test in terp re tatio n (C B TI). Efforts to “test” th e behavioral m anifestations o f b rain d am ag e can be traced back to the work o f K urt G oldstein in th e 1920s. G oldstein’s (1939) im p o rtan t book, The Organism, and his subsequent m on o g rap h w ith a col­ league (Goldstein & Scheerer, 1941) spelled out his theories an d procedures for assessing intellectual im p airm en t o cc u rrin g with b rain dam age. G old­ stein felt th a t a key sym ptom was the presence o f a deficit in abstract th in k ­ ing. It was quickly recognized, however, th a t brain d am ag e su b su m ed a broad spectrum o f complex organic conditions with corresponding variable behavioral p attern s, which, in tu rn , were influenced by such factors as age an d d u ratio n o f cerebral pathology. T h e initial efforts m ade in the differential diagnosis o f brain dam age uti­ lized already existing tests, in particular, the W echsler scales and the Bender-Gestalt. Later, as psychologists acquired a g reater d egree o f sophis­ tication in evaluating organic pathology, systematic attem p ts were d irected to developing com prehensive test batteries w hich ta p p e d a wide variety o f neuropsychological functions and could be ad m in istered a n d scored in a relatively stan d ard ized m anner. The two best known batteries o f this type in c u rre n t clinical use are the H alstead-R eitan N europsychological B attery and the L uria-N ebraska N europsychological Battery. T he H alstead-R eitan has been developed and researched extensively over a lengthy perio d o f tim e (H evern, 1980; R eitan & Davison, 1974). T h e cli­ nicians utilizing this battery typically include 11 tests which assess such fac­ tors as sensorim otor functioning an d th e presence o f aphasia. In contrast

Psychological Testing and Psychiatric Diagnosis 1 1 3 to the H alstead-R eitan, th e L uria-N ebraska ord in arily takes less th a n half the tim e to ad m in ister an d is considerably m ore stan d ard ized in term s o f content an d adm inistrative an d scoring procedures. It consists o f item ra th e r th a n test units designed to provide m ore extensive coverage o f pos­ sible organic pathology as well as a g re a ter d eg ree o f specific localization o f brain d am ag e (G olden, 1979; L u ria, 1973). T h e responses to each o f th e 269 item s on the L uria-N ebraska are scored on a th re e-p o in t norm al to b rain -in ju red co n tin u u m an d then com bined into areas to obtain total scores on such scales as m o to r functions, expressive speech, a n d memory. D espite this quantification pro ced u re, it is to be recognized th a t the items com posing this battery were selected on the basis o f their qualitative clinical significance in diagnosis. C o m p u ters b eg an to be used in psychological testing shortly afte r they becam e available. Not unexpectedly, the first program s developed were for the MMPI and becam e operational some 25 years ago (Fowler, 1985). While the earlier C B T I systems for the MMPI drew largely on individual scale clinical interpretation s an d some fairly elem entary co nfigurational rules, later m ore sophisticated systems included, am ong o th er factors, actuarialbased in terp retatio n s (L achar & A lexander, 1978) an d d em ographic d ata to generate reports (N ational C o m p u ter Systems, 1984). Piotrowski (1964) was the first to undertake the far more dem anding task o f developing a C B T I for a projective instrum ent, the Rorschach. Ten years later, a more quantitatively-oriented Rorschach interpretation approach was published by E x n er (1974) based on the E xner R orschach C om prehensive System. E x n er em phasizes in terp re tatio n based on the stru ctu ral features o f the R orschach expressed in various ratios an d percentages. By contrast, Piotrowski includes content interpretation as an im portant aspect o f his sys­ tem . T h e Piotrowski system is n ot now com m ercially d istrib u ted , while the E xner system underw en t a p erio d o f revision and becam e a fully o p e ra ­ tional service in 1983. C om puter program s have been developed for interactive testing, provid­ in g au to m ated adm in istratio n o f a variety o f tests including the WAIS (Elwood, 1969). Neuropsychological testing has been an area to which p a r­ ticular attention has been devoted. A fter reviewing c u rre n t co m p u ter p ro ­ gram s designed to analyze an d in terp re t neuropsychological test data, A dam & H eaton (1985) concluded, however, th a t p rogram s now available d o not achieve the sam e level o f accuracy as h u m a n clinicians. T hey rec­ om m end th a t such pro g ram s best serve as “ancillary inform ation sources for exp erien ced clinicians.” In an overview o f present applications an d fu tu re directions o f com ­ puterized personality assessment, Butcher, Keller and Bacon (1985) note th a t co m p u ter usage has g ained widest acceptance in stan d ard iz ed test

14 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning scoring and/or administration. They observe that in this role, which cap­ italizes on the com pu ter’s speed and accuracy, it essentially functions as a reliable, but unskilled, clerk. More recently, however, the com puter has been p u t to m ore complex tasks such as producing interpretive psycho­ logical reports akin to those w ritten by clinicians. B utcher and his col­ leagues believe, however, th at the com puter need not be confined to established assessment strategies. Rather, the potential exists in the future for utilizing the com puter’s adaptive capabilities and versatility to modify standard testing m ethods, as, for exam ple, tailoring evaluation procedures to the individual exam inee. Not to be overlooked with respect to C B T I reports are some unresolved ethical issues concerning who is qualified to use such reports which are often distributed by mail-in services. A related problem pertains to the ready availability o f C B T I software, in m any instances to persons who lack app ropriate professional testing credentials. As mentioned briefly at the beginning o f this chapter, the efficacy o f psy­ chological testing clearly interfaces with the reliability o f psychiatric diag­ nosis. At this juncture, it would be meaningful to examine the development o f the A m erican Psychiatric Association’s Diagnostic and Statistical Manuals (DSM-I, DSM -II, D SM -III and DSM-III-R).

DIAGNOSTIC AND STATISTICAL MANUALS (DSM) DSM-I Although the first edition o f the American Psychiatric Association’s Diag­ nostic. and Statistical Manual (DSM-I) did not ap p ear until 1952, it had been apparent for a num ber o f years that there was a compelling need to develop a uniform nom enclature system in the U nited States. In the late twenties, for example, virtually every large psychiatric teaching institution had a clas­ sification system o f its own. As a result, there was a plethora o f diagnostic labels that effectively disrupted m eaningful communication. As recently as 1948, the confusion th at existed was manifested by three separate nom en­ clatures (Standard, A rm ed Forces, and Veteran’s Administration) in general use in America, none o f which complied with the international classification system o f the time. DSM-I was the first official manual o f mental disorders to include a glos­ sary describing the diagnostic categories. T he influence o f Adolph Meyer’s psychobiological orientation that mental disorders reflect personality reac­ tions to psychological, biological, and social factors was reflected in the use o f the term “reaction” thro u g h o u t the DSM-I. T his m anual limited itself

Psychological Testing and Psychiatric Diagnosis ! 15 solely to the classification o f m ental disturbances, excluding, for exam ple, neurological diseases. It employed the nam e “diso rd er” generically to encom pass a group o f related psychiatric syndromes. All mental disorders were separated into (1) disturbances o f mental functioning primarily having a known organic etiology and (2) a group consisting o f conditions o f more general adaptadonal difficulties in which any related brain function pathol­ ogy was ju d g e d secondary to the psychiatric disorder. In contrast to prior diagnostic usage, the term Mental Deficiency was applicable in DSM-I only to those cases where there was intellectual im pair­ m ent w ithout recognizable organic brain pathology prenatally, at birth, or in childhood. O th er long-standing organically-based disorders o f intellec­ tual functioning were listed u n d e r Chronic Brain Syndromes. DSM-I expanded the n u m b er and type o f Schizophrenic Reactions found in oth er nosology systems to p erm it more detailed diagnoses, while reducing the num ber o f Manic Depressive Reactions and grouping them with Psychotic Depressive Reaction into an Affective Reaction cat­ egory. In addition, psychosomatic disorders were classified u n d e r Psychophysiologic and Visceral Disorders to capture the interaction between psychic and somatic factors implicated in these disturbances. Titles in Personality Disorders and Transient Situational Disorders were also elab­ orated and extended. DSM-I nomenclature perm itted the use o f three qualifying phrases: with psychotic reaction, with neurotic reaction, and with behavioral reaction. These qualifiers were intended to describe the appearance o f a m ajor change in the clinical symptomatology o f a diagnosed condition, occurring when fu rth e r psychological sym ptom s are superim posed on the existing disorder.

DSM -II T he second edition o f the Diagnostic and Statistical Manual (DSM-II) was published in 1968 by the American Psychiatric Association and revised the 1952 standards for recording and reporting psychiatric diagnoses. The nom enclature o f DSM-I and the diagnostic system presented in the sixth revision o f the World Health Organization's International Classification of Dis­ eases (ICD-6) were not com patible. DSM-II attem pted to brin g American nomenclature more in line with international practice as reflected in ICD-8 which was also published in 1968. C om pared with DSM-I, DSM-II modified the names o f many o f the dis­ orders as well as defining them differently. T here were also changes in the organization o f the nomenclature. T he reporting o f multiple diagnoses and

16 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning related physical conditions was specifically en couraged an d qualifying phrases were altered. M ore explicitly am ong th e changes, th e term “reaction,” which was th o u g h t to be som ew hat restrictive, was rem oved from m any diagnostic categories. O rganizationally, in lieu o f the th re e m ajor d iso rd er catego­ ries o f DSM -I consisting o f organic, functional, an d m ental deficiency diagnostic groups, DSM-II was divided into 10 categories. T h e basic dis­ tinction, however, between organic b rain syndromes and all o th er condi­ tions found in DSM -I was retain ed in D SM -II. A significant new diagnosis— Schizophrenia, Latent Type— was ad d ed for disorders previ­ ously d esignated unofficially as incipient, prepsychotic, pseudoneurotic, pseudopsychopathic, o r b o rd erlin e schizophrenia, and classified in D SM -I u n d e r Schizophrenia Reaction, C hronic U ndifferen tiated Type. In D SM -l, Sexual Deviations, Alcoholism, and D ru g D ependence were single diagnoses. To perm it far g reater specificity, DSM -II listed these three diagnoses as m ajor h eadings, u n d e r each o f w hich were listed a n u m b er o f new diagnostic categories. W hile DSM-I d id not classify acute reactions to stress o f psychotic propo rtio n s u n d e r T ransient Situational Personality D isturbance, D SM -II d id explicitly p e rm it psychotic d isturbances th a t are viewed as reactions to inordinate environm ental stress to be included in this category. The category, No M ental Disorder, which d id not explicitly a p p e a r in DSM -I, was a d d e d to D SM -II as a “positive” diagnosis which could be rep o rted . By com parison with DSM-I w here each o f th ree qualifying phrases could be used with any diagnostic category as long as the p h rase was not re d u n ­ d a n t w ith the disorder, DSM -II h ad seven d ifferen t qualifying phrases, all b u t one, “in rem ission,” linked to specific sections o f the diagnostic m anual. T h e rem ain in g six D SM -II qualifiers were: acute, chronic, not psychotic, m ild, m oderate, an d severe. A lthough D SM -II was ju d g e d to reflect significant gains over DSM -I, it was n o t w ithout its critics (K orchin, 1976). A m ong th e m ajor criticism s was the lack o f com prehensive and explicit criteria for the various diagnostic categories as well as the significant sym ptom overlap am ong dif ferent diag­ noses. Some dissatisfaction was also expressed over the absence o f adequate coverage o f a n u m b e r o f clinical problem s, p articu larly those p ertain in g to children, adolescents, and the aged, for which the DSM-II diagnostic cat­ egories ap p eared unrealistically com pacted. Further, the principles o f clas­ sification seem ed to be bewilderingly variable with some conditions defined by patient characteristics, o th ers by behavioral sym ptom atology, and still o th ers by etiology. Finally, th e largely descriptive an d loosely em pirical n a tu re o f the D SM -II categories w ithout theoretical u n d e rp in n in g s an d their different “w idth,” with some highly focused an d others a rath er sweep­

Psychological Testing and Psychiatric Diagnosis ! 17 ing group o f disorders u n d er one rubric, were regarded in some quarters as shortcomings.

D SM -III In 1974, the American Psychiatric Association appointed a task force to begin work on the developm ent o f DSM -III. Concern was expressed th at ICD-9, scheduled to become official at the very beginning o f 1979, would not be fully suitable for use in the U nited States. Specific ICD-9 classifica­ tions did not seem sufficiently detailed for clinical and research application, while the glossary was perceived as not reflecting such im portant m ethod­ ological advances as explicit diagnostic criteria and the multiaxial approach to assessment. T he task force, therefore, em barked upon p reparing a new classification and glossary consistent with the most cu rren t state o f knowl­ edge pertaining to m ental illness and com patible with ICD-9. T h ere was agreem ent at the time, am ong members o f all the mental health professions, that DSM-II was both comparatively unreliable and rarely as useful as it should be. A fter five years in developm ent, two years more than had initially been anticipated, D SM -III was published in 1980. DSM -III represented a far m ore extensive undertak in g th an its predecessors in term s o f planning, deliberation, n um b er o f clinicians involved, and field trials. According to Spitzer (1980), the prim e architect o f D SM -III, the most im p o rtan t m od­ ification accomplished by D SM -III is having specified diagnostic criteria for all disorders, rath e r th an am biguous, stereotypic descriptions. This, he felt, would greatly enhance clinician comm unication. A second m eaningful change in Spitzer s estimate was the multiaxial eval­ uation system, providing that, in fact, the optional Axes IV and V, dealing with psychosocial stressors and highest level o f functioning, respectively, are found helpful and are used regularly with the clinical syndrome, person­ ality, and developm ental disorders, and with the physical disorders axes. W hile multiaxial systems were not new, this was the first one actually incor­ porated into an official classification system. Lastly, he felt th a t including the restrictive requirem ent o f overt psychotic features at some time d u rin g the illness in the definition o f schizophrenia was a major and very significant clarification. Pointing to the m uch richer, more comprehensive, and detailed descrip­ tions o f the diagnostic categories, Spitzer also cited com parable efforts at organizational clarity. T he form at rigorously followed initially presents the core or essential features o f the disorder, then the characteristics always pres­ ent, and, finally, features commonly but not necessarily in evidence. In can­

18 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning dor, he notes th a t afte r a dialogue with th e A m erican Psychological Association, a statem ent which was to be included in D SM -III indicating th at the m ental diso rd ers in th e m an u al were m edical d iso rd ers was w ith­ draw n as not being a co ntribution to the process o f classifying an d describ­ in g m ental disorders. T h e re were o th e r im p o rta n t features o f D SM -III th a t d iffered from DSM -II. T h ere wrere four times as m any diagnostic categories o f childhood disorders, m irroring the great increase o f knowledge in this area. T h e label o f B orderline M ental R etardation has been deleted, however, since these persons typically do n ot have m arked difficulties in adaptive behavior. O rganic m ental diso rd ers were no longer divided into acute o r chronic based on a reversibility criterion, as in DSM -I an d D SM -II. Rather, these d iso rd ers were classified m uch m ore precisely by the syndrom e they cause and th e ir etiology, if known. T h e substance use diso rd ers section o f DSMIII com bined D ru g D ependence an d Alcoholism categories o f D SM -II to em phasize the sim ilarity in th e m aladaptive use o f all substances o f p o te n ­ tial abuse. In ad dition, the D SM -II categories o f Schizophrenia, Sim ple T ype an d L atent Type, in w hich psychotic sym ptom s were absent, are not included in D SM -III, b u t were covered by th e new severe personality d iso rd e r cat­ egories such as Schizotypal o r B orderline Personality Disorder. T h e Schiz­ ophreniform D isorder o f D SM -III generally replaced the diagnosis o f Acute Schizophrenic Episode o f D SM -II with the ad d ed stipulation th a t duration o f the illness is less th a n six m onths b u t m ore th a t two weeks. In D SM -III, Schizoaffective Disorder, the one diagnosis lacking specific criteria because consensus was not achieved on defining it, was reserved for those situations w here a differential diagnosis c an n o t be m ade betw een S chizophrenia an d Affective Disorder. T h e affective d iso rd e r classification was very likely the only sphere in which D SM -III may be som ew hat sim pler th an D SM -II. In D SM -II, all m ajor affective diso rd ers were categorized as psychoses except those p re ­ cipitated by stressful life events. Affective diso rd ers in D SM -III were grouped together u n d e r the subclass Major Affective Disorder. Bipolar Dis­ o rd e r replaced M anic-Depressive Illness, Manic o r C ircu lar Type, o f DSM -II, based on the rationale th at virtually all individuals who have expe­ rienced a m anic episode inevitably develop depressive episodes. O n the other hand, the DSM-II Manic-Depressive Illness, Depressed Type, was con­ sidered a U nipolar disorder, an d was classified as Major Depression in DSMII I. T h e neuroses n om enclature o f D SM -II was d ro p p e d . T h e diso rd ers found u n d e r this classification were g ro u p ed mostly to g eth er as A nxiety D isorders in D S M -III, with a few classed as Dissociative D isorders and Som atoform D isorders an d the diagnosis o f Depressive N eurosis o r

Psychological Testing and Psychiatric Diagnosis 1 1 9 D ysthym ic D isorder placed in the Affective D isorders category. Posttraum atic Stress D isorder, which a p p e a re d only in DSM -I, was reincluded am ong the A nxiety D isorders o f D SM -III. DSM -II Sexual Deviations w'ere term ed Paraphilias in D SM -III, a sub­ class o f Psychosexual D isorders. A n o th er subclass is G en d er Identity Dis­ o rd ers w hich cover T ranssexualism and G en d er Identity disturbances in childhood. Ego-Dystonic Homosexuality is substituted for the DSM -II cat­ egory Sexual O rientatio n D isturbance, o r Homosexuality, the form er p e r­ ceived as a m ore accurate description. A new category in D SM -III, Factitious Disorder, described individuals who simulate physical o r psycho­ logical sym ptom s in th e classical M unchhausen o r G an ser Syndrom e m a n ­ ner. A djustm ent D isorder replaced the D SM -II category o f T ransient Situational D isturbance; in contrast to the latter, it excludes reactions o f psy­ chotic proportions. As indicated earlier, Axis II was utilized to code Personality D isorders, en su rin g th at they are not ignored in the presence o f a m ore floridly obvious Axis I disorder. T h e V codes o f D SM -III su p p lan ted the C onditions W ith­ o u t M anifest Psychiatric D isorder o f D SM -II. T h e V code category was for conditions n o t attrib u tab le to m ental d iso rd er b u t still a focus o f attention or treatm ent. Unlike the DSM -II category, a m ental disorder may addition­ ally be present. M arital Problem and U ncom plicated Bereavem ent are exam ples o f V code conditions. As was the case in c o m p arin g DSM -II with DSM -I, the advent o f DSMIII m arked considerable diagnostic im provem ent over D SM -II, though som e substantial problem s clearly rem ained. Schacht an d N athan (1977) pointed to the “enorm ous u n d erly in g com plexity” o f the m ultiaxial classi­ fication system which was m asked by its a p p a re n t simplicity. T hey question particularly the ability o f the clinician to use the ra tin g scales o f Axes IV an d V in a m eaningfu l fashion. Further, they recom m end the inclusion o f an add itional axis for co d in g response to treatm en t, w'hich they feel m ight help to classify the diagnosis in certain difficult situations. O th e r issues raised by Schacht and N athan, prim arily from a conceptual stan d p o in t, p e rta in to w hat they reg ard as an erroneous view o f the rela­ tionship between organism an d environm ent postulated in DSM -III which, in tu rn , im pacts on the concept o f organismic dysfunction. A n explicit d ef­ inition o f psychological health against which to evaluate deviance, not c u r­ rently found in D SM -III, would, according to Schacht an d N ath an , deal with questions o f environm ental versus organism ic preem inence in psycho­ diagnosis. Concomitantly, d efining health would shape the diagnostic proc­ ess to address the ind iv id u al’s problem s an d needs rath e r th a n th in k in g in term s o f illness models. T he stigm atizing effects o f attaching D SM -III diagnostic labels to certain

20 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning behaviors not ordinarily regarded as psychopathological have also been crit­ icized (G arfield, 1983). For exam ple, a child who is “significantly below the expected level” an d n ot functio n in g up to intellectual capacity in read in g o r arithm etic skills can be given new D SM -III diagnoses o f Developmental R eading D isorder o r D evelopm ental A rithm etic D isorder, if evaluated by a psychologist o r psychiatrist.

D S M -III-R C ontrasted w ith the difference betw een DSM -II and D SM -III, the revi­ sions m ade in the latter to produce D SM -III-R are considerably more m od­ est. In a th re e year p erio d after the publication o f D SM -III in 1980, a n u m b er o f significant inconsistencies an d am biguities h ad su rfaced which need ed to be resolved. A work g ro u p was, therefore, a p p o in te d by the A m erican Psychiatric Association, again ch aired by R obert L. Spitzer, an d ch arg ed w ith addressin g these difficulties. D SM -III-R , published in 1987, essentially incorporates m odifications derived from the wealth o f clinical experience an d research d ata accum ulated since the a p p ea ra n ce o f DSMIII. Advisory com m ittees o f ex p erts were utilized th ro u g h o u t th e revision process to review proposals for diagnostic criteria and textual changes. In com parison to a small n u m b er o f D SM -III codes not com patible with ICD-9 codes, all D SM -III-R codes were revised to legitim ate ICD-9 codes as well. T he m ajo r th ru s t o f D SM -III-R m odifications entail: w ording clarifica­ tions, criteria revisions to yield richer and m ore m eaningful clinical descrip­ tions, an d , lastly, some reg ro u p in g o f categories. T h e m ost pro m in en t category changes occur in the Substance Use and Personality D isorders sec­ tions. M oderate revisions have been m ade in the A nxiety D isorders and C h ild h o o d D isorders categories and only com paratively m inim al m odifi­ cations in the rem ain d er o f the diagnostic classifications. In so fa r as the multiaxial com ponent o f D SM -III-R is concerned, particularly noteworthy are the inclusion o f new groupings o f Developmental D isorders u n d e r Axis II and the revision o f Axis V to incorporate a 100-point Global Assessment o f Functioning scale. T h e latter now p erm its the clinician to rate psycho­ logical functioning in ad d itio n to the previously evaluated social a n d occu­ pational functioning, on a hypothetical con tin u u m o f health-illness. T h e focus o f changes in w hat is labeled Psychoactive Substance A buse D isorders in D SM -III-R is a significant b ro ad en in g o f th e d efinition o f dependence to encom pass an array o f sym ptom s which reveal a serious loss o f control o f substance use an d sustained use o f the substance in the face o f patently adverse consequences. Most o f the D SM -III cases o f substance abuse are covered by th e D S M -III-R categories, which also contain a resid­

Psychological Testing and Psychiatric Diagnosis / 21 ual classification for a d isorder which does not m eet the dependence criteria yet indicates a m aladaptive p a tte rn o f use. Also covered in D S M -III-R b u t not found in D SM -III is in h alan t abuse. T h e p rim ary revision for the personality d iso rd ers entails providing a one-sentence, broad description for each o f the disorders. T h is is followed by a list o f explicit behaviors so th at no single behavioral m anifestation is req u ired for o r sufficient for the diagnosis. A dditional behavioral d escrip ­ tors have also been provided for most o f the diagnostic categories, while som e confusing items have been rem oved. N otew orthy is the m arked d if­ ference in the DSM-I II-R concept o f Avoidant Personality D isorder which m akes it no longer m utually exclusive with Schizoid Personality Disorder. T h e form er now corresponds to the clinical notion o f “phobic ch aracter.” C hanges have also been m ade in the diagnostic criteria in a n a tte m p t to clarify the distinctions am ong H istrionic, Narcissistic an d B orderline p e r­ sonality disorders. In essence, the suicide item has been elim inated from H istrionic to afford m ore d ifferentiation from B orderline, while an item p ertain in g to preoccupation with feelings o f envy has been a d d e d to N ar­ cissistic to distinguish it m ore clearly from the H istrionic diagnosis. Most significantly, th e hierarchic rule th a t an A nxiety D isorder is p re­ em p ted by the presence o f an o th e r m ental disorder, such as S chizophrenia o r M ajor D epression, has been rem oved in D SM -III-R . Panic d iso rd er has been given m ore prom inence a n d now is divided into subtypes based on w hether o r not agoraphobia is also present. To exclude tran sien t anxiety reactions, the d u ratio n necessary for the diagnosis o f G eneralized A nxiety D isorder has been extended from one m onth to six m onths an d th e sym p­ tom list ex p an d ed to o ffe r a m ore com prehensive d escription o f th e d iso r­ der. T h e stressor criteria for Post-traumatic Stress D isorder have been better d efin ed to convey the notion th a t it is beyond th e usual bou n d aries o f h u m an experience and would be m arkedly disruptive to virtually everyone. T he range o f sym ptom s have additionally been expan ded for the diagnosis o f Post-traum atic Stress D isorder to include those specifically applicable to children. U nder the rubric o f Developmental Disorders, M ental Retardation, Spe­ cific Developmental Disorders, and Pervasive Developmental D isorders have been a d d e d to Axis II. In contrast to Axis I, therefore, all d iso rd ers coded on Axis II share an on set in child h o o d o r adolescence a n d ordin arily con­ tinue into adu lth o o d in stable form . T h e new su b ty p in g o f C onduct Dis­ o rd e r in D SM -III-R reflects a significant distinction betw een aggressive, antisocial behavior th at is evident in solitary activity an d antisocial behavior th a t occurs in a g ro u p situation with o th e r children. A m ong o th er modifications in D isorders Usually First Evident in Infancy, C h ild h o o d an d Adolescence a re criteria revisions to raise th e threshold for

22 / Psychological Assessment, Psychiatric Diagnosis, ami Treatment Planning diagnosing Avoidant D isorder o f C hildhood an d Adolescence and O veran­ xious D isorder; to include o ld er an d abused o r neglected ch ild ren u n d e r Reactive A ttachm ent D isorder o f Infancy o r Early C h ild h o o d ; an d to d if­ ferentiate O ppositional D isorder, ren am ed O ppositional D efiant D isorder in D SM -III-R , from C onduct D isorder. T h e distinction betw een th e DSMIII diagnoses Infantile Autism an d C h ild h o o d O nset Pervasive D evelop­ m ental D isorder was ju d g e d as lacking validity and as a result these categories are com bined into the single D SM -III-R category o f Autistic Dis­ order. Schizoid D isorder o f C hild h o o d o r Adolescence is elim inated in DSM-I II-R as it has been perceived only in the presence of sym ptom atology indicating a Pervasive D evelopm ental Disorder. E xam in ing o th er im p o rtan t specific changes o f D SM -III-R , am ong the Schizophrenic D isorders the paranoid subtype o f schizophrenia in DSM -III has been red efin ed to em phasize its system atized delusional aspects, while D SM -III P aranoid D isorders have been ren am ed D elusional Disorder, reflecting a d istu rb an ce having g re ate r b re a d th th a t m ere suspiciousness. O th e r modifications am ong the psychotic disorders include: the elimination o f the criterion th a t schizophrenia begin before age 45; specific diagnostic criteria for Schizoaffective D iso rd er— a d iso rd er for w hich no explicit c ri­ teria were provided in D SM -III; and acknow ledgm ent th at a B rief Reactive Psychosis may persist for as long as a m onth, along with clarification o f the criteria for this disorder in o rd e r to exclude culturally-sanctioned reactions. T h e affective disorders have been given the more descriptive and accurate nam e M ood D isorders an d have been reorganized so th a t the B ipolar Dis­ ord ers a n d Depressive D isorders are each classified together. T h e criteria for m elancholia have been revised and specification can be m ade th a t the Major Depression is o f a melancholic type. A seasonal p a tte rn o f Major D epression can also be indicated. T h e D SM -III diagnosis o f Ego-Dystonic H om osexuality has been elim ­ inated from DSM -III-R. T h e removal o f this category was based on the rea­ soning th a t it conveyed th e im pression th a t hom osexuality itself was a d iso rd e r an d also th a t it has been infrequently em ployed clinically an d in the scientific literature. Furtherm ore, it has been noted in the U nited States th at alm ost all hom osexual individuals ex perience an ego-dystonic phase w ith re g a rd to th eir homosexuality. T h e re have been some significant appendices m odifications to DSMII I-R. T h e detailed Sleep an d A rousal D isorders classification which was found in an ap p en d ix in D SM -III has been sim plified an d included in the body o f D SM -III-R ra th e r th a n as an ap p en d ix . A m ong o th e r sleep dis­ orders, diagnostic criteria are provided for Insom nia Disorder, D ream A nx­ iety D isorder, and Sleepw alking Disorder. T h re e new diagnostic categories which have been proposed were ju d g e d controversial and deem ed “needing

Psychological Testing and Psychiatric Diagnosis / 23 fu rth e r study” and are located in the appendices o f DSM -III-R. They are: Late Luteal Phase Dysphoric D isorder (a more narrowly defined version o f prem enstrual syndrome), Self-Defeating Personality Disorder, and Sadis­ tic Personality Disorder. Basically, they were assigned to an appendix because o f some questions raised about their scientific potential for misuse. A num ber o f professionals felt th at the categories would result in the misdiagnosis o f norm al women as having mental illness (Late Luteal Phase Dysphoric D isorder and Self-Defeating Personality Disorder) or would be used in the courts to allow men who abuse women to escape legal punish­ m ent (Sadistic Personality Disorder). Several oth er appen d ix changes worth noting are the inclusion o f 18 defense mechanism s and their definitions in the D SM -III-R Glossary o f Technical Terms and a new Index o f Selected Symptoms included in the Diagnostic Criteria. This symptom index perm its the clinician to locate, and review conveniently, all o f the D SM -III-R disorders th a t have a particular sym ptom as one o f their defining features.

DSMs, PSYCHOLOGICAL TESTIN G AND TR EA TM EN T PLA N N IN G By virtue o f the impressively higher reliability o f the diagnostic categories o f D SM -III and D SM -III-R in com parison to their predecessors, psycho­ diagnostic testing becomes a m uch more m eaningful and viable activity. It is to be noted that DSM-III-R is an essentially atheoretical classification sys­ tem. Its descriptive approach necessitates a reliance on sym ptom -oriented and historical d ata in the form ulation o f diagnoses. Although DSM -III-R does not preclude an intrapsychic or psychodynamic understanding o f psy­ chopathology, neither does it, for the most part, include criteria that are fundam entally useful to a psychodynam ic perspective. O n the oth er hand, psychodiagnostic testing tends to be based on the prem ise that an individual’s test perform ance reflects an internal state in terms o f such factors as defenses, ego strengths, and inner conflicts, as well as the more proximal im pact o f cu rren t psychological difficulties and psy­ chiatric disorders. Psychological test d ata are not necessarily atheoretical nor, for th at matter, congruent with one specific personality theory. A lthough such d ata may contribute to an u n d erstanding o f how an indi­ vidual interacts with the world, test findings ordinarily do not provide a clear sym ptom atic and/or historical picture. It is apparent, then, th at D SM -III-R and psychodiagnostic testing have largely com plem entary roles as sources o f inform ation which can differen­ tially delineate a m ental disorder and offer a com bined fram e o f reference for treatm ent planning.

24 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Studies o f psychiatric diagnosis have indicated improving, if somewhat variable, reliability over the period d u rin g which the three DSMs were developed. Reliability research using DSM-I and DSM-II revealed generally poor or, at best, fair reliability for most o f the m ajor diagnostic categories (Spitzer & Fleiss, 1974). T he Field trials for DSM -III involved 450 partic­ ipating clinicians, conducting evaluations o f nearly 800 patients o f all ages in one o f the largest reliability studies ever done. T h e results reported by Spitzer, Form an and Nee (1979) indicated good in terra ter reliability for most diagnostic categories, m uch above the levels achieved for DSM-I and DSM-II. In sum m arizing the overall reliability d ata on the DSMs, Spitzer (1980) gives reliability coefficients mostly in the .40 range, but occasionally around .60 for DSM-I and DSM-II categories like schizophrenia and depression, wile personality and neurotic disorders, at their highest levels, were .30 and .40. In sharp contrast, for a DSM -III study group o f adults, schizophrenic disorders averaged .81 over two phases o f field trials; affective disorders .76; and substance abuse disorders .83. T he reliability was lower for childhood categories but substantially b etter th an w hat was obtained utilizing DSM-II. Not surprisingly, the frequency o f requests for diagnostic “labels” in refer­ rals for psychological testing appears related to the am ount o f effort directed towards enhancing nosological reliability at the time. O ne study (Dollin & Reznikoff, 1966) reviewed questions on a psychological testing referral form posed for a population o f inpatients and outpatients by psy­ chiatrists and psychiatric residents at a large psychiatric hospital. In 1956, only four years after DSM-I was introduced, a specific diagnosis was requested in 64 percent o f the cases. By 1965, diagnostic enthusiasm seem ed to have waned and in only 29 percent o f the referrals was a diag­ nosis requested, a statistically significant decrease. In a 1976 replication o f the prior study (Dollin & Phillips, 1976) in the same setting, the referral requests for a diagnosis had risen significantly to 53 percent. T h e authors in terp ret their findings in light o f an ap p aren t re tu rn to traditional diag­ nosis concurrent with the interest in the then ongoing preparation o f D SM -III. It is the confluence o f psychological testing, the D SM -III-R diagnostic system, and ongoing work for DSM-IV, and their overlapping and unique contributions to treatm ent planning for the individual patient th at is the focus o f this book. T h e im provem ent o f a diagnostic system to a point at which it is reliable and operational enough to guide differenital diagnoses and related treatm ent planning and encourage research is a q u an tu m leap forward. We feel that this is such a m ajor event th at psychological testing used in the assessment o f m ental disorders cannot be the same as before. T hus, this book, while in the tradition o f psychological testing in psychiatric

Psychological Testing and Psychiatric Diagnosis / 25 hospital settings (R ap ap o rt, Gill & Schafer, 1945-1946), is at th e sam e tim e a d ifferen t approach . In contrast to the role traditionally played by psychological assessm ent, psychiatric diagnosis can now be m ade efficiently th ro u g h inform ation g ath ered in a m ore o r less stru ctu re d clinical interview, o r w ith som e o f the sem istructured interviews for the diagnosis o f Axis I an d Axis II conditions (e.g. S tructured Clinical Interview for Diagnosis (SCID) o r Personality Dis­ o rd e r E xam ination (PDE)). In th a t the c u rre n t diagnostic system includes behavioral m arkers w ith a specific tim e fram e (e.g. depressed m ood for at least two weeks), this kind o f d a ta may be best obtain ed in an interview and is n ot ta p p e d in tests th a t are a cross-sectional sam ple o f behavior. However, m ost im portantly, th e DSM diagnosis is necessary b u t not suf­ ficient for treatm en t p lan n in g (B eutler & C larkin, 1990). T h e DSM d iag ­ nosis provides a goo d b eg in n in g for focusing on feelings, behaviors, and sym ptom s th a t are tro u b lin g to the patient. But m uch m ore th an this is n eed ed to plan intervention. As an illustration o f this fact, it m ust be rec­ ognized th at two patients with the sam e Axis 1 an d Axis II diagnoses may req u ire quite d ifferen t treatm en ts in term s o f setting, form at, techniques, and m edications. W hat, then, is a relatively exhaustive list o f inform ation areas needed for com prehensive treatm ent planning? T he relevant research suggests th a t the con sultant needs inform ation on the p atien t’s sym ptom s an d troubled behaviors. T his is often, b u t n o t always, the focus o f th e p atien t p resenting for help, the so-called c h ief com plaint. T h e details o f these sym ptom s in term s o f the severity and frequency and im pact on the p atien t’s daily fu n c­ tioning are often cap tu red in the DSM diagnostic categories. For treatm ent planning, however, th e clinician m ust obtain inform ation not only on the problem atic behaviors an d sym ptom s, b u t also on the p atien t’s personal assets. As every clinician knows, a sym ptom o r problem com plex o f m od­ erate severity is quite different in term s o f treatm ent and prognosis d ep en d ­ in g on w h eth er it is a perso n w ith considerable assets o r an individual with relatively m eager strengths. N ot only does one n eed to know the ta rg e t sym ptom s and behaviors th at are problem atic an d th e focus o f change, b u t also one needs to know the source o f these difficulties. D epression, for exam ple, can be th e end result o f acute environm ental stress o r it can be th e result o f th e individual’s chronic an d pervasive ways o f conceptualizing the world. F urtherm ore, som e sym ptom com plexes a p p e a r to be relatively habitual an d autom atic ways o f responding to the environm ent (e.g. panic attacks). T h e d ata suggest th a t in these situations, intervention directed at sym ptom atic habits may be the m ost efficacious m ethod o f intervention. In o th er situations, however, it seems more profitable for treatm ent plan­

26 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning ning to conceptualize the problematic sym ptom s and behaviors as essential m anifestations o f u n d erly in g intrapsychic conflict. T h e assessm ent, o f course, m ust provide in form ation on b oth the behavioral level and the conflictual level. T h e re are m any tests w hich provide in form ation along these treatm en t relevant dim ensions (C larkin & H u rt, 1988). It is precisely in these areas th at are crucial to tre a tm e n t p lan n in g th a t d a ta from psycho­ logical tests can contribute most significantly to the clinical assessment proc­ ess. In ad dition, th ere are also situations in which testing can be helpful in d efining underlying organic factors and/or assisting in defining the func­ tional level an d capacities o f individuals with such organic conditions.

S E C T IO N I

AXIS I DISORDERS

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CHAPTER 2

Disorders Usually First Evident in Infancy, Childhood, or Adolescence A. EATING DISORDERS: ANOREXIA NERVOSA AND BULIM IA NERVOSA A norexiaandbulim iaaretw o eatin g d iso rd ers that are related but somewhat different symptomatic constellations involving the disruption o f the routine o f food intake. T here is some indication th at th esy m p to m so f anorexia (e.g., the restriction o f food intake with the subsequent reduction o f body weight) are associated with fewer personality and interpersonal problems than bulimia (the usual intake o f food, but its elimination by unusual means such as laxatives and vomiting). D isorders o f food intake are more prom inent am ong women, especially young women preoccupied with their appearance, all o f which seems strongly influenced by the values o f o u r culture.

ANO REX IA NERVOSA: T H E CASE OF MS. C Ms. C was a popular, bright young girl who had always done well in school. She was active in her new school, although her family had just moved to the area a few weeks before when h er father had relocated because o f his new job. She lost a very close race for head cheerleader o f her ninth grade class, but her parents thought she got over it after a few days o f disappoint­ m ent. In tru th , Ms. C was quite upset about the event and particularly so when she learned that the girl to whom she lost the election was later diag­ nosed as having anorexia nervosa. Ms. C, now 15, had been trying to lose weight for the last year and a half. She and her 19-year-old sister had begun a program o f vigorous exercise and severe dieting d u rin g the previous school year. H er exercise regim en had included up to four hours o f long-distance ru n n in g per day, along with m orning and evening calisthenics and practicing her cheerleading routines. 29

3 0 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning H er weight had d ro p p e d to 82 pounds, som e 40 p o u n d s below norm al for som eone 5'7" in height. O n two occasions in the last 18 m onths h er p e d i­ atrician had becom e concerned enough about h er weight loss an d accom ­ panying retardation o f physical developm ent (for example, Ms. C had never m en stru ated ) th a t he h ad h er medically hospitalized for w eight gain. She passively coop erated with th e intravenous feeding b u t simply re tu rn e d to h er old routine upon discharge. A lthough Ms. C h ad been able to m aintain weights slightly over 100 po u n d s in o rd e r to continue to ru n with the school’s track team , h e r loss o f the election caused h er to redouble h e r efforts to lose weight. She h ad been restricting h er food intake d u rin g the day and h ad been eatin g only at night. D u rin g the evening, she would spend h o u rs in the kitchen p re­ p a rin g sm all am ounts o f m any differen t kinds o f foods. Now, she sto p p ed eatin g entirely. As h er weight began to d ro p rapidly, h er p ed iatrician once again had h er hospitalized and insisted that, on discharge, her parents take an active role in restricting h e r exercise, scheduling h e r meals, an d p re p a r­ ing h er food. At hom e, in response to this new regim en, Ms. C beg an to bite herself, pull h er hair, and b an g h er head. W ithin a few days, she began to feel th a t h er life was “w orthless” and talked o f suicide. Frightened at this tu rn o f events, h er parents b ro ught h er to a different hospital with an eating d iso rd ers pro g ram for psychiatric consultation an d treatm en t. O n adm ission, Ms. C was described as an attractive b ut em aciated 15-year-old girl who looked qu ite a bit o ld er th an h e r 15 years. She was Fid­ gety an d restless d u rin g the adm ission interview, but h e r physical restless­ ness d id not a p p e a r to interfere with h er attention and concentration. She d escribed h er m ood as “O kay” and ad m itted to p erio d s o f feeling “b lu e” o r “depressed” on occasion. H er affect was described as irritable an d she often m ade faces o f disgust when asked to provide details o f her experience. T h e exam ining clinician found no evidence o f severe d isturbances in Ms. C ’s perceptions o r thinking. She knew she was u n derw eight an d “th in ” and was aware o f the medical problem s this caused. She realized she was in need o f treatm en t, b u t despite h er rep eated hospitalizations an d h er o u tp atien t treatm en t, she claim ed to have no idea w hat was b o th erin g her. She simply stated th a t she felt b e tte r w hen she was dieting.

D S M -III-R D iagnosis Axis I: Axis II: Axis III:

A norexia nervosa None E m aciation, b rad y card ia, lanugo, en larg ed su b m a n d ib u la r salivary glands an d absent d eep tendon reflexes

Disorders in Infancy, Childhood, or Adolescence ! 31 Axis IV: Axis V:

M oderate— Father had a serious h eart attack six m onths pre­ viously; loss o f election Poor— h e r d ietin g an d exercise regim ens h ad forced h er to give up all h er friends; h er school work h ad b eg u n to suffer

T reatm ent a n d H o sp ita l C ourse Ms. C was placed on an initial treatm ent regim en involving fixed am ounts o f p rep ared foods served several times p e r day, daily weights, m onitoring o f h er intake and o u tp u t, an d restriction o f h er exercise an d activity. She tolerated this app ro ach w ithout the hostility an d self-injury she displayed at home. However, she was u nable to eith e r gain o r sustain h er weight on this regim en and began her second week o f the hospitalization on frequent oral feedings o f a n u tritio n al supplem ent. R egular foods o th e r th an fruit juices were elim inated from h er ro u tin e d ie t an d the am o u n t o f n utritional supplem ent was gradually increased to supply sufficient calories. D u rin g the next six weeks, Ms. C was able to achieve h er ta rg e t weight ran ge o f 122-127 pounds. H er n utritional supplem ents were discontinued and she was re tu rn e d to re g u la r foods. She was enrolled in a full school schedule and did well in school. In her individual psychotherapy, she began to explore the reasons for h er illness and cam e to focus increasingly on her m o th er’s a n d sister’s critical an d teasing com m ents to h er which she felt dem eaned by and resented. However, she seem ed detached and aloof in her social relations with peers and often needed a great deal o f encouragem ent to be even m odestly candid a bo u t h er own tho u g h ts an d feelings.

Psycho logical A ssessm ent Psychological testing was p o stp o n ed upon adm ission until Ms. C had achieved h er targ et weight. W ith this achievem ent, h er th erap ist requested an assessm ent o f Ms. C ’s personality functioning an d , in particular, wished to assess h er capacity to utilize fu rth e r insight-oriented psychotherapy. She received a WAIS-R, Bender, DAP, Rorschach, TAT, SCT and MMPI d u rin g the course o f h er psychological evaluation. Ms. C evidenced no u n usual behavior d u rin g the evaluation. She was pleasant and cooperative d u rin g the testing process, falling silent upon occa­ sion w hen she seem ed to ex p erien ce some m ild anxiety. H er intellectual functioning fell in the Very Superior range. She achieved a Full Scale IQ o f 130 with verbal and perform ance IQs o f 124 and 130, respectively. Subscale scores ra n g ed from high average to very su p erio r levels. H er best p e rfo rm ­

32 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning ance was achieved on a subtest requiring abstract reasoning (Similarities). She also perform ed at very superior levels on tasks m easuring h er u n d e r­ standing o f ordinary social conventions (Comprehension), her ability to antic­ ipate and plan appropriately in an interpersonal context (Picture Arrangement), her integration o f visual-spatial m aterials (Block Design and Object Assembly), and a visual-motor task assessing new learning ability (Cod­ ing). H er weakest perform ances were given on those subtests req u irin g a wide range o f factual d ata (Information & Picture Completion), use o f words (Vocabulary) and easily deployed attention (Digit Span). Ms. C ’s perform ance on the MMPI indicated some mild distress (scale F) com bined with some depressive (scale 2) and anxiety (scale 7) sym ptom a­ tology. T he most prom inent feature o f h er profile (scale 0) indicated a p ro ­ nounced tendency for social withdrawal. Although h er scaled scores all fell within the norm al range, she endorsed several unusual items on the MMPI. These included “hearing very queer things” w hen with o th er people, feel­ ings o f unreality, and concerns th at there is “som ething w rong with [her] m ind,” that people were trying to “steal [her] thoughts and ideas” and “m aking [her] do things by hypnotizing [her].” She also expressed the belief th at she “deserved punishm ent for [her] sins” and th at she was “a special agent o f G od.” Ms. C app eared to hold alternating and conflicting views o f herself. Weight and physical appearance are given a prom inent place in h er reactions to herself and others. O n the SCT she completed the sentence stems I used to daydream about with the phrase “being skinny,” my first reaction to her was “She’s skinny,” her reaction to me “is she’s pretty,” she felt she couldn’t succeed unless “she was th in n e r” and I could hate a person who “eats like a pig and stays skinny.” H er efforts to achieve h er goal o f weightless perfection, however, have left her feeling guilty and ashamed. She reports being asham ed th at “I starved myself,” th at she dislikes to “worry about my weight,” that she was most depressed when “I weighed n o th in g ,” her conscience bothered h er most when “she exercised obses­ sively,” she was most dissatisfied when “I was skinny,” and she feels sad about “my disease.” H er striving to achieve both physical and emotional perfection through control o f her body shape has clearly failed. Although she worries th a t h er “disease” has ruined the life o f those in h er family, she nevertheless finds home to be the safest haven from her troubles. H er parents are described in ideal term s, but even in the safe h arb o r o f home, her conflicts continue. In her TAT stories, m aternal dem ands are rejected (cards 1 and 2) and death by poisoning d u rin g a d in n er party at home is the fate o f one child (card 18GF). H er idealization o f her parents ap p ears to consist in p a rt o f a hope that they have not been exhausted by her constant need o f them . She fears

Disorders in infancy, Childhood, or Adolescence I 33 that she has been, like the man in card 14, “using too m any outlets,” “blew a fuse,” and after opening the door “to get a little more light,” is still “tra p p e d in the d ark .” H er attem pts to hold on to the more com forting world o f childhood are also evident in her figure drawings. H er self-portrait is o f a young child, her h air up in ribbons, h er body unencum bered by the ap purtenances o f adult sexuality. O n the Rorschach, prom inent child-like elements predom ­ inate. She sees very few well organized, whole responses and emphasizes animals in the content o f her responses. O ral features are also conspicuous. She reports “an anteater” to the upper red details on card / / because o f “the long nose,” a “b ird ’s head” on card V, and “2 doves” on card VI because o f the “beak,” “a bulldog” on card VII because o f “the mean black line through the face,” and “a face” on card X with a mouth. In the exam ining psychologist’s report, Ms. C’s reality testing was reported as largely intact. She was described as feeling alone and vulnerable, but with an interest in maintaining interpersonal relationships. T he chief factors mit­ igating against the possibility o f additional benefit to be derived from an insight-oriented therapy were her difficulties in accepting responsibility for h er own actions and the absence o f any evidence suggesting she was expe­ riencing any significant distress.

Treatm ent P la n n in g an d O utcom e Ms. C rem ained in the hospital for an additional 2!/2 m onths following completion o f her psychological testing. D uring th at time, she was able to m aintain her weight within h er target range. As the psychologist had sug­ gested, she was difficult to engage in individual psychotherapy, focusing her hopes for recovery on learning to ignore her continuing preoccupation with food and her caloric intake. H er family psychotherapy m et with g reater success. She was able to dis­ cuss her guilt in criticizing h er parents and her overattachm ent to them. Also discussed was her competition with her sister and her wish to be closer to her. Ms. C felt relieved at being able to express these negative feelings and her family was able to tolerate h er expression o f them . This resulted in her being able to develop a somewhat more realistic view o f h er parents and o f herself. Based on her in-hospital achievements, the hospital psychotherapist rec­ om m ended she continue in individual psychotherapy with her present ther­ apist, but on an outpatient basis, and with a reinstatem ent o f her previous weight m anagem ent plan which would include medical rehospitalizations for refeeding if her weight d ro p p ed significantly. As an alternative, given

34 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning the prior difficulties with this regim en, the therapist suggested a residential placem ent w here Ms. C could be m ore closely m onitored. Ms. C was not able to m ake satisfactory progress in h er o u tp a tie n t tre a t­ m ent an d re tu rn e d to h e r preadm ission p a tte rn o f behavior. She shifted h er entire eatin g perio d to th e evening h ours an d re tu rn e d to a strenuous exercise regim en to control h e r weight. A lthough she was able to m aintain her weight w ithin a few pou n d s o f her hospital target weight, the re ap p ear­ ance o f h er previous m aladaptive eatin g an d exercise p attern s, h e r c o n tin ­ ued preoccupation with food an d d ieting, an d , finally, a re tu rn to her self-destructive behavior w hen h er routines were interfered with resulted in her rehospitalization 10 m onths after her discharge. T his hospitalization was brief and served as a retraining interregnum before Ms. C began b o ard ­ ing school. She responded well to the hospitalization an d was able to accom­ plish the transition to b o a rd in g school w here h er family rep o rts she has m ade a satisfactory adjustm ent.

Disorders in Infancy, Childhood, or Adolescence / 3 5

EXHIBIT

I.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

Sym ptom s/D iagnosis Anorexia Nervosa — refusal to m ain ­ tain body weight

Refuses to m aintain n o r­ mal body weight

None

— fear o f gaining weight

Believes weight gain und erm in ed her elec­ tion success

Hopes to rem ain a child by re ta rd in g her physi­ cal developm ent

— d istu rb an ce in body experience

None

Equates physical charac­ teristics with psycho­ logical characteristics

— am enorrhea

H as never m enstruated due to m aturational lag related to weight

None

None

Rigid an d overcontrolled. Conflicted about her attem pts to stop her m aturation

Above average intelligence

Above average intelligence

Conflicts with parents involving self-control

G uilt-ridden over her relentless pu rsu it o f "physical perfection" despite its overvaluation

None

Active conflict reg ard in g her sym ptom s, al­ though there is no overt anxiety C om pliant with external stru ctu re

G ood academ ic record

C apable o f goal-oriented behavior and high level o f motivation

H istory o f stable friendships

Desires friendships and can relate to others

II. Personality Factors

III. Cognitive Abilities IV. Psychodynam ics

V.

T h erap eu tic E nabling Factors

VI. E nvironm ental D em and and Social A djustm ent

36 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests

Scaled S

Inform ation Similarities A rithm etic Vocabulary C om prehension Digit Span

12 18 14 12 14 12

Performance Subtests Picture Completion Picture A rrangem ent Block Design Object Assembly C oding

11 15 14 15 16

Verbal IQ P erform ance IQ Full Scale IQ

124 130 130

M M PI S u m m a r y F-LK: 027-813694/5: R o rsc h a ch Sum mary

N um ber o f Responses Rejections Populars O riginals Average R/T Chrom atic Average R/T Achromatic F% F+ % A% H% W:M M :Sum C m:c

26 0 4 0 35" 39" 50 88 58 31 5:2 2:2.5 3:2

Disorders in Infancy, Childhood, or Adolescence ! 37

R orsch a ch Sum mary

VI11-X% Fk + F + Fc% (H + A ):(H d + Ad) A pperception W D d Dd + S

31 54 19:5 19% 61% 8% 12%

38 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

3

R o rsch a ch Sum mary

Response

Inquiry

Scoring

I. 6"

1. Looks like a bat. Is that—

1. It was shaped like a bat.

drFA

2. A person— like a dancer. T h at’s it.

2. The pointed toes and the skirt shape (What about the pointed toes and skirt shape . . . dancer?) How at the bot­ tom it looked like toes and a skirt of a dancer. Looks like she’s standing on her toes.

DM HP

II. 10" 1. Looks like two Chinese guys. (laughs)

The whole thing (Chinese guys?) How they were kneeling with their hands up against each other.

WMHP

2. And a, like, ogre.

Right here ju st the face— the red. (An ogre}) The long nose and the horns made it look evil. (Anything else?) No— well the little eyes. (Was it marked off by the red or did you see the ogre as red?) It was a red ogre—devilish.

DFC(Hd)

3. And an anteater. T h at’s it.

Like that. (Anteater?) The long nose and it was crawl­ ing on all fours.

DFMA

III. 14" 1. A butterfly.

1. The red. (Butterfly?) The red was the butterfly. (Wav it marked off by the red or was it a red butterfly?) It was a red butterfly.

DFCAP

Disorders in Infancy, Childhood, or Adolescence / 39

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

2. A crab.

2. W ithout the blob—every­ thing. (Crab?) Cause o f the claws sticking out and the rounded body (Anything else?) No.

WFA

3. A seahorse. T h a t’s it.

3. O ne o f these things. (Sea­ horse?) T he long tail kind o f thing and the hooked shape here.

DFA

1. Like a giant.

1. T he whole thing. (Giant?) T he two huge legs and feet.

WF(H)

2. A king.

2. It looked like a king—the head o f a king because o f the crown.

DFHd, Crown

3. A witch.

3. The hat and the pointed nose. (Anything else?) No. The hat and the pointed nose and the h at— where the lighter part is— one pointed nose.

DFC'(H)

4. A penguin. T h a t’s it.

4. The black and white and the beak. (Black and white?) Cause the blot was in black and white and the penguin is in black and white.

DFC'A

1. A bat.

1. The whole thing. (Bat?) T he wings and the little head.

WFAP

2. A bird’s head. T h a t’s all.

2. T he beak. (Anything else?) No.

dFAd

1. T hat. (Wasp?) T he long body and the wings.

DFA

IV. 7"

V. 51"

VI. 70" I. Some kind o f like an insect, like a wasp or something.

4 0 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R orschach S um mary

Response

Inquiry

Scoring

(Takes blot with hands to see, turns card) 2. Iwo doves. T h a t’s it.

2. T he rounded bodies and the little beaks. (Anything else}) No. (Beaks'?) See the two little openings— right there. (That’s the beak of each dove?) Yeah like that, the m outh opening. (Mouth openings?) T he little U shape.

drFA

1. A rabbit— a rabbit’s head really— no the whole rab­ bit— now that I look at it a different way.

1. Right there— kind o f a dem ented rabbit. (Rabbit?) T he long ear and the little tails.

DFA

2. A bulldog. T h a t’s it.

2. Just this (Bulldog?)— Hm I don’t know— the broadness o f it— the little ears and the m ean black line through the face (Black line?) When the bulldogs walk like this, the short little stubby arms. Wide and short. (Arm?) How it goes in.

DFM-A

1. A pum a.

1. T he long body prowling and the rounded back, four legs.

DFMA

2. A Chinese fat face. (Laughs)

2. The long moustache and the slanted eyes.

diFcH

3. I'he Eiffel Tower. T h a t’s it.

3. (And the Eiffel Tower?) T he painted building and the beams. Gorgeous. (Painted?) T he color.

drFC A rch.

Amazed when I couldn’t see the beaks.

VII. 4"

V III. 70"

Disorders in Infancy, Childhood, or Adolescence ! 41

R o rsc h a ch Sum m ary

Response IX.

Inquiry

Scoring

75" 1. The pink part. (Elephant’s head?) Two big ears and the eyes— (Was the elephant pink or did you just use that to mark off the elephant?) T he ele­ phant was pink.

DFC-Ad

1. T he seahorses again.

1. T he green. (Seahorses?) The hooked shape head and the long body. (Anything else}) No.

DFA

2. Cockroach.

2. W here did 1 see it— this gray. (Cockroach}) T he an­ tenna and the little round body and the legs.

DFA

3. A wishbone.

3. The little orange. (Wish­ bone?) Just looked like a wishbone. (In what way}) H ad the same shape.

DFAObj.

4. A face. T h a t’s it.

4. T h at whole thing. (Face}) The two yellow eyes— the blue lines like a moustache and the orange little mouth. (Was the moustache blue}) Yeah. And the wish­ bone looked like a mouth that way.

W F/CHd

1. An elephant’s head. T h a t’s it.

X. 5"

42 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 (Give me an example) Y uk— A boy who w anted to play a n in s tru ­ m ent an d he wasn’t su re w hat he w anted to play a n d his m o th er used to be a violinist and she b ro u g h t h er old violin for him to look at and he’s ju s t sitting, try in g to decide if he wants to play it. (What’s he feeling}) C onfused (what happens}) he decides he doesn’t w ant to play it. C A R D 2 4" T here’s a young girl who likes this guy a real lot an d she’s e m b arrassed about it an d she wants to tell him b u t she’s afraid to an d he’s really cu te and stron g an d he works the fields all day an d she wants to stay back at school— she delays going to school so she can talk to him b u t h er m o th e r’s stan d in g rig h t th ere and he doesn’t w ant h er to get involved with h im — she doesn’t like h im — the m o th er says he’s ju s t a farm h a n d an d she can d o m uch b e tte r b u t the girl ignores h er an d goes over to talk with him an d they start to d ate each other. T h e end. C A R D 3G F 8" T h is woman ju s t finds out th at h er h u sb an d was killed in war. She’s totally freak in g o u t— she doesn’t know how to control h er em otions— she loved him so much and she doesn’t know how she’ll live with­ o ut him . She cries constantly for ab o u t a week (that's it) (what happens after that?) she still misses him a lot— b u t she learns to accept it grad u ally — b u t she never forgets him . C A R D 5 OK there’s a wom an she lies all alone an d she was sleeping one n ight an d she h eard a noise dow nstairs. She g ot o ut o f bed to see if there was an y th in g th e re — th a t’s it (youre sure?) (what happens?) she found a b u r­ glar. (What she feeling?) Scared. C A R D 10 T here’s a father and a son who haven’t seen each o th er in a long tim e— the boy was away at w ar an d the w ar en d ed an d he cam e back safe. T h e fath er was so happy th a t he h a d n ’t been killed so they em braced for awhile (that’s it) (what was the boy feeling?) homesick. C A R D 12F 6" T here’s a young girl an d it’s h er old m other’s birthday and as a present she w ants to give h er a p ain ted p o rtra it o f h erself w ith her m other and there sitting in the a rt studio posing for a painter and he paints the picture and she gives it to the m other and she’s very happy with it (who?) the m other. C A R D 12M 4" T h is m an is at his wife’s fu n eral— wake— he’s kneeling in front o f h e r— praying for h e r he loves h er very m uch an d he misses h er

Disorders in Infancy, Childhood, or Adolescence ! 43 T h e m a t ic A p p e r c e p t io n T e st

trem endously. No one will ever take h er place in his life b u t he’s going to try to continue his life. C A R D 13MF T he m an and his wife are the characters and the m an comes to wake up his wife and he finds her dead in bed. He’s shocked and he starts to cry. {What led up to this}) She had a h eart attack (what happens?) she ju s t d ied u nexpectedly— it was a total shock an d he loved her very m uch and he was very d isappo in ted . C A R D 14 5" T here’s this m an in this house all alone an d he’s using too m any outlets and he blew a fuse all the lights w'ent out and he was left alone in the dark . He went to th e d o o r to try to get some light (that’s it) (what’s he feeling}) alone (what happens}) he leaves the d o o r o p en to get a little m ore light b u t he’s still tra p p e d in the dark. C A R D 15 4" T here’s this sick m an an d it’s ab o u t m idnight an d he decided to go into the graveyards. He’s really crazy an d he’s th in k in g about d ig g in g up som ebody’s grave. H e decides not to and ju s t goes aro u n d and looks at all the graves in th e m iddle o f the n ight (7'20"). (How’s he crazy}) C ause most people don’t w ant to go d ig up graves (and sick})— I m ean like sick crazy— a sick m ind (Blah— chews gum— sits immobile). C A R D 18GF Everybody's dy in g — this woman was with h er son— and he had , an d he ju s t dies in h er arm s. Someone poisoned his d in n e r (laughs) they don’t know who d id it (speaks mechanically) because they h ad a big d in ­ n er p arty th e n ig h t before— she’s m o u rn in g his d e ath a g reat deal and she’s o u t to get w hoever d id it. (That’s it) (What happens}) They never find who d id it.

44 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

2.

She often wished she could “walk to school alone.”

4.

She felt to blame when she “p u n ch ed h er b ro th e r in the face.”

6 . I used to feel I was being held back by “a stro n g force.” 8 . As a child my greatest fear was “b ein g alone.” 9. 10.

My father always “was g rea t.” The ideal man “is like my d a d .”

12. / was most depressed when “I w eighed n o th in g .” 14.

When he turned me down, I “felt w orthless.”

17.

Sometimes she wished she “was pretty.”

18.

Usually she felt that sex “was gross.”

19.

I could hate a person who “eats like a pig an d stays skinny.”

20.

Her earliest memory of her mother “was g re at.”

21.

The ideal woman is “like my m om .”

22.

When people made fu n of her, she “felt ash am ed .”

24. 25. 26. 30.

When I think back, I am ashamed that “I starved m yself.” I f I think the job is too hard for me, “ I q u it.” A relationship with a sister “can be h a rd .” Most men “are ugly.”

31. 36. 39.

When I have to make a decision, I “get c o n fu sed .” Taking orders is “b eing w eak.” Most women are “chesty.”

40.

After he made love to her, she “felt guilty.”

42.

When I am criticized, I “feel rejected .”

44. 45.

She felt she couldn’t succeed unless she “was th in n er.” I used to feel down in the dumps' when I “was u n d erw eig h t.”

52.

Most of all I want “to be n o rm al.”

53.

My sexual desires are “nil.”

54.

Her conscience bothered her most when she “exercised obsessively.”

55.

She felt she could murder a woman who “was happy.”

59. 61.

His reaction to me “is yuk!!” Sexual intercourse is “disg u stin g .”

Disorders in Infancy, Childhood, or Adolescence / 45 S e n t e n c e C o m p l e t io n T e st

63.

Whenever she does below average work, she “feels guilty.”

64. She felt blue when “she was hungry.” 65. I fell most dissatisfied when “1 was skinny.” 67.

My first reaction to her was “she’s skinny.”

68 . When they put me in charge,I “messed

up.”

69. I feel guilty about “ru in in g my families lives.” 71. Her reaction to me is “she’s pretty.” 72. When she was punished by her mother, she “was

angry.”

77. When they told her what to do, she “resented it.” 79. Her greatest worry was “d e a th .” 80. When she was spanked by her father, she “felt ash am ed .” 81. Most women act as though “m en m ean the w orld.” 82.

When I feel others don’t like me, I “get q u iet.”

84. Most people are “angry.” 87. I am afraid o f “d e a th .” 94. When with her mother, she “felt secure.” 99. I wish that my mother was “w ith m e.”

100. I feel sad about “my disease.”

46 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

BULIM IA NERVOSA: TH E CASE OF MS. V Ms. V, a single, white, 21-year-old college sophom ore, had becom e increas­ ingly worried about h er health over the last year. She had entered outpatient treatm ent after retu rn in g home from her freshm an year in college. D uring h er freshm an year, she went on frequent eatin g binges with h er college room m ates. A fter these eatin g binges, she vom ited m ost o f w hat she h ad eaten so th a t she would not gain weight. She acknow ledged th a t she always h ad been weight conscious an d h ad begun dieting at age 15 because she was “chunky.” Until her freshm an year in college, she h ad vom ited occasionally; periodically, she h ad abused d iet pills, diuretics, and laxatives to help h er lose weight. However, d u rin g the last year, she was binge eatin g an d vom iting fo u r to five times p e r day and taking 20 to 30 aspirins a day to “shrink my stom ach” so th a t she could better control her appetite. It was this change th at concerned her. H er stom ­ ach was constantly upset, she h a d a p ersistent “b u rn in g ” in h er esophagus, an d she felt like she was “o ut o f control.” Ms. V ’s p aren ts becam e aware o f h er difficulties only w hen she en tered o u tp atien t treatm en t, since, to all outw ard ap p earan ces, she was enjoying college. She h ad com pleted the year with grades sim ilar to those she had achieved in high school, m ain tain in g a B- average. H er relationship with h er boyfriend was a source o f su p p o rt for h e r and she actively p articip ated in the school’s in tram u ral sports pro g ram . W hen she re tu rn e d hom e, Ms. V ho p ed th a t h er family would rally to h e r su p p o rt. However, she found h er parents’ hom e to be filled with tension an d apprehension. H er m o th er an d father were constantly fighting over h er fath er’s d rin k in g . H er fath er stayed away from hom e to work late at the office. At first, Ms. V ’s m o th er accepted this excuse since th ere was a financial crisis at Mr. V ’s com pany w here he was ch ief financial officer. However, w hen he cam e hom e at all, he usually arrived sm elling o f alcohol an d looking disheveled. Ms. V’s m o th er suspected th a t Mr. V was having an affair. Mr. V d en ied his wife’s accusations b u t confided to his d a u g h te r th a t he was having an affair. Ms. V knew h er parents’ m arria g e had been u n h ap p y for the b o th o f them in the last two o r th re e years. She was glad h er fath er h ad “found som eone else” b u t was uncom fortable keeping the secret from h er m other. Ms. V ’s m o th er suspected th a t h er d a u g h te r knew m ore about h e r fath er’s activities than she was adm itting. Ms. V h ad always been closer to her father th a n to h e r m o th er an d Mrs. V attem p te d to get h er d a u g h te r to tell h er w hat she knew o f h er fa th e r’s activities. Ms. V kept h er fath e r’s secret. She m an ag e d to regain some m easure o f self-control an d re tu rn e d to school. She soon learned th a t h er p aren ts h ad

Disorders in Infancy, Childhood, or Adolescence / 47 separated and th at h er m other had moved back to her parents’ home where Ms. V ’s g ran d fath er was seriously ill with h eart trouble. She saw little o f her m o th er and spent m ore tim e with h er father. A t the en d o f the semester, she learn ed th a t he an d his com pany were u n d e r g ran d ju r y investigation for misuse o f funds. U n d er the stress o f her parents’ separation, h er g ran d ­ fa th e r’s declining health, an d h e r fath er’s legal troubles, Ms. V once again lost control o f h er eating an d retu rn ed to the p attern o f bingeing and vom­ iting th at h ad overtaken h er tow ard the en d o f h er freshm an year. W hen she cam e hom e for C hristm as vacation, she pleaded with h e r father to be ad m itted to th e hospital an d he reluctantly agreed. At the tim e o f h e r adm ission to the hospital, Ms. V wras d escribed as an attractive and fashionably thin young w oman who arriv ed casually dressed an d well groom ed. She gave as h er reason for seeking adm ission, “I feel th a t I need help to stabilize my h ealth .” She described h er m ood as “depressed and a n g ry ” an d h er affect was ju d g e d to be mildly depressed, b u t appropriate and w ithin norm al range. She gave no evidence o f any dis­ tu rb an ce in h er percep tio n o r cognition o th e r th an to ad m it to some though ts o f taking h e r own life. W hen questioned about these, she denied any intention o f acting on h er ideas. She com plained o f difficulty concen­ tratin g and insomnia. Formal exam ination revealed no significant difficulty concentrating an d h e r recent sleep problem s seem ed best u n d ersto o d in the context o f her binges and vomiting which, while at home, had been car­ ried out secretly at night.

D SM -III-R D iagnosis Axis Axis Axis Axis

I: 11: III: IV:

Axis V:

B ulim ia nervosa None Rule o u t ulcer; irre g u la r menses Severe— separation o f parents; severe illness o f g randparent; possible indictm ent o f father Fair— m oderate im pairm ent in her family relations; adequate b u t circum scribed social relations; no decline in school functioning

Treatment and H ospital Course Ms. V was able to recognize the extent o f h er difficulties. She entered the hospital very motivated for treatm ent was adm itted to a treatm ent program specializing in eatin g disorders. T h e pro g ram was a highly stru ctu re d ,

48 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning behaviorally oriented program . Ms. V found the im posed discipline quite helpful and quickly adjusted to the routine o f the unit. She was assigned a target weight range to m aintain and began to learn how to m aintain this weight on a well-balanced diet. H er rapid adjustm ent to the treatm ent milieu confirm ed h er motivation for treatm ent. As the initial evaluation continued, attention began to focus on her difficulties in her family relationships. She expressed an g er at her m other for w hat she felt was h er failure to su p p o rt her father and was su r­ prised to find her m other supportive o f her own hospitalization. She viewed her father, on the oth er hand, as someone whom she had always felt more in sym pathy with and supported. She was h u rt by his lack o f su p p o rt for her hospitalization and, following her admission, she found him resentful o f her efforts to get well. In contrast to h er father, her boyfriend was quite understanding o f her desire for treatm ent and agreed to meet with the hos­ pital staff to help them get a b etter view o f her life at college and her rela­ tionship with him. From information gathered from her m other and her boyfriend, the treat­ m ent staff began to form a b ro ad er picture o f Ms. V H er fath er’s alcohol abuse was found to be o f g reater severity and extent than previously rec­ ognized. Moreover, his own father and an uncle had also been alcohol abusers, if not alcohol dependent, and his m other had com m itted suicide. Ms. V’s own history raised questions about the possibility o f a m ajor affective disorder. T here were periods in her life when, for several weeks at a time, she reported being somewhat incapacitated by feelings o f depression. Usu­ ally, these periods were accom panied by feelings o f guilt, tearfulness, and sleep difficulties. T he treatm ent team requested psychological testing not only to explore the contribution o f a m ajor affective disorder to Ms. V.’s present difficulties, b u t also, given her rapid adjustm ent to the more stru ctu red aspects o f her treatm ent, to evaluate the possibility o f entering her into a m ore insightoriented psychotherapy.

Psychological Assessment Ms. V was examined by the treatm ent staffs psychologist du rin g the third week o f her hospital stay. She was given the WAIS-R, the Bender-Gestalt, the MMPI, the Rorschach, and the SCT. She com pleted her testing in an efficient fashion, requ irin g ju st over two hours o f time. T he exam iner described h er attitude towards the testing as cooperative and form ed the im pression that she enjoyed the testing. Ms. V was pleased with h er b etter perform ances and was obviously fru strated by her weaker perform ances.

Disorders in Infancy, Childhood, or Adolescence ! 49 O n the WAIS-R, Ms. V’s achievement on both the verbal and perform ance subtests indicated th a t h e r intellectual abilities were w ithin the average range, with her perform ance scores somewhat better th an her verbal scores. H er p attern o f p erfo rm an ce on the WAIS-R subtests indicated th a t her interactional style was one o f adaptation an d accom modation. A lthough her low Comprehesion subscale score suggests some difficulty in ad o p tin g and acting w ithin conventional norm ative guidelines, her Digit Span, Picture Com­ pletion an d Picture Arrangement subscale scores indicate a stro n g reliance on ex tern al reality to provide contextual cues to orient h er behavior. T his mix o f features suggests th at she is attentive to an d easily influenced by her inter­ personal surroundings. She seem ed generally able to concentrate and there was no evidence o f psychom otor slowing th a t would indicate a serious depressive disturbance. O n the M M PI, Ms. V d id endorse several item s suggesting some d eg ree o f depression was present an d lending som e su p p o rt for the treatm ent team ’s concern. T h e depression subscale (scale 2) was scored at 79T, a clin­ ically significant elevation, an d one o f only th re e scales scored in the clin­ ically significant range. Also elevated an d in the clinical ran g e were the hysteria (scale 3) an d p a ran o ia (scale 6) scales. T his 3 -point configuration (2-6-3) reflected h er difficulties in expressing her feelings, particularly hos­ tile o r aggressive feelings. Individuals with sim ilar MMPI profiles are usu­ ally described as som ew hat naive an d u n assu m in g an d typically hold them selves responsible for th e problem s o f others. Consequently, the tre a t­ m ent team ’s concerns re g a rd in g the presence o f significant depressive fea­ tures and accom panying feelings o f guilt were seen as consistent with her overall personality m akeup. Ms. V’s R orschach protocol help ed to illustrate h er personality style but d id not strongly su p p o rt the possibility th a t Ms. V was very depressed at the present tim e. She gave a total o f 40 responses an d over 15 p ercen t o f these contained color as a d eterm in a n t. H er productivity on the Rorschach was consistent with h er perseverance on th e WAIS-R. However, she p ro ­ duced a predom inan tly form -d eterm in ed record an d few w ell-integrated, whole responses, indicating h er efforts to cling to the obvious and h er d if­ ficulties in creatively ex ertin g herself. H er only response to card III, one o f her better whole responses an d one o f her p o p u lar responses, is o f two peo­ ple “try in g to keep w arm over a fire.” T h is response reflects her need for external sources o f enco u rag em en t a n d n u rtu ra n c e , factors critical for the m aintenance o f h er own self-esteem. H er general concern re g a rd in g how she is viewed by o th ers is also su p p o rted by the large n u m b er o f shading responses (cards /, IV and VIII). T he rem ainder o f h er whole responses often involved hum ans o r hum an details, including “two little kids playing on a see-saw” on card VII, and

50 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning “faces” on cards VII and IX. T he faces to cards VII and IX are poor form responses and the latter “face” occurs in an interesting sequence o f responses to card IX. She begins by seeing a “Halloween witch, orange, and with a pointed chin and h at and laughing.” She sees this face as a “m ean face. These are the nostrils right in hers, the eyes and a long, m ean m outh.” She next reports som ething “melting and separating.” T he basically poor form quality o f the responses and their somewhat fluid characteristics reflect her own fluid identity. She is uncertain about how h er self-integrity and fearful o f literally “melting and separating.” She seems most secure if the environm ent is one filled with love and laughter (see also SCT 32) and most threatened if it is filled with m eanness, req u irin g her to be dis­ trustful o f the behavior o f o th er people. O n the SCT, Ms. V gives the most graphic indications th at h er own sense o f self is intim ately bound up with w hat others think and feel about her. She reports, for exam ple, that when he refused her, she “m ade sure she knew that it wasn’t because she was a bad person,” that when I am criticized, I “listen and usually tru st the opinion,” and th at she felt inferior when “she felt she wasn’t as good as anyone else.” Although these responses most likely rep ­ resent long-standing trends in Ms. V’s personality style (e.g. as a child my greatest fear was “not being loved“), they are currently exaggerated by family circum stances (/ am afraid of “losing the people I love m ost” and SCT 45). H er disappointm ent in h er father is especially evident in h er SCT responses. She is depressed and annoyed with her father and finds his affair confusing and threaten in g (SCT 9, 12, 34, 70 & 88 ). For Ms. V, h er father’s affair appears to seriously u nderm ine her ability to see him as the “loving and caring m an ” (SCT 33) he was to h er earlier in h er life and she wishes th at her father “w anted to be a father again” (SCF 96). Equally confusing to h er is h er experience o f h er mother. She reports th a t when with her mother, she felt “both happy and sad” and wishes th at her m other “stuck by feelings.” Although angry and h u rt by h er parents’ sep­ aration (SCT 100), at bottom , it is herself she most often blames for her problem s (e.g. SCT 4, 6 , 27, 43, 57 & 63). C entral to h er feeling o f self­ blam e is h er failure to com m unicate h er own feelings (SCF 2 and 24), a skill she holds in high esteem (SCT 10 and 21). Finally, despite h er feelings o f disappointm ent, an g er and self-blame, the SCT also gives evidence o f h er desires to succeed and to prove herself. She reports th at she felt proud that [she] “recognized h er problem s and set forth to face them .” T he exam ining psychologist reported that Ms. V’s test results gave ample evidence o f her difficulty in m aintaining an adequate level o f self-esteem and th at depression and an g er were feelings she struggled with in attem pting to overcome h er difficulties. T h e psychologist did not feel th at these feelings were sufficiently overwhelming to Ms. V to w arrant a d iag­

Disorders in Infancy, Childhood, or Adolescence ! 51 nosis o f a depressive d iso rd e r at the time o f testing. However, because o f her difficulty in adequately coping with these feelings without a high degree o f directedness and environm ental support, the psychologist recom m ended against a m ore insight-oriented psychotherapy at th e present time.

Treatment P lanning and Outcom e Ms. V’s treatm ent team reviewed the results o f h er testing with the exam ­ ining psychologist and developed a treatm ent plan focusing on h er relation­ ship with h e r parents, particu larly h er role as a go-betw een in m ain tain in g her parents’ m arital relationship. She was able to understand th at h er eating d iso rd e r served as a distraction from h er feelings o f discom fort and em o­ tional turm oil. She was able to see this discom fort as resulting in p a rt from h e r role as go-betw een an d recognized th at h er efforts to present each o f her parents to the o th er in a positive light was an effort on her p a rt to invent an idealized family constellation on which she could rem ain d ep en d en t. To im plem ent h er treatm ent plan, separate weekly m eetings, on alternat­ ing weeks, were arran g ed between Ms. V and each o f her parents. T his plan allowed her to deal directly and separately with each parent. In her sessions with h e r father, she was able to express h e r d isap p o in tm en t in him for fail­ in g to live up to h er idealized view and later to address h e r resentm ent o f his separation from the family. In her sessions with her mother, she was able to express h er a n g e r at h er m o th er and explore how h er previous inability to confront these feelings was related to h er bingeing an d vomiting. As these sessions continued an d Ms. V was b e tte r able to confront and explore h er feelings for b o th h e r parents, she becam e concerned abo u t m ain tain in g control o f h e r bin g ein g an d vom iting outside the stru c tu re o f the hospital’s treatm en t pro g ram . She was en couraged by h er treatm en t team to explore h er new found abilities by a rra n g in g for short leaves from the hospital. At first, these leaves were explicitly arran g ed around times and activities th a t d id not involve an o p p o rtu n ity for her to ea t w hile o u t o f the hospital. She was able to enjoy these leaves an d was relieved to find th a t im pulses to overeat d id not in tru d e on h er enjoym ent. As h e r confidence in h erself increased, she was able to extend the length o f these leaves so th a t m eals away from the hospital could be included. She was reassured to discover th a t the strategies she had learn ed while in th e hospital were equally effective outside the hospital. Ms. V’s confidence in h erself continued to grow an d d ischarge plan n in g was b egun. Initially, she wished to re tu rn hom e to live, but quickly realized th a t this was not in h e r best interest. She finally accepted th e treatm en t te a m ’s recom m endation to establish an in d ep en d e n t living arra n g e m en t

52 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning and, with the help o f her boyfriend, found a small ap artm en t close to h er school which she could share. She was discharged at the end o f a two-month stay, planning to work as a salesgirl until she was able to resum e her studies at the start o f the new semester. She continued in outpatient psychotherapy with her hospital psychotherapist. W hen contacted a few weeks after her discharge, she reported th at she was doing well and enjoying her new job. H er parents had initiated divorce proceedings and although she was sad­ dened by their inability to work things out between them , she accepted the fact th at she and they would now pu rsu e independent lives.

Disorders in Infancy, Childhood, or Adolescence / 53

E X H I B I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

I. Sym ptom s/D iagnosis bulimia Nervosa Episode binge eating

C onsum es large q u an ti­ ties o f food several times a week

None

Feeling o f lack o f control o f eating

Reports feeling “o ut o f control”

Vacillates between efforts at overcontrol and experienced lack o f control

Vomits, abuses laxa­ tives, diuretics, etc. to stop weight gain

Admits to abuse o f laxa­ tives, diuretics and diet pills

None

At least two binges p e r week for at least three m onths

4 - 5 binge/vomit episodes p e r day for most o f last year

None

Persistent overcon­ cern with weight

Vomits/purges to control h er weight

None

None

In ap p ro p riate guilt; often feels responsible for things outside her control

II. Personality Factors

Very d ep en d en t on others for m aintenance o f self-esteem III. Cognitive Abilities

Average intelligence R eports dim inished con­ centration; intact on exam ination

Average intelligence Mild concentration difficulty

IV. Psychodynam ics

M ediates conflict between her p aren ts to alleviate her own dependency feelings

Idealizes parents and feels she contributes to th eir shortcom ings

Motivated for treatm ent

Strives to p u t forth her best effort

V.

T herapeutic E nabling Factors

54 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

A rea of

C l in ic a l

A ssessm ent

E x a m in a t io n

VI. Environmental Demand and Social Adjustment

P s y c h o l o g ic a l E x a m in a t io n

Rapid adjustm ent to the structure o f the treat­ ment milieu

None

Has m aintained academic progress

Difficulties in self­ assertiveness and emo­ tional expression

Good relationship with h er boyfriend

Seeks n u rtu rin g relationships

Peer influence diminishes her self-control

H ypersensitive to exter­ nal criticism

Disorders in Infancy, Childhood, or Adolescence / 55

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests Inform ation Digit Span V ocabulary A rithm etic C om prehension Sim ilarities

Scaled S

8 13

11 9 7 9

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ P erfo rm an ce IQ Full Scale IQ

11 12 9

11 12 97 106

101

M M PI S u m m a r y F-K/L 2 6 3 '7 1084-5/9: R o rsc h a ch Sum mary

N u m b er o f Responses Rejections Populars O riginals F% F+ % A% H% W :M M :Sum C m :c

40

0 6 0 63 82 40 35 7:3 3:3.5 3:6

/

Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o rsch a ch Sum m ary

VIII-X% FK + F + Fc% (H + A):(Hd + Ad) Apperception W 17% D 62% d 8% Dd + S 13%

45 73

22:8

Disorders in Infancy, Childhood, or Adolescence I 5 7

EXHIBIT

3

R o rsc h a ch Sum m ary

Response

Inquiry

Scoring

I. I have to find some sort o f picture? 1. A profile o f a G erm an shepherd.

1. Shaped like a shepherd.

drF-A

2. A face, distorted, b ut . . . a jack-o’-lantern face.

2. T he shape with the white eyes and m outh.

DF(Hd)

3. Legs and body.

3. Just the shape.

DFHd

4. T his is also a person. T he o u ter shading shows the clothes and it has a head.

4. Shaped like a person. It looked like it was w earing a dress from the way the shaded p a rt looked.

DFcHP

1. H eart

1. T he way the red goes like that (traces with f inger). Shape and color.

DFCAt

2. Dog

2. Shape

DFAP

3. Face with eyes, nose, and m outh. A nd this is the rest o f the face.

3. Shape

DF-At

1. Looks like it.

W MHP

1. Leg and shoe o f Big Foot.

1. Shape only.

DF(H)P

2 . l o p view o f a monster, a dinosaur o r an alligator.

2. Shaped like a din o sau r or alligator.

DFA

3. M ushroom

3. Fine lines and shading.

dFcBt

4. I f you flipped this over, these leg-type things, this could be one long thing, and this would be the spine.

4. Shaped like legs and the spinal colum n.

WF-At

II.

III. 1. Person. Whole thing looks like they are trying to keep w arm over a fire.

IV.

5 8 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rschach Sum m ary

Inquiry

Response

Scoring

1. A bat

1. Just the shape.

WFAP

2. A silhouette, on the side. T here’s a nose, m outh and hair.

2. Looks like nose and m outh. Shaded like hair.

DFcHd

3. Snails head with those slimy antennae

3. S hading makes it look slippery, like a snail’s head.

dFcA

VI. 1. T his is definitely some sort o f anim al, a fish or som ething. Fins o r wings on it.

1. Fins o r wings m ake it look like an anim al.

DFA

2. A head.

2. T h e shape o f the head makes it look like a m an.

D FH d

3. T his whole d ark area, a light bulb. T here’s the base an d the p a rt you screw in. A lam p w ithout a shade.

3. Shaped ju s t like a bulb, a lamp.

diF Obj

4. T his is the m oon, here in the dark p art, th e cres­ cent, carve it out here and a face, an old m an’s face. Like in those books you’d see a face in the moon.

4. Shape

drF -H d , Moon

1. Two little kids playing on a seasaw and facing each other.

I. T he ponytail sticking up.

W M NHP

2. C ould also be a dog.

2. Way it’s shaped and the snout over here.

DFA

3. Face

3.

W(s)F-Hd

VII.

I'he eyes and cheekbones and m outh, big face, whole thing.

Disorders in Infancy, Childhood, or Adolescence I 5 9

R o rschach Sum mary

Inquiry

Response

Scoring

VIII. 1. A nim al on the side. T hese anim als are climb­ ing to top o f peak and being pushed like over here but they’ll m ake it up.

1. Face, legs and tail.

DFM A

2 . H eart

2. Color an d the shape, even though this is here. I see the shape form ing even though it’s not clear.

DFCAt

3. Water, ocean, moving kind of. It seem s like it’s expanding. Rem inds me o f H 9O.

3. Color. T h e way it shades the waves and ripples.

drcF.m F Nat

I. Halloween witch, orange w ith pointed chin and hat and laughing.

1. T he shape. Looks very

DM.F(H)

2 . I see like a face b u t I’m

2 . Shaped th a t way. A

IX.

trying to . . . a m ean face. T hese are nostrils rig h t in here, eyes an d long m ean m outh. 3. T his in n er th in g is melt­ ing an d separating.

m uch like it. DF-H

h u m an face from the o u t­ line. (?) Ju st looks m ean.

3. T he way it’s shaped and the shading.

dm FcF Obj

1. B unch o f bugs.

1. Shapes

WFA

2 . Worm

2 . G reen and its shape.

DFCA

3. Scorpion

3. All the legs.

DFA

4. Cricket

4. 1 think th a t’s the nam e o f a bug, they’re leggy.

DFA

5. Bugs with antennae.

5. T h in g s sticking up, insects.

DFA

6 . Snail o r slug

6 . T he hum p, its body is fat

DFA

X.

and curvy.

6 0 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum m ary

Response 7. 2 doves facing each o th er and this is a music note they’re singing.

8 . Note (musical).

9. Yellow things are canaries o r birds.

Inquiry 7. Beaks an d heads and wings, maybe color, maybe shape. T hey’re kissing.

8.

It ju s t comes away from the kissing or singing doves an d the shape.

9. Color and the shape, the feathered tail. (Feathered,}) T he way 1 picture it. It doesn’t really look th at way.

Scoring DF.FCA

DF Obi

DFCA

10. W hite is a profile o f a face on either side and

10.

Shape o f h u m a n face.

SFH d

11. T h en the pink is also a face.

11.

Shape. A person’s face.

D FHd

12. I f I look at the whole

12.

T he shape, it’s not filled in or anything, the colors on either side, and the points up here are antennae.

th in g I see a butterfly. T his could be the m iddle (draws line with finger) an d the rest is wings.

WFC-A

Disorders in Infancy, Childhood, or Adolescence ! 61

EXHIBIT

4

Se n t e n c e C o m p l e t io n T e s t

2.

She often wished she could “have an easier tim e co m m unicating her feelings.”

4. She felt to blame when “she failed to atte m p t h er goals.” 5. When he refused her, she “m ad e sure she knew th a t it wasn’t because she was a bad perso n .”

6 . I used to feel I was being held back by “my own h an g u p s.” 7. She felt proud that “she recognizes h er problem s an d set fo rth to face th em .”

8 . As a child my greatest fear was “not being loved.” 9. My father always “m ad e me believe th a t he sp en t all his tim e on his family.” 10. The ideal man “should be honest, open, loving, an d am ong others, have the quality o f com m unication.”

12. / was most depressed when “1 learned my father h ad an affair.” 19. I could hate a person who “is dishonest an d deceiving.” 24. When I think back, I am ashamed that “1 couldn’t com m unicate a lot o f feelings I h a d .” 27. She felt her lack of success was due to “h er lack o f self-esteem .” 29. I used to daydream about “bein g a talented an d well-known dancer.” 30. Most men “get to a p o in t in life w hen they feel th a t they only need them selves.” 32. Love is “a beautiful an d grow ing feeling.” 33. My earliest memory of my father “was a loving an d carin g m an .” 34 / was most annoyed when “I couldn’t u n d erstan d w hat my father had do n e.” 35. When she thought of her mother, she “felt badly.” 42. When I am criticized, I “listen an d usually tru st th e opinion.” 43. She felt she had done wrong when she “realized she was taking h e r p ro b ­ lems o u t on herself.” 45. / used to feel ’down in the dumps’ when “I th o u g h t a b o u t all the h u rt my family an d I were feeling.” 57. She did a poor job became “she d id n ’t try h er h a rd e st.”

62 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning S e n t e n c e C o m p l e t io n T e st

63. 70. 87. 88 . 94. 96. 99. 100.

Whenever she does below average work, she “knows she could have done above average.” When my father came home, / “was confused.” I am afraid of “losing the people I love m ost.” When with her father she felt “like she did n ’t know w hat to say.” When with her mother, she felt “both happy and sad.” / wish that my father “wanted to be a father again.” / wish that my mother “stuck by feelings.” / feel sad about “my parents’ separation.”

Disorders in Infancy, Childhood, or Adolescence / 63

DISCUSSION We illustrated the testing results and related treatm ent planning of patients with eating disorders with the cases o f two young women: Ms. C, a 15-yearold adolescent, who presented with sym ptom s o f anorexia, and Ms. V, a 21-year-old college sophom ore, who presented with bulimia. Both women were hospitalized on a behaviorally oriented treatm ent unit. It is im portant to note th at on this unit, which specializes in the treatm ent o f eating dis­ orders, testing is not ord ered until the patient has adjusted to the unit and eating habits and weight have been somewhat normalized. Thus, the testing results cannot be totally explained by initial stress on entering the hospital or gross m alnutrition resulting from the eating d isorder itself. Ms. C, an energeuc high school student who was active on the track team, took the insult o f losing an election as cheerleader badly. H er disappoint­ m ent m agnified h er obsession with weight into anorexic proportions. As the parents, with direction from the pediatrician, moved in to help her, she became more distraught and suicidal. Once adm itted to the treatm ent unit, she quickly attained h er target weight, and psychological testing was requested to evaluate her personality strengths and difficulties and her abil­ ity to profit from dynam ic psychotherapy. Intellectually, she tested in the very superior range. Symptomatically, she reported primarily depression, anxiety and social withdrawal on the MMPI. Despite her intelligence, the projective materials revealed a simple, some­ what dependent and regressed individual who wanted to avoid the assum p­ tion o f adult roles and individual responsibility. C onsidering these aspects o f her personality, she responded better to family therapy than to individual therapy but was hospitalized a second time before some substantial progress in overcom ing her anorexia was accomplished. Ms. V’s sym ptom atic bulim ia presented in the context o f otherwise nor­ mal development. She was making satisfactory progress in college, obtaining m arks that were representative o f her high school work, and she had social skills that helped her to develop a relationship with a boyfriend and with peers. It would a p p ea r th at a “coping” strategy o f eating bu t avoiding p u t­ ting on weight by vomiting becam e a p attern o f bulimic abuse slowly but surely. T here was, to be sure, considerable strain in her parent^ relationship that developed coincident with her symptoms, but she was away at college and it is difficult to directly link her symptoms with the parental strife. How­ ever, the relationship between father and d au g h ter seem ed overly intense and exclusive o f the mother. T he extent o f the bulim ia occasioned a hospitalization, and she was placed on a behavioral program . Testing was requested to explore the extent and sever­

64 / Psychological Assessment, Psychiatric. Diagnosis, and Treatment Planning ity o f associated depression. T h e p atie n t’s ad ju stm en t to th e unit, receptivity towards treatm ent, and test results all suggested th at she could utilize her con­ siderable strengths to o btain significant assistance from treatm en t. C oncern­ ing the b re a d th and severity o f depression, on the MMPI the patient rep o rted some sym ptom s o f depression, enough to have a T score in th e significant range. H er projective m aterials also suggested low self-esteem related to her depressive affect. A nother prom inent feature o f h er test protocol was paranoid ideation, suggested by the high score on scale 6 o f the MMPI an d th e m ultiple faces and eyes perceived on the projective m aterials. Ms. V was seen as reacting to considerable family discord, a situation in which she was trian g u late d , b u t w ith considerable personal strengths. She was not seen as having substantial personality d iso rd e r pathology. H er school accom plishm ents and social skills a n d social successes indicated th at she is likely to make a good therapeutic alliance and fu rth e r h er own growth th ro u g h good use o f individual psychotherapy. In co m p arin g these two cases, Ms. V was m ore in d ep en d e n t an d had a w ider ran g e o f stren g th s th a n Ms. C. O f course, Ms. V was o lder and her developm ent m ore advanced th a n was Ms. C ’s at the tim e o f hospitalization and testing. Given this difference, however, it d id seem that Ms. V was more in dependent, less shy, an d m ore able to leave the protection o f the hom e base. However, Ms. V seem ed to be m ore influenced by family conflict, whereas Ms. C was idealizing her family and found family m eetings helpful in aiding a m ore realistic expression o f h er feelings tow ards them .

B. CON DU CT D ISORD ERS: G R O U P A ND U N D IF F E R E N T IA T E D TYPES C onduct d iso rd er is a diagnosis in D SM -III-R u n d er the general h ead in g o f disorders usually first evident in infancy, childhood or adolescence. T he conduct disorders are subdivided into g roup type (conduct diso rd ered behavior as a group activity with peers), solitary aggressive type (individual aggressive behavior), an d u n d ifferen tiated type (a m ix tu re o f solitary and group conduct disordered behavior). T he defining characteristic o f the con­ duct diso rd ers is a persistent p a tte rn o f behavior in which ag e-ap p ro p riate norm s and rules o f conduct are violated. These behaviors, which break soci­ etal norm s, include stealing, ru n n in g away from home, lying, truancy from school, destroying others’ property, using weapons and initiating fights, and cruelty to people o r anim als. It certainly seem s quite plausible th a t disruptive behavior which breaks society’s rules may be motivated by quite different constellations in different individuals. T his differential p ath to comm on conduct disordered behavior

Disorders in Infancy, Childhood, or Adolescence / 65 is one o f the m ain reasons for psychological testing in these cases. O ne c ru ­ cial assessm ent question is the possible absence o f superego structures. It is common clinical wisdom that when conduct disordered behavior is related to a cry for help and depression in an individual who does have developed superego structures, the prognosis for treatm ent is m uch better th an if these factors are not present.

CON DU CT D ISORD ER, G R O U P T Y PE A ND M IX E D SUBSTANCE ABUSE Mr. P, a 17-year-old student about to repeat the 10th grade, was transferred from a local com m unity hospital w here he was being trea ted for a sedative overdose. I'he overdose followed on the heels o f his m o th er’s exasperation at his continued d ru g abuse and h e r in fo rm in g him th at she was abo u t to seek psychiatric consultation on his behalf. A fter she went to sleep that night, her son removed a bottle o f pills from his m other’s bathroom cabinet an d took them “to get h ig h .” For the last year, Mr. P h ad “sto p p ed caring about an y th in g b u t g ettin g h ig h .” He h ad stolen money from his m other to p u rch ase d ru g s, h a d been arrested by the police for “joy rid in g ”with some friends— using the cars o f his friends’ p aren ts w ithout perm ission, had set fires in an effo rt to get money from arcad e gam es in o rd e r to p u r­ chase d ru g s, was chronically tru a n t from school, an d o ften cam e home bloodied from fights he’d had while high. H e h ad re tu rn e d hom e only a few days before after an absence o f nearly a week. He said he’d “ru n away” but had retu rn ed home when he ran out o f money and had no place to stay. T h e previous sum m er, Mr. P’s m other h ad gotten him into a d ru g tre a t­ m ent an d rehabilitation p ro g ram . He had rem ained d ru g -fre e for th ree weeks after com pleting the p ro g ram , b u t w hen school started in the fall, he h ad quickly re tu rn e d to his previous d ru g habits with a vengence. He began ex p erim en tin g with hallucinogens, PCP, and heroin an d was re g u ­ larly using m ariju an a an d Valium. He was especially fond o f Valium since it helped him “not care” about things. H aving developed a tolerance to the d ru g , he found him self in need o f ever-increasing am ounts an d th e cash to purchase it on the street. In the year prior to the onset o f his d ru g abuse, Mr. P h ad m aintained a B average. His average d u rin g th e last two school years h ad fallen o ff to a D. Mr. P was found in a sem icom atose state by his m o ther the following m orning. She h ad him taken by am bulance to a local com m unity hospital w here he was placed in intensive care to m onitor his recovery. O n the advice o f his physicians there, Mr. P’s m other sought admission for him at a nearby psychiatric hospital.

66 / Psychological Assessment, Psychiatric. Diagnosis, and Treatment Planning W hen adm itted to the psychiatric hospital, Mr. P was casually bu t neady dressed and was described as an attractive young m an with striking green eyes and short, curly brown hair. He was oriented to time, place, and person and ap p eared to be suffering no untow ard aftereffects o f his d ru g over­ dose. He insisted that the overdose was not a suicide attem pt, but did acknowledge that he had “stopped caring” about what happ en ed to him and was nonplussed by his recent brush with death. Although he had accepted the recom m endation for a psychiatric hospitalization, he gave as his only reason for seeking admission th at “I have got problem s.” Asked to expand on this rem ark, he stated, “I want to go out and not take d ru g s.” He adm itted to feeling despondent over the last few weeks, bu t there were no o th er signs suggestive o f depression. However, the exam iner did note that his mental state du rin g the last few weeks was difficult to assess in light o f his chronic abuse o f sedatives.

D SM -III-R D iagnosis Axis I: Axis II: Axis III Axis IV: Axis V:

Conduct disorder, group type Mixed substance abuse, chronic None None M oderate— new school year and im pending rem arriage o f his m other Poor— m arked im pairm ent in his school functioning and m oderate im pairm ent in his p e e r relationships

Treatment and Hospital Course Mr. P was adm itted to a m ixed adolescent and young adult unit where he very quickly m ade friends with the o th er patients and adjusted to the milieu with no difficulty whatsoever. As far as he was concerned, being in the hospital relieved him o f the problem o f m anaging his d ru g intake. He was placed on a schedule o f random urine samples for d ru g screening and was enrolled in the therapeutic school on the grounds o f the hospital. He was able to rem ain d ru g -free and attended all his classes where he did quite satisfactory work. D uring his first m onth in the hospital, occasional periods o f dysphoric m ood com bined with a continuation o f his desultory attitude towards himself, his treatm ent, and his school work led to a referral for psychological testing with a specific question reg ard in g the possibility o f a clinically significant affective disorder.

Disorders in Infancy, Childhood, or Adolescence I 67

P sychological A ssessm ent Mr. P was referred for psychological assessm ent at the end o f his first month in the hospital. His hospital psychotherapist wished to have the pos­ sibility o f an underlying depression assessed and also asked for an estim ate o f the ex ten t o f his sociopathy. T his inform ation was requested in o rd e r to aid in determ ining if he would benefit most from continuing his inpatient treatm en t o r if he m ight be m ore app ro p riately placed in a stru c tu re d o u t­ patien t d ru g tre a tm e n t pro g ram . Mr. P received a WAIS-R, Rorschach, TAT and the B ender from the assessing psychologist. O n the WAIS-R, he achieved a full scale IQ o f 100 with verbal and perfo rm an ce IQs o f 98 and 102, respectively. A consider­ ation o f his age-corrected subscale scores revealed th a t his perform ance on the WAIS was less consistent th a n these IQ scores m ight imply. His subscale scores ranged from low average to superior levels. His relative strengths were in those areas w here concentration an d attention to detail were req u ired and his relative weaknesses were in those areas dependent on school-related past learn in g (i.e. Information, Arithmetic an d Vocabulary). He was poorest on tests o f practical and social ju d g m e n t and visual-spatial com prehension. O n the R orschach, Mr. P p ro d u ced a total o f 23 responses w ith no rejec­ tions. As he had been tested before, he m ade frequent references to his pre­ vious experien ce with the test. Several responses indicated his fam iliarity w ith the altered sense o f reality en g en d ered by his d ru g -ta k in g history, especially his response to card II o f som ething “breaking ap a rt.” A nu m b er o f his responses began ra th e r conventionally, b u t th en were elaborated in idiosyncratic fashion. His h u m a n percepts were especially d istorted, for exam ple. O n card II, he described “some sort o f beast” with moustache and beard and a “big body an d feet” from Fantasia. O n card VII he characterized the “dancing girl” he saw as “w eird.” H e seem ed to be experiencing a some­ w hat peculiar world which he couldn’t quite fully fathom , leaving him frus­ trated an d angry, even o u t o f control, at times, like th e “n u clear explosion” a n d the “oil sp u rtin g o u t.” M any o f his responses were seen in movem ent o r with a sense o f move­ m ent im plied. D ancing (cards II 8c VII), flying and sup p o rtin g and crashing (card X), exploding (card IX), an d gushing (card IV) are all descriptions in the active voice an d even the “skin as a ru g ” on card VI p ro m p ted him to observe th a t it “looks like w hen they kill a lion o r so m eth in g .” Finally, his sensitivity to the shading in the blots, including shading in the colored areas (e.g. cards VII 8c VIII), taken to g eth er w ith th e features already n oted, m ir­ rors pervasive in n er distress and anxiety which he was endeavoring to con­ trol th ro u g h action.

68 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Mr. P carries th ro u g h and ex p an d s on this them e th ro u g h o u t a n o ta­ bly unreflective TAT. A lthough he beg an conventionally en o u g h with a story o f a boy practicing his violin for a conccrt th a t n ight (card 1), he never again m an ag ed to relate a typical story involving a m eaningful em otional relationship betw een the figures. T hem es o f grandiosity such as the “rich lady” on card 2, th e ap p e a ra n c e o f H aley’s com et on card 14, or the d enigratio n o f m ajor political figures on card 7BM alternate with them es o f rem orseless exploitation o r violence (cards 13MF, 10, 4, 12M, 8BM and 20). Violence seem ed to be the p referred response and crim inality the preferred setting. G angsters, o th er crim inal activities, and w artim e provided the settin g for cards 6BM, 12M, 8BM and 20. Even com m on m isfortunes such as b ein g laid o ff tem porarily from a jo b resulted in contem plated m ayhem (card 4). Each o f these stories was related in a bland, matter-of-fact m anner, at best; in several cases, a m ore chilling u n d e rto n e was a p p aren t. For exam ple, his response to card 15, which he found “m orbid,” was “I love it!” ; the shooting on card 8BM left the shooter “Feeling satisfied”; selfdefense was invoked to explain the shooting o f a psychopath whose vio­ lence was co u rted in revenge for a close frien d who was killed by the sam e m an. Mr. P had p e rh a p s th e sam e them e in m ind w hen he was asked for the m ean in g o f Strike while the iron is hot on the WAIS and responded, “G et people in a m ore vulnerable p erio d w hen they are m ore vulnerable to w hat you w ant.” T h e psychologist’s report contained the observation th at several o f Mr. P’s responses ap p eared to be delivered for th eir “shock value.” Certainly, this is correct as re g ard s th e ir im pact, if not th eir motivation. His attem p ts to distance h im self from any tro u b lin g affects were seen, in overall context, as best u n d ersto o d as an atte m p t to avoid any pain fu l situational stress. T h e absence o f any em otional control, except to rem ain vigilant to w hat others expected o f him , an d the precipitousness o f aggressive and sadistic im pulses w hen th w arted left little reason to im agine th a t he would be am enable to p sychotherapeutic efforts. His p re fe rre d m ode o f op eratio n a p p e a re d to be a co ntinuation o f his su b ­ stance abuse p attern as a m eans o f providing a ready excuse for his m ore in ap p ro p ria te behavior. In sum m ary, the psychologist form u lated the case as one with prim arily dyssocial aspects characterized by avoidance o f feeling, absence o f rem orse, casual exploitation o f others for im m ediate, personal gain, and an inability to em p ath ize with o r ap p reciate the rig h ts o f others.

Disorders in Infancy, Childhood, or Adolescence ! 69

Treatment P lanning and O utcom e Mr. P continued to be well behaved, if uninvolved, d u rin g th e next few weeks o f his hospital stay. His individual psychotherapy sessions were ch ar­ acterized by a perfunctory compliance with the rules o f attendance and con­ duct, b u t little o f real value was accom plished despite increasing them in n u m b e r from two to th re e times p er week. His family sessions with his m other seem ed m ore anim ated in th a t he apparently wished to re tu rn home an d m ad e m any efforts to reassu re his m o th er th at he h ad finally recog­ nized the e rro r o f his ways and inten d ed to reform . His m o th er rem ain ed unconvinced, b u t quietly so, and following the rep o rt o f th e psychologist’s exam ination, his hospital psychotherapist attem pted to place him in an outpatient d ru g treatm ent program . Although he was interviewed by the personnel o f the program , he was refused accept­ ance into the program . T h e social worker who c arried o ut th e intake eval­ uation stated th at Mr. P d id not seem to sincerely wish to give up d ru g s and, in light o f his p o o r m otivation an d his history o f dyssocial behavior, she felt he was a p o o r risk for the p rogram . U pon learn in g o f th e outcom e o f this interview, Mr. P’s m o th er becam e adam ant in her refusal to take him home. Following a heated arg u m en t d u r­ ing a fam ily session, Mr. P re tu rn e d to the u n it an d cut his h an d w hen he broke a window. H e followed u p on this o u tb u rst by quietly h elp in g to plan a New Year p arty for the un it, for which he supplied “nonalcoholic” beer. D espite w hat h ad by now becom e routine u rin e screens, Mr. P re tu rn e d from a pass seem ingly intoxicated and the d ru g testing revealed recent alco­ hol and m ariju an a ingestion. Subsequently, he was cau g h t cheating on his exam s at school an d a h u n tin g knife was found am ong his personal pos­ sessions at the hospital. Although several o f these events prom pted the staff to consider discharg­ ing Mr. P, he was retained each time as alternative discharge plans continued to be explored. He grew increasingly angry at the slow pace o f his discharge an d a rra n g e d to have him self accepted at a youth shelter from which he could re tu rn to his old school. S ubsequent m eetings with the head o f the shelter, who felt able to su p p o rt him in his wish to leave the hospital, m an ­ aged to prevent an im pulsive d e p a rtu re . Feeling som ew hat su p p o rte d in his own plans, Mr. P was able to m ake a good im pression at an interview at a residential school in a d istan t state an d wras shortly disch arg ed to this facility. H e was able to stay o u t o f trouble for several weeks b u t was caught sneaking back into th e d o rm ito ry an d was placed on closer supervision. At six m onths, he still rem ained on close supervision, b ut was not taking dru g s an d his school perfo rm an ce h a d been satisfactory.

70 ! Psychological Assessment, Psychiatric, Diagnosis, and Treatment P lanning

E

I.

X

H

I B

I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Symptoms/Diagnosis Conduct Disorder, group type Six-month distu rb ­ ance o f conduct with:

Two-year history o f diffi­ culty with:

Stealing without confrontation o f victim

Stealing from m others purse for d ru g purchass

Disrespectful o f others rights

Often lies

Lies about school attend­ ance, dru g - taking

Uses d ru g abuse as an excuse for inappropri­ ate behavior

Deliberate fire-setting

Sets fires at video game arcades

None

O ften truant

Very frequently tru an t

Accepts no responsibility for his behavior

O ften initiates phys­ ical fights

O ften returns home bloodied in fights

Easily prone to aggressive or even sadistic acts

Superficially charm ing and compliant

Overtly cooperative and engaging

Able to profit somewhat from imposition o f external structure

Complies with dem ands only when it does not interfere with his own wishes

Average intelligence

Average intelligence A ttuned to external real­ ity cues as guides to the expectations o f others

Disregards the rights o f others and shows no remorse when they are perfunctorily violated

No regard for rights o f others when they stand in his way

II. Personality Factors

III. Cognitive Abilities

IV. Psychodynamics

No well-integrated capac­ ity for tolerating pain­ ful affect; prefers im mediate action

Disorders in Infancy, Childlwod, or Adolescence 1 7 1

A rea of

C l in ic a l

A ssessm en t

E x a m in a t io n

V. T herapeutic E nabling Factors

VI. E nvironm ental D em and and Social A djustm ent

P s y c h o l o g ic a l E x a m in a t io n

Able to contain d ru g abuse habits to some d egree with external restraint

Ability to focus on and recognize others expectations

History o f b etter th an average school p e r­ form ance prior to d ru g abuse

No evidence o f learning disabilities

N oncompliant with the d em ands o f others if they thw art his own desires

Generally unable to com­ ply with the dem ands o f others unless im pulses are restrained

H istory o f being able to m ake and keep close friends prior to d ru g abuse

Quickly m anages to engage with others on an im m ediate needgratifying level

72 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests Inform ation D igit Span Vocabulary A rithm etic C om prehension Sim ilarities

Scaled Score

8 12 7

8 6 8

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ P erfo rm an ce IQ Full Scale IQ

10 11 11 7

10 98

102 100

R o rsch ach S u m m ary N u m b er o f Responses Rejections P opulars O riginals F% F+ % A% H% W :M M :Sum C m :c V III-X % Fk + F + F c % (H + A ):(H d + A d )

23

0 5

0 39 82 30 30 14:3 3:1.5 8:5 26 39

10:1

Disorders in Infancy, Childhood, or Adolescence / 73

R o rsch a ch Sum mary

A p p erc e p tio n

W 61% L> 30% d 4% Od + S 4%

74 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

3

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

1. A bat.

1. Cause o f the black and the way it’s shaped.

W FC 'A P

2 . It ju s t looks like an insect, a

2. Just the shape. Two wings an d the body. (?) C ould be eith er really, if you ju st think about the shape.

WFAP

1. T his looks like som ething som ebody would see when trip p in g on acid. Bugs me out, very weird.

1. T he whole thing and the way its draw n. Ju st the shape. It looks like it was all one th in g and it looks like it’s breaking ap art. (Any­ thing else?) No.

WmFAbs

2. A nd it kind o f resembles a face.

2. Eyes, nose, looked like some sort o f beast. M outh, moustache beard. (Beard}) Just the position. (Anything else?) No.

W(S)F-Hd

3. Ever see th at movie Fanta­ sia? It looks like one o f those dancers with a big body and feet.

3. Legs, fat bodies, eyes. (Anything else?) No.

W F(H)

4. A pit, maybe. If it were 3-dim ensional it would be a bottom less pit or som ething.

4. T h a t one wasn’t too good. / wasn’t sure if you were seeing it in three dimension. No.

SFPit

butterfly. T h a t’s all. N oth­ ing else.

II. O h no!

Disorders in In fa m y, Childhood, or Adolescence / 75

R o rsc h a ch Sum m ary

Response

Inquiry

Scoring

III. O h my favorite (sarcastic). 1 can’t u n d erstan d who drew these and why they all look like bugs.

1. Fop view o f a bug, arm s,

1. T h e shape.

WF-A

eyes, m outh. T h e red has nothing to do with it. 2. Two people with arm s, legs, heads. 1 don’t know what they are doing. They’ve got a bowling ball. A nd this could be like an alley going down there and these are lights.

(Alley}) It doesn’t. None o f these things look exactly like anything. I'm saying it’s two people bowling so th at’s w hat it would be. (Lights}) T hey’re hanging. (Else}) No.

W M .Fm H , Obj P

I . It looks like a tree.

T ru n k going u p and if it were filled in m ore then it would resem ble a tree more. (Anything else}) Shape and line going up the middle.

WFPN

2. A nd a m onster o r one o f those things like Godzilla.

Feet. T his has noth in g to do with it. I cu t th a t out. Unless he’s going to the bathroom . Well feet, claws, head.

WFM(A)

3. An oil— you know— when you have a hole in the ground and oil comes sp u rtin g out.

T here’s a hole in the g round and oil’s ju s t com ­ ing up. G ro u n d oil pushing out and spilling out. (Any­ thing else}) Black color.

WmF.C'FO.

IV.

76 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

Ro rsc h a ch Sum m ary

Scoring

Response

Inquiry

1. They all look like insects o f some so n . T his one even looks like a bat, too.

1. T h e shape and color. Its black and bats are black.

W FC 'A P

1. T he whiskers com ing out. T h e basic stru ctu re o f the whole thing. Looked like they cut it open and spread it out. {Skin}) T he way it’s lying down.

WFAobj.P

2. Smokestack, g u n , a fire, like in a war.

WF-Obj, Fire

1. Looks like the side o f a m ountain. Just using half, is th at OK? (Km. It's entirely up to you.)

1. Tree here, cliffs, down here is a stream or a valley. (Any­ thing else made it look like cliffs}) T h e color— like at night tim e— grey with fog or som ething.

DC'F'N

2. Not counting the bottom . In d ian ladies, with feath­ ers, facing each other.

2. Just shaped th at way Looks like that.

DMH

3. T his is weird. T his h alf looks like a girl, arm s, legs, dress, and big hairdo.

3. T h a t’s how it looked to me. Looks like someone in cos­ tum e, dancing.

DMH

V.

VI. 1. It looks like w hen they kill a lion or som ething an d use the skin as a rug. O r some kind o f anim al.

H rntn . . . 1 never noticed that. It could look like a ship. H alf the picture.

VII. I never saw this one.

Disorders in Infancy, Childhood, or Adolescence / 77

R orschach Sum mary

Response

Inquiry

Scoring

VIII. T his one is my favorite. 1. Water because it’s the same thing on both sides. (Rocks':) Cause th a t’s what I want them to be. Well, the way they are draw n, with crevices. (Crevices?) Looks indented, the different colors, it’s darker. (Reflec­ tion?) T he way that it’s the same on both sides.

WFM.cFA.N

1. A nuclear explosion. T h e m ushroom cloud.

1. Blowing up here an d this is the m ushroom . (Explosion?) T h e color.

WmF.CF Explosion

2. Looks like a hippie with his eyes and long hair. Looks like sunglasses, if you take of f the green and pink.

2. Just the outline— eyes, hair, sunglasses,

d rF -H d

1. A m ountain lion on some rocks and a reflection on some w ater he’s peering into. T his one is so perfect, it looks so m uch like that, it’s h a rd to see som ething else.

IX.

7 8 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch Sum mary

Response

Inquiry

Scoring

T his is the weirdest one o f all. 1. It looks like som ething in a cartoon cause o f colors. T h e blue is rock th a t this guy crashes thro u g h .

1. Looks like som ething I would see in a cartoon. T he position o f it and general form (?). It could be blue because it’s in a cartoon.

DCFRock

2. It looks like a birdm an creature sort o f thing. Fly­ ing dow nw ard. T his th in g will break, this th in g will clip on and he’ll land in there.

2. H as wings. Looks like some green b ird m an -ty p e crea­ ture. H as th a t shape.

DFM .FC(H)

3. Just the shape. Some kind o f h ands here holding this th in g up.

DFM(A)

(A nything else?) 3. Just two creatures holding this up from d ro p p in g down.

Disorders in Infancy, Childhood, or Adolescence ! 79

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 I hate this one. C an I tell the sam e stories I told last time? T h e boy has a violin. He plays the violin. R ight now he’s stu d y in g th e music. Not really, his m ind is w andering. (?) To a girl. He stops th in k in g ab o u t the girl and practices. (?) H e has a concert to perform th a t night an d he’s studying the music to m ake su re he gets it right. CARD 2 A rich lady sitting in h er room. T h e do o r bell rings an d she won­ ders who it is an d all o f a su d d en the m aid comes in and tells h er w ho it is. (?) It’s the bill collector an d she gets angry. (?) She pays the bill. CARD 3BM Kid is playing with his friends in his house and they are play­ ing rough and ru n n in g aro u n d . He hits his knee an d he’s holding it. He fell dow n right there on the couch and th a t’s a toy g u n he was playing with. CA R D 4 T his looks g ood. A guy and his wife. Hey, w hat’s this lady d o in g in background? As they went in th eir house, som eone knocks at d o o r and they o pen it and let the person in. It’s some guy. T h is guy looks angry. T his guy says I’m from so and so, the com pany where this guy works an d he says “you are laid o ff for a w eek.” He’s walking out an d his wife holds him back an d says “don’t worry, you’ll be back in a w eek,” so he doesn’t go o ut and tell guy o ff an d m aybe hit him . C A R D 6BM T his looks like a gangster. Comes in, tells the m o th er the head o f m afia, his father, is d ead . T hey’re both upset and he feels like: “I have to be one to tell her.” C A R D 7BM Two m en at a political cam p. T h e politician is speaking. R and B are th ere b u t they are hum ble. T his guy is disgusted with w hat he saw. T h e other, sees his expression and asks him w hat’s w rong. He says I ’m angry and disgusted w ith how they presented themselves. C A R D 8BM I hate this one so m uch. T h a t’s a gun. T his teen a g er shot this lady o r m an. I ’ll m ake it a m an. It’s in g an g ster days over m oonshine. E arlier in the night, he tried to take th e bullet o ut an d here he is beside his gun. (?) T hey are go in g to catch him . (?) Feeling satisfied. C A R D 10 Two kids are in a classroom , college. T h is good looking girl walks into the room . She’s new. T hey th in k she’s a knockout. I ’d like to go o ut w ith her. O ne guy— he’s leaning over telling his friend w hat he thinks.

80 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

CA R D 12M Are his eyes open o r shut? A kid goes to war. He’s fighting on the front line. He gets shot. B rought to hospital a n d he dies. The fath er comes over to sh u t his eyes an d pray. CARD 13MF T his looks nasty. Guy goes out, gets in a fight with his wife, an d goes out to a bar, m eets a girl. T h is girl gets a ro u n d . T hey go back to h er place an d they go to bed. A nd he wakes up next m o rn in g with a h a n g ­ over. He goes hom e an d confesses to his wife w hat h ap p en e d . (?) She’ll for­ give him ’cause he was d ru n k . C A R D 14 A o f the T V an d the full effect, it. Excited. (?)

guy comes hom e afte r work, gets a beer, sits down in front watches the news. Soon H aley’s C om et will go by a n d to get he shuts o ff the light to watch for it. (?) H e can’t wait to see H aley’s C om et will pass by an d he’ll go to bed.

CARD 15 O h my G od, w hat’s that? I’ll m ake up a scary story! T his is m or­ bid, I love it. It is Sunday. Wait, I w ant to think. A nd this guy is d riv in g along and he sees som ebody on the ro ad who looks like his d a u g h te r who is dead. So he goes to h e r grave and visits. He’s m o u rn in g in fro n t o f h er grave. I t’s very d ark o ut an d you can see he’s worn o u t by all th at has h a p ­ pened with his daughter. CA R D 20 T his is C entral Park in the city. T his guy has had a few too m any to walk in the park an d he knows th ere is a psychopath loose. He wants to get the psychopath ’cause he killed a close friend o f his. So he’s walking. All o f a sudden, he hears som ething and this guy with a knife says “I’m going to kill you.” T his guy calmly pulls out his g u n an d says “L et’s go, I ’m taking you to police.” Psychopath ru n s at him an d he shoots him . Police came, he’s let go ’cause o f self defense. Psychopath stays alone.

Disorders in Infancy, Childhood, or Adolescence / 81

C O N DU CT D ISO R D ER , U N D IF F E R E N T IA T E D TY PE Ms. A was “d ro p p e d o ff at the hospital” by h er parents afte r she was re tu rn e d to h er hom e by the police. She h ad left hom e several days previ­ ously after stealing a n eig h b o r’s c a r and some money from h er m other. She was arrested by the police, after a h igh-speed chase, in a city several hours away, w here she h ad gone to visit friends. She ran away this tim e because h er fath er had “g ro u n d ed h e r” afte r she was fired from h e r last jo b as a hostess for stealing. A lthough only 17, she h ad n ot a tten d ed school since the beg in n in g o f the school year an d had only com pleted the 10th grade. T his was not the first tim e Ms. A h ad ru n away from th e family home, n or was it h er first theft. Since th e b eg in n in g o f the present school year, she h ad refused to atten d school. She had been staying hom e an d “having fun .” H er chief entertainm ent had been shopping with credit cards she stole from h er m o th er an d d riv in g h e r fa th e r’s ca r w ithout perm ission. She had two jo b s for a few days each but was fired from both for stealing either m er­ chandise or cash from the register. She had been a “behavior problem ” since the eighth g rad e an d h ad been expelled from two b o ard in g schools for chronic lying, ru n n in g away, cheating, and p oor academic perform ance. She had been seen in outpatient treatm ent several times, b u t had always refused to continue after a short time. A lthough she always prom ised to follow the rules at hom e an d school, she was soon in trouble again. T his tim e, after consulting with a prom inent local psychiatrist with a specialty in conduct disorders, h er fath er finally p e rsu a d e d h er m o th er to ag ree to having her hospitalized for treatm en t. At the tim e o f h e r adm ission, Ms. A volunteered th a t she was requesting hospitalization “because I w ant to try to m ake a b etter life for m yself and be able to succeed in the outside world.” H er mental status exam was u n re ­ m arkable except for a noticeable ap ath y w ith re g a rd to the seriousness o f her behavioral difficulties. She expressed ag reem en t with th e view th a t h er hospital stay would help h er to “take responsibility” for h er actions.

D SM -III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV: V:

C onduct disorder, un d ifferen tiated type, severe M ixed personality d iso rd er None M ild— chronic family arg u m en ts an d m arital conflict Poor— no close friends; d ro p p e d out o f school

82 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

Treatment and H ospital Course Following h er adm ission, Ms. A expressed feeling “tra p p e d ” in th e hos­ pital and focused on g ettin g the hospital staff to “come u p with some kind o f treatm ent for me outside the hospital.” She claimed th at her parents had inappropriately hospitalized h er “because I w ent to Cleveland” and she prom ised to m end h er ways if released. T h e efforts o f the hospital p sychotherapist to contact the p aren ts were fru stra te d by th eir d e p a rtu re from th e country. For several days, no one seem ed to be able to contact them . D uring this time, Ms. A was on the phone frequently and eventually acknow ledged th a t she was in contact with h er parents several times a day. T hese conversations consisted prim arily o f h er prom ising to follow h e r fa th e rs rules and p leading with him to get h er released from the hospital. T h e hospital sta ff contacted the p aren ts, who a g reed to lim it h er phone contact with them and to su p p o rt h er staying in the hospital. Ms. A b eg ru d g in g ly com plied with restriction o f h e r overseas calls to her parents, b ut gave out her m others telephone credit card n um ber to the other patients on the unit. W hen confronted about this by the hospital staff, she stated th a t h er p aren ts would ju s t think the charges were h er own and could easily afford to pay them .

Psychological Assessm ent A lthough Ms. A evidenced few clinically significant signs o r sym ptom s o f an affective disturb an ce, h er chronic history o f impulsivity, behavioral dyscontrol an d occasional te a rfu l pleadings for release from the hospital led to a referral for psychological testing to ru le out the possibility o f a p ri­ m ary af fective disord er and borderline personality disorder. She was exam ­ ined by the psychologist d u rin g the second week o f h er hospital stay an d received the M M PI, WAIS-R, the Forer S tru ctu red Sentence C om pletion Test, the R orschach, TAT, B ender and DAP T h e ex am in in g psychologist found the patient engaging and cooperative. She required little encourage­ m ent to put forth her best perform ance. She was exam ined on two occasions an d although she kept b o th ap p o in tm en ts, she d id so on one occasion at the exp en se o f a concurrently scheduled psychotherapy session which she “forgot.” Ms. As WAIS-R perform ance indicated a verbal IQ o f 114, a perform ance IQ o f 126 and a full scale IQ o f 120, placing h er in th e su p erio r ra n g e o f intellectual f unctioning overall. H er relative weaknesses were on the verbal subscales o f Information and Similarities, but even here her perform ance was

Disorders in Infancy, Childhood, or Adolescence / 83 within the average ran g e o f f unctioning. H er relative strengths were on the Digit Span an d Picture Arrangement subscales, which indicate an absence o f anxiety an d readily mobilized attention an d concentration. She was quick and efficient on the tim ed tasks and, where possible, alm ost always received tim e bonuses for h er productions. O il the verbal subtests, the efficiency o f her perform ance was occasionally d isrupted by her desire to dem onstrate h er personal feelings. For example, on the Comprehension subtest, she gave “feeling guilty” as a reason for b o r­ row ing money from a bank ra th e r th an from a friend b u t then went 011 to note th a t “I d ju s t feel uncom fortable.” Later, on the sam e subtest, Ms. A gave “if you’ve got a chance, go for it” as an in terp re tatio n o f the proverb Strike while the iron is hot and also said that to her this m eant “take advantage o f all that you can.” Finally, reflecting both personalizations and a tendency for in ap p ro p ria te playfulness, she gave as h er first definition o f matchless, a Vocabulary item , “T h a t’s me rig h t now', I ’m on m atch restrictions.” O n the stru c tu re d an d se m istru ctu red personality tests (the MMPI an d SCT, respectively), there was additional evidence o f her general lack o f anx­ iety. She reported no significant distress on the MMPI (Fscale) and although show ing a clear u n d e rsta n d in g o f social norm s (K scale), en d o rsed m any item s indicating difficulties in im pulse control an d a generally rebellious an d nonconform ist a ttitu d e (scale 4). Individuals with sim ilar profiles are m ost often described as egocentric and shallow, do not pro fit from the con­ sequences o f th eir prior experience, and often have an unusually high tol­ erance of, a n d threshold for, p unishm ent. Although 011 the SCT she occasionally makes reference to these latter dif­ ficulties (e.g. When I have to make a decision, / “usually don’t think about it for long en o u g h ”), she m ost often presents a picture o f a happy, serious young woman with hopes an d aspirations for a life o f m iddle class success an d conformity. H er life is m a rre d only by the m arital discoi d betw een her p aren ts an d she is quick to p o int out th a t although she feels “sad about my p a re n t’s relationship with each other,” h er own relationship with each o f them individually is harm onious an d fulfilling. She rep o rts th a t My father always “m ade me feel like I was a special person, I was always his ‘little girl’” and th a t My mother always “took care o f m y sister an d I very well.” By con­ trast, on the less structured TAT (card 7GF), she sees parents as insensitively d esertin g th e ir child to go 011 a trip. T h e them es o f family d isharm ony an d conflicting values serve as the touchstone for virtually all o f h er TAT stories. Most often, opposing loyalties serve to e n g en d er th e conflict: self-fulfillm ent versus filial d u ty (cards2 8c 12M); honor and d u ty versus love (card 6GF); loyalty to friends o r family (cards 4 8c 13MF). Such crises are most typically resolved by break in g with the family (cards 2, 3BM, 8c 12M), which allows the central ch aracter to

84 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning achieve great fam e o r wealth o r glory, som etim es in an antisocial setting. A lthough these stories are presen ted as conflictual, th ere is less tension in them th a n m ight be ex pected. T h e u n d erly in g them e of ab an d o n m en t, as previously m entioned, seems to provide more th an sufficient motivation for the unab ash ed p u rsu it o f self-interest an d , as card 3BM makes clear, selfdefense or self-protection provides sufficient rationale for ju stify in g even the m ost heinous o f crimes. Cards 3BM an d 12M are instructive in an o th e r sense. T hese two stories p o in t o ut, in tu rn , the vindication th a t comes from determ ination in the face o f family objections an d lack o f family su p p o rt . Ms. A’s w illfulness is equally in evidence on the Rorschach. H er aside on card 11— “See, w hen I get one pictu re stuck in my head, I can only see one th in g ”— and h er com m ent on card VIII— “I know [it] is im possible but that is the way it looks”— both illustrate her proclivity for responding with what first catches h er attention. H er im pulsivity occasionally im pairs h er reality appreciation, despite the general ability to view test stim uli along m ore acceptably conventional lines. This was reflected on the R orschach where she com bined incom patible concepts solely on th e basis o f th e ir location in contiguous areas o f the blot. O n card VII, for exam ple, she saw “cats crawl­ ing on the side o f a flower.” H er overall emotional life may have a poorly integrated, explosive quality, as well as conspicuous dysphoric com ponents like h er R orschach p e rcep t (card II) o f a “space ship blasting off. . . in a black atm osphere.” At the same time she feels enorm ously angry, dram atically revealed in the female figure she drew w ith a pronounced scowl and h an d s clenched, at an environm ent experienced as rife with shifting an d contradictory behavioral dem ands on her. Males and associated sexuality may be especially un fath o m ab le to her. In consonance w ith this confusion, h er draw ing o f a m an em erges as an androgenous-looking m a n n eq u in , b u t w earing a distinctly phallic-shaped tie. By com parison, h er response to R orschach card IV is a very destructive h um an-like “Big Foot eatin g a tre e .”

Treatment P lanning and O utcom e In his rep o rt, the ex am in in g psychologist highlighted Ms. As im pulsive potential, despite an ad eq u ate u n d e rsta n d in g o f conventional m odes o f th o u g h t an d behavior, and th e general absence o f any evidence o f e ith er anxiety o r guilt in h er record. T h e psychologist also noted th a t she evi­ denced little likelihood o f profiting from psychotherapy. H er need for more im m ediate gratification an d the absence o f any strong, in tern al motivation for change were described in this context. Ms. As psychotherapist stru g g led with w hether o r not to take h er p ro m ­

Disorders in Infancy, Childhood, or Adolescence / 85 ises to rem ain well behaved at face value. A lthough she a p p e a re d to take some responsibility for h er conduct when discussing these m atters with him , there was little evidence in h er daily life on the unit th a t she could be taken at h er word. W ith the h ope o f establishing a g reater atm osphere o f tru st and also o f providing an o p p o rtu n ity to dem o n strate h e r abilities to follow th ro u g h on h er com m itm ent to a hospital treatm en t, she was allowed to come an d go unescorted to h e r scheduled activities o ff h er in p atien t unit. Ms. A was pleased at having won the tru st o f h er psychotherapist and was aware th a t this h a d caused some friction betw een h er an d the o th e r m em bers o f h er treatm ent team . She reassured her therapist that this trust was not m isplaced an d th a t she would not directly d isap p o in t him in this reg ard . For several days, she seem ed to keep to h er word. Little o f conse­ quence was reported reg ard in g her behavior in the com m unity and it began to seem th a t she m ig h t have Finally come to term s with herself. However, w ithin short order, the situation reversed itself when she failed to re tu rn from an activity at her usual time. H er psychotherapist, who was on vacation at the tim e, was notified o f Ms. As absence an d h er parents were contacted. They rep o rted th a t they h a d not h eard from her, but were not su rp rised at h er elopem ent from the hospital. Ms. A rem ained o ut o f direct touch with h er family for several weeks, although a general know ledge o f h er w hereabouts could be gained from the trail o f credit card receipts th at flowed back to h er parents’ home. Finally, h er parents reported th eir credit cards stolen and Ms. A was picked u p by the police in a d istan t state w hen she attem p te d to use a credit card to m ake a large purchase. She was retu rn ed to her parents home when they refused to press charges an d at last contact h er p aren ts were seeking a n o th e r psychiatric adm ission for th e ir daughter.

8 6 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

I.

1

A rea ok

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Sym ptoms/Diagnosis Conduct Disorder, undifferentiated type Six m onth d istu rb ­ ance o f conduct with:

T h re e year history o f d if­ ficulty with:

Stealing without confrontation o f victim

Uses family credit and car; steals on jo b

Places her own im pulses and desires first before all else

R un away overnight, at least twice

R uns away to friends for several days an d does n ot inform family o f h er w hereabouts Lies about w hereabouts

None

O ften lies

O ften tru an t II. Personality Factors III. Cognitive Abilities

O ffers w hatever first comes to m ind to ju s ­ tify her behavior, occa­ sionally distorts reality

Has refused school attendance for last year

None

Awareness o f ordinary social conventions

Prefers to flaunt authority

At least average intelligence

Above average intelligence A ttentive to and easily utilizes social cues

IV. Psychodynam ics

V.

T herapeutic E nabling Factors

C hronic disreg ard for the rights o f others; exploits the sym pathy o f others who offer help

Uses h er knowledge o f o rd in ary conventions an d social privilege to prom ise and exploit others

Feels no rem orse for her past behavior

Takes no responsibility for h er own behavior

Has used past treatm ent o pportu n ities only to appease her parents

Claims ap p ro p riate am bitions

Disorders in Infancy, Childhood, or Adolescence / 8 7

A rea of

C l in ic a i.

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

VI. Environmental D emand and Social Adjustment

Responds to limits by dis­ regarding rights of others when her own impulses are thw arted

Will not tolerate for long any attem pt to limit her behavior

88 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning E X H I B I T

2

WAIS-R S u m m a r y Verbal Subtests Inform ation Digit Span Vocabulary A rithm etic C om prehension Sim ilarities

Scaled S 9 13 10 11 10 9

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ P erfo rm an ce IQ Full Scale IQ

10 15 13 12 12 114 126 120

M M PI S u m m a r y K 'L/F: 4 '8 3 6 7 9 2 1 15 :0 # Ro rsc h a ch Sum mary

N um b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% W:M M :Sum C

12 0 2 0 9" 4" 33 88 58 8 10.1 1:2.5

Disorders in Infancy, Childhood, or Adolescence I 89 R o r sc h a c h S um m ary

m:c V III-X % (H + A ):(H d + Ad) A pperception W D d Dd + S

4:2 33 8:0 83% 16% 0 0

90 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

3

R o rsch a ch Sum mary

Response

Inquiry

Scoring

I. 2" 1. Like a sting-ray sort of.

1. Just the way it’s going out . . . like the . . . Sort o f just going like that. (?) And the little tentacles up there.

WFA

2. And a dog . . . the face o f a dog.

2. These are the ears, the nose and then the two eyes here, and I don't know what these are supposed to be. These are just two extra . . . little white blobs.

W(S)FA

1. This is the black part of the atmosphere, and this thing here is the space ship, and this is the fire that it’s sort o f blasting off with. (Space shipi) Just the shape o f it. (Atmosphere) Although because when I saw the space ship that just sort of looks like the black of night or whatever. (Blasting Off) The way the ink is sort of splurted out and there’s always fire when a space ship is taking off.

W(S)Fm.C'F,mF Obj, Fire

II. 10" Oh my gosh (laughs). Can 1 turn it upside down? (Yes) 1. Okay, this is sort o f a space ship blasting off, and this is the atmosphere.

Disorders in Infancy, Childhood, or Adolescence I 91

R orschach Sum m ary

Response

Inquiry

I. T his looks like a m irro r im age o f two people. Two women probably. No, two people. Should I tell you why? See w hen I get one picture stuck in my head I can only see one thing.

1. This is a person and th a t’s a person and it’s the view' in the m irro r because the same th in g is sort o f tu rn ed opposite. H ead, nose, the body, the arm s, the legs and the little feet. She’s resting her hands on a toilet o r som ething o r a ball.

W M H , Obj P

1. Because there are pictures in Colorado o f Bigfoot and it looks like him . And because it looks like he had som ething com ing out o f his m outh an d the picture in Colorado had som ething com ing o u t o f Bigfoot’s m outh. (Bigfoot?) Yeah, it had big feet. Because it looked alm ost a little out o f proportion b ut it would look m ean because Bigfoot was not really th a t m ean. (Tree?) Part looks like the roots down here.

WF(A),PI

I . Because it looks like it had wings and it sort o f h ad lit­ tle designs on the wings. (Designs?) H ere. Not really designs b ut little teeny smudges. A nd also the shape. It’s sort o f like a wavy-like line.

WFA

Scoring

III. 4"

IV. 6" 1. T his looks like Bigfoot e a t­ ing a tree.

V 5" 1. It looks like a butterfly.

92 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsc h a ch Sum m ary

Response

Inquiry

Scoring

VI. 3" I . A star with an o th er star on top o f it.

Because the bottom one was shaped like a star and so was the top little one. (Else) No. (show me) T here’s one there (points) and the top one is a little more deform ed and it doesn’t really look like a star. T he like little sparks going out is like sort o f the light ju st shining from it.

W FmObj

V II. 5" 1 T his looks like a m irro r im age o f two rabbits look­ ing both like they’re facing forw ard b u t looking back.

1. Because it looks like the long th in g on top was an ea r an d th eir hands were sort o f p ut in a rabbit sort o f position like little paws sort o f like that. I think their bodies were ju s t sort o f shaped like a rabbit. (?) Ears, face or the head, the paw and they’re going down to the h ind legs which are sort o f blobbed together.

WFMA

1. It looks like a flower.

Because the shape and the colors. T h e pink and the o range colors and the shape, and sort o f the stem and the leaves. T h e green leaves.

DCFTI

2. With two cats crawling on the side o f it which I know is im possible b u t th at is the way it looked.

It sort o f looks like a cat with the body there with the legs and the tail and you can sort o f see a little eye there, a little d a rk spot.

DFMA

V III. 10"

Disorders in Infancy, Childhood, or Adolescence / 93

R orschach Summary

Response

Inquiry

Scoring

IX. 8" 1. A pink mouse in a green jacket with orange pants.

1. T he shape o f the head and the big round ears, and that was pink. T hen the green looked like almost a jacket because it had two arm s going down. And then the orange pants just look like two legs with orange pants on. (Mouse}) Because head here and two ears. T he arm s going this way. The body o f the jacket sort o f going down, and the two legs there, (where}) Not really this part, no and this line.

WF/C(A)

Because it’s ju st nothing. It’s ju s t splotches. (Picasso}) Because a lot o f his pic­ tures is m odern art and I don’t understand it and it ju st looks like paint thrown on canvas.

WCF A rt

X. 12" 1. Umm, that ju st looks like a Picasso. Just bright colors.

94 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 R ight now the . . . w h at’s he d o in g . . . he looks like he’s try in g to give h er a violin. H e doesn’t know w hat’s w rong with it. I t’s broken. He’s confused. How do I lead up to this? (Laughs) His d o g steps on it, I guess. T his is h a rd . (?) A nd he w ent to class an d he was p u t out o f class because his violin was broken. A fterw ards his teacher is going to com e in an d get him an d tell him to play the tu b a for today in class an d send his violin to get fixed. But in the m ean tim e he plays the tuba. (?) C onfused because he w ants to be in class and he loves his violin an d can’t figure out how to fix it. CA R D 2 Okay, rig h t now this is a girl who comes from sort o f a farm in g family an d she sort o f wants to break away from the farm life and becom e an edu cated person. Okay, before she talked to h er p aren ts ab o u t it an d told them she didn’t want to work on the farm. A nd by the look on h er face, and h er parents’, they d id n ’t agree. A nd she doesn’t know w h eth er she should go lead h er own life o r stay with h er family. (So they won’t be angry with her?) But she doesn’t know which way to tu rn . A fterwards, um , she goes back an d tries to talk to them an d they say no way, you e ith e r farm o r you go o u t on your own. A nd so she decides to go study an d she becomes one o f the first women to have a position in the A m erican G overnm ent an d she never hears from h er family again. (?) She’s to rn between family and herself. (?) T hey are feeling sort o f an g ry tow ards her. (?) To go get an education and try to do som ething more. She w anted to really be successful an d do all she could with h e r life. C A R D 4 U m , okay. T hese two are m arrie d an d he says he has to go leave hom e because, because. (Why?) Because. O h gosh, this is so h a rd . . . because um , well . . . he’s goin g to go with his friends an d they have this big b ank robbery planned and he couldn’t tu rn on them now because it was the day o f the big robbery an d he had to go. His wife knows w hat he’s going to do an d she’s try in g to hold him back for the fear th a t he’ll h u rt him self, h u rt o th e r people, or get p u t in jail. R ight before this, they wrere like a rg u in g about i t . . . and he stood u p an d storm ed o ut and she went like ru n n in g afte r him . A nd rig h t after, he’s going to tu r n aro u n d an d say to his wife “you’re m ore im p o rta n t th an the b an k ” o r som ething. (?) H e really doesn’t want to do it b u t he can’t let his friends dow n. (?) A nd like it’s th e last hope to keep them together. CA R D 6G F

Okay, the wom an is su rp rised to see th e m an because she

Disorders in Infancy, Childhood, or Adolescence I 95 th o ught he was goin g to E u ro p e for like the rest o f his life and he ju s t showed u p at h er house an d she’s like su rp rised . T his is d u rin g the Second W orld War an d they’re in A m erica b u t he’s a Frenchm an an d he felt he had to go back and fight for his country. A nd she was all upset because she was w orried he’d be killed fighting. A nd after he shows up, um , she asks why he’s not in France and he says because it’s not w orth like losing everything 1 have in A m erica. T h e n they live happily ever after in the U nited States. (?) O h, the story chan g ed . I decided to m ake it ju s t for the war. (?) He’s sort o f d eterm in ed an d happy w ith this decision. CA R D 7G F U h. R ight now it’s the n an n y talking to the little girl. And h er nanny is ad m irin g the new doll h er m o th er ju s t gave h er b u t the little girl isn’t paying attention to anything the nanny is saying because she’s look­ ing o ff at a picture o f h er w hen she was a little girl which is on h er m o th er’s dresser. O h, the n an n y ’s re ad in g a book! So instead o f talking to her, she’s read in g the little girl a book. U m m , before the p icture, the little g irl’s m o th er gave h er the doll because the m o th er an d fath er were going on a trip for ab ou t a m onth. A nd th e little girl is ju s t looking at the picture h e r­ self o f w hen she was a baby an d w ondering w'hen she was real small if h er m o th er would never leave her. A fter she goes to bed, an d she tucks in her doll and tells the doll th at even when it gets o lder she’ll always be th ere for it. (?) O f h er w hen she was younger. (?) T h in k in g th a t she’s never going to do to her doll w h at her p aren ts d id to her. (?) E u ro p e. CA R D 13M F Okay, this is a depressing picture. U m , a m an walks into sort o f a dark room . D ark an d d reary room . A nd he sees his wife lying on the bed naked an d he bends down to look at h er an d she’s d ead . U m , he tu rn s away an d covers h er eyes so that he won’t see her. Before this h a p ­ pen ed , the girl was sitting alone in h er room and h er h usband was a p art o f the m afia. A nd the husband defected from it because his w ife didn’t want him to be involved in it. A nd in retaliation, some m afia person cam e in and killed his wife. A fterw ards, he feels very guilty because his wife h ad paid for his mistakes. Um . . . so he knows he can’t get the police involved, so he ju s t has his wife b u rie d an d goes and lives in the w ilderness sort o f far away for the rest o f his life, sort o f in isolation. (?) Feeling grief, and he feels th a t he alm ost caused his wife’s d eath . (?) T hey strangled h er I guess. (?) H e was ju s t a m em ber (?) Ju st sort o f sits in his log cabin an d lives o ff the land and ju s t thinks. C A R D 3BM Okay. Okay this is going to be a b o rin g one. (Laughs) T h e wom an was d eco ratin g th e room . No I don’t want to m ake it b o rin g — cross th a t out. She is in a jail cell. A nd she tried to kill h erself with a scissor lying on the g ro u n d but th en she decided she h ad to pull herself to g eth er an d

96 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning get m ore stren g th . So she d ro p p e d the scissors an d sort of ju s t collapsed on the bed and started crying. Before this she was p u t in jail for a crim e th a t she d id n ’t com m it and she had a sentence o f 20 years. It becam e such a scandal and she was so em barrassed she never wanted to see anyone again because everybody th o u g h t she was guilty. T his pictu re took place w ithin like h er 17th year. She ju s t lost all h ope afterw ards. But th en after the a ttem p ted suicide, she regained h e r stren g th an d how to m ake h er life go on. A nd she becam e a stro n g er perso n because o f the whole incident. (?) A ccused, she was accused o f m u rd e rin g h er . . . a m an th a t h ad actually tried to kill h er (?) He was try in g to rob her things. (?) Because things in the outside world were g ettin g worse an d worse an d h er family was still tu rn e d against h er afte r 17 years an d she realized she h ad n o th in g to go back to. (?) She’s going to be so strong th a t she’ll be able to survive with o r w ithout the su p p o rt o f h e r family and friends. CA R D 16 O h my gosh— okay . . . why am I looking at this. O nce upon a tim e, th ere was a m an who crossed the road and bou g h t some eggs an d went hom e to m ake scram bled eggs an d as he cracked one o f th e eggs, a chicken cam e o u t . . . a little baby chick . . . so he decided to keep it as a p et and raised the chicken and they lived happily ever after. I ’m too tired to be creative. (?) A little shocked an d then he was really psyched because this cam e to be his little buddy. (?) Because w hen I th o u g h t o f chickens I th o u g h t o f crossing the road. CA R D 12M Okay. I'his picture is the gran d fath er and his grandson. And the g ran d so n is asleep w hen the g ra n d fa th e r comes in an d so rt o f ju s t blessed him goodnight. Before th a t the g ran d fath er h adn’t seen his g ran d ­ son in m any years an d th a t n ig h t was the first n ig h t th a t the g ra n d fa th er h ad come o u t to C alifornia. T h e fa th e r o f the boy had com e o u t to Cali­ fornia m any years before to m ine gold b u t the g ra n d fa th e r felt his loyalty sort o f tow ards the co p p e r mines. No, tow ard the steel ind u stry if it existed back then. So he finally comes o u t to C alifornia an d sees his g ran d so n an d he’s very proud o f w hat a strong sm art young boy he is. After, the next day, the g ra n d fa th e r decides to stay in C alifornia to get to know his son an d grandson better and they all work together m ining for gold, and they strike it rich an d becom e millionaires.

Disorders in Infancy, Childhood, or Adolescente ! 97

EXHIBIT

5

Se n t e n c e C o m p l e t io n T e s t

2. She often wished she could become a fam ous broad way star. 9. My father always m ade m e feel like I was a special person,

I was

always his “little girl.” 12.

/ was most depressed when I was younger and my fath er hit my mother.

14.

When he turned me down, I was d isap p o in ted for a while b u t th en I moved on.

15. Her new neighbors were an English family with th re e young

girls.

21.

The ideal women would be intelligent, m otivated, fem inine, loving, and w ell-m annered.

29.

I used to daydream about a huge, clear, calm lake with n o th in g b u t a daisy floating in th e m iddle.

31.

When I used to make a decision, I usually don’t th in k abo u t it for long enough.

33. My earliest memory of my father was w hen he used to throw m e u p and dow n in o u r library and then tickle me. 35. 43. 49. 52. 56.

When she thought of her mother, she h ad only fond m em ories o f th eir good times together. She felt she had done wrong when she stayed out past h er curfew and w orried h er m om an d d ad . People seem to think that I am a ch eerfu l and intelligent girl. Most of all I want to m ake my parents tru st me. At times she worried about if she would forget to send h er a u n t a b irth ­ day card.

62. Responsibility is a vital p a rt o f m aturity, and is necessary to lead a successful life. 73. People in authority are d eserving o f th eir position, so we m ust respect them . 100. I feel sad about my p a re n t’s relationship with each other.

98 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

DISCUSSION T he two cases we have chosen to illustrate the test b attery o f adolescents w'ith conduct disorder involve a 17-year-old woman (conduct disorder, un d if­ ferentiated type) and a 17-year-old adolescent m ale (group type). In both cases, the disruptive conduct was b latan t an d could easily be assessed via history taking and interview m ethods. In b o th cases, psychological testing was called for in o rd e r to assess the possibility o f depression an d the relative stren g th o f superego structures. Most recently, it has becom e clear th at adolescents, an d even children, can an d d o m anifest the classical signs o f depression. T h e notion th a t depression in adolescents can be “m asked” by acting-out behaviors which cover up the underly in g depressive affect is still a clinically p ro m in en t one. It is quite possible th a t this latter clinical hypothesis was related to the test referrals in these two cases. Ms. A. presents as a 17-year-old girl who was d u m p ed at the hospital d o o r by her wealthy parents. O ne gets the im m ediate impression from the history that h er behavior is related to rage at her parents who ignore her no m atter how outlandish her behavior becomes. She ap p ears to be willing to perform any outrageous act (e.g., loaning her telephone credit card to the whole psy­ chiatric unit) to get h e r parents’ attention an d the atten tio n -g ettin g quality o f h er behavior seems at odds with a truly psychopathic character. As noted before, testing was called for to assess the presence o f depression in this context. Testing revealed a bright young woman who adm its to rebellious and non­ conform ist attitudes. T hem es o f family d isru p tio n an d conflict were ram ­ p an t in h er TAT stories, alm ost a literal translation into projective m aterial o f w hat was going on in h er daily life. T h e central ch aracter breaks from the fam ily to achieve great success in an antisocial m anner. T h e re seem s little d o u b t th a t a sense o f deprivation a n d ab an d o n m en t is d riv in g her behavior. O ne m ight expect signs o f depression in this context. Depression, in fact, m ight be a good prognostic sign as an expression o f u n m et needs. U nfortunately, this p atien t showed few signs o f depression. For exam ple, h er score on scale 2 o f the MMPI is w ithin norm al limits. Moreover, her superego structures are weak or nonexistent. H er prognosis, even with treat­ m ent, is quite poor. Mr. P., a 17-year-old high school stu d en t, cam e to the attention o f m ental health personnel after a year o f “gettin g h ig h ” on various d ru g s, clim axed with an overdose. T his is an intelligent young m an whose B average had p lum m eted in the year o f d ru g abuse. T h e psychological testing was con­ sistent with the history in that projective materials were filled with agitation

Disorders in Infancy, Childhood, or Adolescence / 99 and movem ent strongly suggesting an individual who approaches problems by action ra th e r th a n by p lan n in g a n d /o r th o u g h t. His TAT stories, like his personal life, are devoid o f them es involving m eaningful relationships betw een people. Not only do his stories b ear the tra p p in g s o f violence and crim e, b u t he evidences enjoym ent in the m orbid and aggressive. A gain, this record seem s devoid o f depression except for situational boredom , and th ere are no signs o f su p ereg o concerns, o r o f tact an d e m p ath y in h u m a n relationships. O nce again, th e prognosis for m eaningful treatm en t seems meager.

CHAPTER 3

Schizophrenias

A. U NDIFFERENTIATED A N D PARANOID CHRONIC SCHIZOPH RENIA Historically, th ere has been difficulty in arriv in g at a reliable diagnosis o f schizophrenia d u e to the lack o f clarity o f the d efin in g criteria. W ith the advent o f D SM -III an d DSM -III-R, the criteria are operational and reliable. T he D SM -III-R schizophrenic is characterized by m ajor disturbance in the following areas: content o f th o u g h t (e.g. delusions), form o f th o u g h t (e.g. loosening o f associations, poverty o f content o f speech, neologism s, p e r­ severation, clanging, blocking), disturb an ces in percep tio n (e.g. h allucina­ tions), affective expression (e.g. flat o r in ap p ro p ria te affect), sense o f self (e.g. loss o f ego boundaries, perplexity ab o u t ones own identity), volition (e.g. litde or no self-initiated, goal-directed behavior, m arked ambivalence), interpersonal functioning (e.g. withdrawal, emotional detachm ent), and psy­ chom otor behavior (e.g. reduction in spontaneous movements and activity). D S M -III-R provides criteria for identifying the following subtypes o f schizophrenia: catatonic type, disorganized type, paranoid type, an d un d if­ ferentiated type. In clinical practice, the catatonic subtype has become rare, and the m ajority o f cases are o f the disorganized type. A substantial m inor­ ity are o f the p aran o id type (Pfohl & A ndreasen, 1986). Even those individuals who m eet th e D S M -III-R criteria for schizophre­ nia are a heterogeneous lot, an d the recognition o f subsets o f schizophrenic patients is essential for treatm ent planning. T hus, it is probably not too help­ ful to o ffer a diagnosis o f schizophrenia alone in a psychological report. Rather, one m ust address o th er issues relevant for treatm ent planning such as the n u m b e r an d n a tu re o f negative sym ptom s an d positive sym ptom s, the presence o r absence o f p aran o id ideation, an d the quality o f in te rp e r­ sonal relationships. T h e relative preponderance o f negative sym ptom s (e.g. poverty o f speech, poverty o f content o f speech, affective blu n tin g , 100

Schizophrenias I 101 asociality, avolition, and attentional im pairm ent) or positive sym ptom s (e.g. delusions, hallucinations, form al th o u g h t disorder, and b izarre behavior) not only provides useful prognostic inform ation b u t also helps provide a focus for intervention. T h e distinction betw een paran o id an d n o n p aran o id subtypes is also rel­ evant for treatm ent planning (Pfohl & A ndreasen, 1986). T he paranoid subtype is characterized by w ell-organized delusions, relatively w ell-preserved affect, m inim al behavioral disorganization, an d less likelihood o f a family history o f schizophrenia. T h e p aran o id subtype is also less likely to show rapid deterioration. In contrast, the non-paranoid o r disorganized subtype is twice as likely to have a positive family history o f schizophrenia. T h ere is little collective d ata on the sta n d a rd psychological test battery results in schizophrenic sam ples reliably d iagnosed by D S M -III-R criteria. Just prior to the introduction o f D SM -III, E x n er (1978) su m m arized his data on a large sam ple o f schizophrenics, diagnosed by clinical criteria, and found th a t the Rorschachs were characterized by evidence o f th in k in g dis­ orders, poor form quality, unusual verbal material, confabulatory thinking, and im p aired p ercep tu al accuracy.

SC HIZOPH RENIA, PARANOID, SUBCHRONIC Mr. S, a 19-year-old Jewish adolescent, lived at home with his m other and aunt. He had not graduated from high school and had never been em ployed. He was b ro u g h t to the hospital by his m o th er who had to have him certified as in need o f m ental treatm ent in o rd e r to arran g e his admission. He saw no reason for his adm ission an d gave as his reason for p resenting him self at the hospital, “My m o th er b ro u g h t me h ere.” He had been staying in bed all day and going out for most o f the night for the last several m onths. H e refu sed to give a n account o f this behavior to his work­ ing m o th er an d to his a u n t w ho is physically h an d icap p ed and draw s social security disability. Recently, he was both verbally an d physically abusive to his m o th er w henever she would persist in questioning him re g a rd in g his w here­ abouts. T his abuse has led h e r on th re e previous occasions to atte m p t to take h er own life, an d she has even considered a com bination su icid e/m u rd er in o rd e r to alleviate w hat she saw as b oth h er an d h e r son’s suffering. His au n t learned th a t he h u n g o ut in the neighborhood at night with a group o f adolescents who sm oked m arijuana and hashish together. Two years ago, he had been asked not to re tu rn to his high school after being charged with sm ok­ ing m arijuana on the school grounds and vandalizing school property. He com­ plied and simply d ro p p ed out o f school. In response, his au n t pleaded with his m other to have Mr. S move out. A t that time, he began behaving much as he had

¡0 2 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning been in the last few weeks. His m other finally gave in to her sister’s p leadingand locked him out o f the a p artm e n t. His exile from the family’s a p artm en t was brought to an end after th re e m onths w hen his m o th er visited him an d found him living in filthy squalor. W hen asked about his hom e life by the ad m ittin g psychiatrist, Mr. S ad m it­ ted to som e discom fort living at hom e. He found it difficult to be in the d in in g room because “there is too m uch wood a ro u n d .” H e h ad also not iced changes in his hearing and had to ask his m other and au n t either to speak u p o r to speak m ore softly at times. He was polite d u rin g the interview an d th ere was no evi­ dence o f the belligerence described by his mother. H e was described as being o f slender build an d looking you n g er th a n his 19 years. T h e ex am in er found no direct evidence for hallucinations although at first it was thought th at his “hearing problem s” m ight be the result o f audi­ tory hallucinations. Delusional m aterial was elicited w hen he was cjuestioned about the link betw een his discom fort an d the wood in the d in in g room . He m aintained that the presence o f too much wood stopped his teeth from growing. Additionally, there were noticeable paranoid elem ents in his think­ ing insofar as he attributes his family’s bringing him to the hospital as their way o f “g ettin g back at me for b ein g lazy.” He acknow ledged th a t he an d his m o th er fought a good deal b u t saw this as entirely h e r fault. Formal exam ination o f his cognitive abilities provided evidence o f some difficulty in concentration, b u t otherw ise his m ental status exam was considered to be u n rem arkable.

DSM -III-R D iagnosis Axis Axis Axis Axis Axis

1: II: III: IV : V:

Schizophrenia, p ara n o id , subchronic None None M ild— chronic fig h tin g with his m o th er and aunt Very p o o r— m arked im p airm en t in b oth social an d occupa­ tional functioning

Treatment and H ospital Course A lthough Mr. S’s psychiatrist considered the diagnosis o f schizophrenia m ost likely, he noted th at both his m o th er an d several o f h e r relatives, including h er sister, gran d fath er, and uncle, h ad all received psychiatric treatm en t for w hat a p p e a re d to be p rim arily depressive disorders. C onse­

Schizophrenias ! 103 quently, he wished to delay th e initiation o f p harm aco th erap y in o rd e r to have a chance to observe him in the hospital setting. Mr. S was enrolled in the hospital school and gradually given a full sched­ ule o f th erap eu tic activities to help assess his abilities. T h ro u g h o u t his hos­ pitalization, he generally coo p erated with the plans m ade for him despite his concern th a t some o f th e sites o f his activities, like his d in in g room at hom e, contained “too m uch w ood.” O n the unit, he becam e friendly with some o f the younger male patients, who generally treated him as a younger sibling, even when the actual age difference showed him as older than them. H e enjoyed playing sm all pranks on the hospital staff, such as hidin g out d u rin g hall checks and having food fights in the com m unity d in in g room . As his four-m onth hospitalization was d raw ing to a close, he had done well enough in school to be scheduled for th e G eneral Equivalency Diploma exam and was considering fu tu re c areer plans as e ith er “a Libyan terrorist o r a pastoral counsellor.”

Psychological Assessm ent Mr. S was referred for psychological testing d u rin g the second week o f his hospitalization to help establish his diagnosis. He accepted the need for the evaluation with some reluctance and was initially wary and somewhat guarded in his answers. He smoked nervously when given the chance to do so. As testing proceeded, he becam e more friendly with the examiner. He becam e more open and less constricted to the p o int w here he was able to express his delig h t when he felt th a t his responses were taken favorably by the exam iner. In light o f the differential diagnosis, he was given a full battery o f tests, including the WAIS, Rorschach, TAT, SCT, DAP an d Bender. His WAIS perfo rm an ce indicated th a t he was functioning in th e Average ran g e o f intellectual ability with a full scale IQ o f 101 and verbal an d p e r­ form ance IQs o f 112 and 87, respectively. His scaled subtest scores ranged from 6 on a pictorial test o f discrim inative ju d g m e n t (Picture Completion) to 14 on tests o f conceptual thinking (Similarities) and rote memory for n u m ­ bers (Digit Span), dem o n stratin g a high d e g re e o f intertest scatter. His highly variable perform ance on the WAIS and his especially poor perform ­ ance on the Picture Completion subtest which required him to differentiate essential from unessential details indicated substantial im p airm en ts in his reality testing abilities consistent with a psychotic level o f functioning. His im p airm en t in reality testing was also evident on the Rorschach w here he gave m any poorly articu lated responses with peculiar co ntent an d on the S entence C om pletion Test w hich c o n tain ed several c o n trad icto ry self-statem ents.

104 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Mr. S’s retention o f the capacity for abstraction and generalization as indi­ cated by his relatively (and absolutely) high Similarities subscale score, taken in conjunction with his present im p airm en t in reality testing, were seen as suggestive o f delusional propensities. A dditional p aran o id elem ents in the test record included his frequent reference to “eyes” as the only feature sup­ p o rtin g his perception o f faces on the Rorschach an d the a ttrib u tio n o f m enacing qualities to otherw ise benign percepts. His preference for detail responses, including the use o f small, idiosyncratic details, also were indic­ ative o f p aran o id elem ents in his th inking. Finally, in his hypervigilant fem ale h u m an Figure draw ing, he drew the eyes closed and then carefully a d d e d the pupils o f the eyes b eh in d the closed eyelids. T h ere were also certain som ew hat grandiose an d expansive elem ents in Mr. S’s test protocol that were consistent with his working diagnosis. He was u nab le to find space on a single sheet o f p a p e r for his B ender draw ings and required a second sheet for the last two designs. On the Sentence Com ­ pletion Test he rep o rte d feeling p ro u d th a t he had “achieved his goal o f ed u catio n ” (which he h a d n ’t) an d th a t his g reatest desire was “to get m a r­ ried and have a good living” and th at w hat he w anted most was a “good jo b with high pay.” W hile these are certainly conventional expectations, they are clearly unrealistic. H e noted th a t he hates to “go to school an d w ork,” an d he felt th a t his boss “worked me a little too h a rd ,” an a ttitu d e which explains, p erh ap s, his history o f unem ploym ent. Additional evidence from the test battery th at was seen as consistent with Mr. S’s diagnosis involved his u n d e rsta n d in g o f an d insight into o rd in a ry h u m an relationships. His low Picture Arrangement subscale score m easuring anticipatory p lan n in g ability in a social context, his stereotyped an d bland TAT stories, the absence o f com plete h u m a n an d m ovem ent responses on the R orschach, an d his caricatu red an d b izarre h u m a n fig u re draw ings all suggested a significant im pairm ent in his relationships with others. He was especially am bivalent tow ards p aren tal an d o th e r au thority figures whom he represented as “loving,” giving advice, and protective on the Sentence C om pletion Test. In his R orschach responses, however, which were m uch less susceptible to conscious control, card s often seen as reflecting attitu d es tow ards m ale an d fem ale authority figures were seen as a “m o n ster” an d a “pig ,” respec­ tively. C onsistent with his p ara n o id stance in this re g a rd was the unusual reference to the th re a t o f u n b rid led aggression seen th ro u g h o u t the SCT (e.g. he could hate a person who “beats people up” and is afraid o f “getting m ugged while riding the train . . . ”) and Rorschach percepts o f horned ani­ mals an d alligators. A sensitivity to such th re a te n in g possibilities probably lies beh in d the vitiation o f his fem ale h u m a n fig u re draw ing by o m itting h er arm s while at the sam e tim e d epicting h e r with clenched teeth. His

Schizophrenias / 105 inherently negative self-image and accom panying experienced vulnerability were m irro red in his clown-like m ale figure draw ing with a silly h at but w ithout shoes, as well as in his Sentence C om pletion item indicating th a t success can n o t be achieved “w ithout cheatin g .” In sum m ary, Mr. S’s test protocol seem ed to su p p o rt a diagnosis o f p a ra ­ noid schizophrenia. T h e findings o f g u ard ed , grandiose, and expansive ele­ m ents in his th in k in g which he utilizes to defend against an u n derlying p o o r self-concept, im p aired reality testing, p o o r social ju d g m e n t, and em pathic abilities were all consistent with the D SM -III-R diagnostic criteria for p aranoid schizophrenia. It may be surm ised th a t these difficulties were o f fairly long stan d in g in th a t th ere was little evidence suggesting the pres­ ence o f anxiety. In this reg ard , his Digit Span p erfo rm an ce on the WAIS was excellent, shad in g responses were virtually absent on the Rorschach, he relied on conventional, stereo ty p ed m ethods o f h an d lin g anxietyprovoking situations on the TAT an d on the Sentence Completion Test, and seem ed to be oblivious to the discrepancy betw een his aspirations an d his abilities an d achievements. W hen he was m ad e aware o f these disparities, he seem ed able to accept some responsibility for, an d the consequences of, his lack o f achievement. In one TAT story, the m an worries th at having lost his jo b he won’t be able to provide food for his family. O n the Sentence Com pletion Test he was asham ed th at he “failed a few subjects.” He went on to acknow ledge th a t it was his own fault w hen “he failed” and he feels guilty about “. . . flunking and a rg u in g .” However, ra th e r th a n ad d ressin g these difficulties directly by becom ing “hardw o rk in g an d am bitious” as he feels m ost people are, w henever he does a po o r jo b he “gives u p ” or, as he reports in one TAT story w here a h u sb an d is n ot in the m ood to have sex with his wife, “go out and get d ru n k to forget his problem s.” A lthough he rem ain ed ho p efu l abo u t the fu tu re an d seem ed aware o f the need to work tow ards his goals, there was evidence th a t he lacked the persistence o r tenacity to fru itfu lly p u rsu e them . In light o f his multiple im pairm ents, history o f p o o r functioning, an d dim inished capacity to p e r­ severe, it was recom m ended some attention be given to b rin g in g his aspi­ rations m ore into line with his present abilities.

Treatment P lanning and Outcom e O n the basis o f his p erfo rm an ce on the battery o f tests, Mr. S was given the diagnosis o f subchronic paranoid schizophrenia and a trial o f neurolep­ tics was initiated. In his individual psychotherapy, efforts were m ade to help him m ake realistic plans for his fu tu re in light o f his illness and his

106 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning resources. He m ade satisfactory progress while in the hospital an d was dis­ charged as improved. His prognosis was seen as g u ard e d in light o f his wish to re tu rn to live with his family an d th e ir continued denial o f the severity o f his illness. H is m o th er expressed the view th a t she could “reach ” h er son and continued to h arb o r expectations for him that proved to be unrealistic. Nevertheless, his m other and his aunt did agree to accept the hospital’s rec­ o m m endation o f partial day hospitalization an d continued o u tp a tie n t psychotherapy. Mr. S rem ained out o f the hospital over the next six years, b u t was never able to attain any level o f in d ep en den t functioning. His days continued to be sp en t in a p artial hospitalization p ro g ram and he continued on m edi­ cation. Several efforts to stop m edication led to increased aggressive o u t­ bu rsts and delusional preoccupations with attem pts to influence him in a variety o f bizarre ways. He wras subsequently rehospitalized following a sui­ cide attem p t by his mother. At th a t tim e, his m ental status exam an d in te r­ vening psychiatric an d psychological history clearly confirm ed the earlier diagnostic impression o f paranoid schizophrenia. Due to the long-standing n a tu re o f his illness an d the severity o f his im p airm en t, he was given the diagnosis o f p aran o id schizophrenia, chronic w'ith acute exacerbation.

Schizophrenias / 107

EXHIBIT

I.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Sym ptom s/D iagnosis Schizophrenia, paranoid, subchronic B izarre delusions

Wood affects dental growth

Im paired reality testing com bined with overly abstract thinking

G randiose delusions

C areer plans

A spirations beyond abilities

D eterioration in school and self-care

H igh school dro p o u t; Poor self-care

None

D uration six m onths— two years

One-two years o f poor functioning

None

None

G u ard ed b u t responsive to praise

11. Personality Factors

Little persistence or tenacity 111. Cognitive Abilities

Delusions Poor concentration Im paired reality testing

IV. Psychodynam ics

V.

T herapeutic E nabling Factors

Average intelligence with cognitive d isruption due to emotional factors

None

T h reaten ed by environ­ m ent, especially women

None

Isolation, idealization and projection as defenses against negative self-concept

None

Affective controls inadequate

C ooperative to somatic treatm ent

H opeful about fu tu re and believes therapy can help

108 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

VI. Environmental Demand and Social Adjustment

No friends Conflict with family

Inability to live up to social expectations Poor understanding of social relationships Markedly ambivalent towards parental and other authority figures

Schizophrenias I 109

EXHIBIT

2

WAIS-R S u m m a r y Verbal Sublests

Scaled Score

Inform ation C om prehension A rithm etic Sim ilarities Digit Span Vocabulary

10 12 9 13 14 11

Performance Sublests D igit Symbol Picture Com pletion Block Design Picture A rran g em en t O bject Assembly Verbal IQ Performance IQ Full Scale IQ

7 6 11 7 9 112 88 101

R orschach Summary N u m b er o f Responses Rejections P opuláis O riginals Average R /T chrom atic Average R /T achrom atic F% F+ % A% H% W:M M :Sum C m :c V II1-X% FK + F + Fc% (H + A ):(H d + A d )

22 0 6 0 22" 8" 82 45 77 14 3:0 3:3.5 0:1 36 82 9:11

110 t Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R o r sch ac h S um m ary

Apperception

W 14% D 73% d 4% D d + S 9%

Schizophrenias / 111

EXHIBIT

3

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

I. 2"

Looks like an inkblot. Looks like it was m ade out o f ink. I. And looks like it could be a butterfly. (Pause.) Looks to me like a butterfly, a b u tter­ fly, o r a butterfly. Not too colorful. If it was m ore col­ orful it would look m ore like a butterfly but the shape makes it look like a butterfly. (More than one thing.) I can’t see any th in g else. (Returns card.) I looked. It looked like a b u t­ terfly. W hat else can I say? W hat do you see in there?

1. T he shape o f it is like the shape o f a butterfly. T hat's w hat it looks like.

WFAP

1. Point o f the head looks like an alligator.

1. T h a t was on the last one, I don’t rem ember. Don't ask me after it’s over. I told you right away. You’re w riting fast enough. (Alligator'?) T h e head was shaped like an alligator and it sort o f had eyes like an alligator.

DF-Ad

2. And the back looked like a butterfly once again. And the m iddle, the head looks like an alligator. (Middle?) They d idn’t put an y th in g there. A nd the tail looks like the back o f a butterfly, a butterfly’s backside.

2. Why d id n ’t you ask me while I was looking at the picture? (Pause.) It was shaped like a butterfly. (Back?) Cause th a t’s the way it was shaped like.

DFAP

II. 11" T his one’s a little m ore col­ orful. H as red in it.

112 / Psychological Assessment, Psychiatric: Diagnosis, and Treatment P la n n in g

R o rschach Sum m ary

Response 3. A nd here I see a face. A face up top. A nd eyes on each side and, ah, ah, a fun n y shaped nose and silly m outh. Sad m outh.

Inquiry

Scoring

Right. T h ere was eyes on each side, not m uch o f a nose and a sad m outh, like a frown.

D(S)M -Hd

1. I see black and red on a w hite board. A nd, ah . . .

1. (A remark?) No, I m eant it as an answer. It's a white background with red and black on it. Like paint. Like red an d black paint.

DCdesObj

2. H ere I see a face on the side here and an o th er face on this side here.

2. T h a t it seem ed to be a pic­ tu re o f eyes an d nose.

DF-Hd

3. A nd here I see a butterfly. (Butterfly}) Yah, Right. H ere’s the butterfly. And th a t’s it. Ju st a butterfly and n o thing else.

3. T he shape. T h e wings.

DFAP

1. I don’t know. (Remind any­ thing?) It was nothin g b u t a crum m y blotch o f ink.

WF(A)

1. Bats are black and this is shaped like a bat.

W FC ’AP

III. 60" (Leaves card on desk.)

IV 9" T his one’s kind o f scary. 1. It looks like a m onster (Long pause.) T h a t’s it. It looks like a monster. (Reads back of card.)

V 10" 1. T his one looks like some sort o f insect. Looks like a butterfly b u t not really a butterfly, looks like a bat. Shape o f a bat, w ingspan o f a bat. C ould be a bird. Not colorful enough to be a bird. Looks like a bat because it’s black.

Schizophrenias / 113

R orschach Sum m ary

Response

Inquiry

Scoring

(Laughs; long pause.) (What do you see?) See ink. Looks like som ebody p ut an ink d ro p here and didn’t really have any object o f what they w anted it to look like.

VI. 2' I. U p here it looks like it m ight be a bird. T h e head o f a bird. T h a t’s all.

1. T he shape o f it.

dFAd

VII. 7" 1. This looks like a butterfly.

1. Just the shape.

DFA

2. T his looks like a pig. That looks like a pig.

2. Formed like a pig’s head. T h a t’s all.

3. Like maybe ra m ’s horns over there. O ne o f those two-way jobs.

3. Look like them . (Two-way jobs'?) O n eith er side o f the head.

DFAd Peculiar verbalization

1. It looks like an elephant. An elephant’s tru n k (Pause).

1. It was an elephant’s tru n k . (Resemble?) T h e shape.

diF-A

2. T his one looks like, a, a, a butterfly.

2. T h e shape and the color.

DFCA

3. A nd this one looks like an o th er kind o f anim al. I don’t know the nam e o f it.

3. You know, it h ad to be som ething so it had to be an anim al. (Animal?) It’s shaped like one. (Particular animal?) A n anim al I saw but I d id n ’t know the nam e of.

DF-A

DF-Ad

V III. 11" T his one’s m ore colorful.

1 1 4 / Psychological Assessment, Psychiatric Diagnosis, an d Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

IX. 18" 1. O h, now, this looks like, over here this red p art looks like . . . a . . . a beetle with horns sticking out. A nd th a t’s all I can make out o f that one. (Again}) All right (Long pause).

1. T he shape.

drFA

2. O h, yeah. A dog. A dog over here. T h a t looks like a d o g ’s face. A nd this one looks like a d o g ’s face. A poodle. Not a poodle. I don’t know the nam es o f dogs b u t one o f those dogs.

2. Just looks like a dog.

DF-Ad

1. T his looks like one o f them m ean sea fishes. Maybe like a crab.

1. T h e ir shape and the eyes. (Mean}) T h e kind th a t bite you. Like a jellyfish. (Mean}) T h e way they looked. T hey’re still right

DFAP

2. A deer. Here’s a d e e r’s head. A little picture there. H ere’s a d e e r’s head.

2. T h e shape o f it.

DF-Ad

3. A nd, ah, (Burps; apologizes). H ere, these are obviously eyes. T h a t’s all.

3. Looks like someone’s eyes.

DF-Hd

X. 12" T hey’re getting difficult.

Schizophrenias / 115

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 3" I t’s a little boy an d he’s th in k in g about playing the violin. Looks like he wishes he knew how to play it. H e looks like he w ants to learn how to play it. H e looks like he wants to take lessons, and perhaps he’s think­ ing about who m ade it o r how it was m ade. Maybe he’ll pick it u p in a little while an d see if he can play it, see if he can m ake any music out o f it. 1'24''. C A R D 3BM 6" T h is guy’s, ah , very sad. I see a g u n lying dow n on the floor. He’s th reaten in g about killing him self. Probably because m aybe he lost his jo b an d his wife divorced him an d has custody o f the children and he has no money an d no friends. (Wait.) A nd the g u n is lying th ere an d he’s th ink ing about killing him self but he’s th in k in g m aybe he can work to resolve his problem s instead o f killing him self so maybe he still has som e­ th in g left to live for if he can find a new jo b an d m aybe work th ro u g h his problem s som ew hat (Wait) and he comes to the realization th a t ju s t killing him self won’t help him any. H e leaves the g u n an d doesn’t kill him self and he gets up, com e to th in k o f it, it looks a little bit like a dress, so instead o f h usband and kids, wife an d kids. She gets up, goes and talks to h er psy­ chiatrist an d they give h er som e therapy and she gets b etter an d learns to deal with h er problem s and goes on from there. 3'45." CA R D 4 8" 10" U hm , Man and lady are in love an d , ah, m an wants to take the lady, lady wants to go to th e movies o r o u t to dinner. Man wants to take h er and says, “Okay, we’ll go.” Takes h er o ut to th e movies. A fter th at they go for seafood and ah, after th at they go d an cin g (Sneezes) and ah, u h m , he says, she says she wants some new clothes. H e says, Okay, takes her to the store and buys h e r a new dress. She says, “T h a n k you for every­ thing, I love you.” T hey ride hom e in the car, watch a little T V an d smoke a few cigarettes and chat and have a nice time. 'ITiey say, “Well, it was a lovely evening and maybe we should do this more often.” And they kiss good night an d go to bed. 2'15". A re m ine corny? CARD 6BM 11" U hm . . . A m an and woman look sort o f distressed and sad about som ething. T hey look up set an d don’t know w hat to say. N either one knows w hat to say to each o th er because (Wait) they’re so sad they’re at a loss for words. They don’t know w hat to say th at could help the situation. (Situation?) Maybe they’re, u h , u h (pause), um , he lost his jo b o r som ething. (Okay.) Is th a t w hat h ap p en s? (Your story.) T h e guy lost his jo b an d he’s sad and up set an d w orried th a t he won’t have food for th e family. 1'58".

116 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t i o n T e s t

CARD 7BM 6". Looks like a father talking to a son. Looks like the father seems kind of, ah, pleased that his son is listening to him and, ah, he’s telling him , ah, th at his, ah, no, he’s telling him . . . t h a t . . . th at, ah, his wife an d children are com ing along fine an d th a t he doesn’t have to worry th a t he d id n ’t get the prom otion on his jo b an d th a t everything will be all right (wait). A nd the son says, the son’s w orried th at his am bition, ah, he wants prom otion for m ore respect an d stu ff a n d the fath er says th a t will come in tim e. Patience is a virtue an d it will come in time. Son says, Okay, d a d , I ’ll listen to you and we’ll see how it works o u t even tho u g h it’s not exactly w hat 1 w anted. 2'20". (Asthma attack). CARD 13MF I see a lady lying down in bed with no clothes on. She looks like she wants to have sex b u t h er h u sb an d looks like he’s n ot in the m ood for it. (Wait.) And he, he’s not, he looks like he’s upset because he can’t please his wife and he’s goin g to go o u t an d get d ru n k to forget his problem s. (Bet­ ter). Do you always show p atients these kind o f pictures? (Yes.) 58".

Schizophrenias / 7 77

EXHIBIT

5

S e n t e n c e C o m p l e t io n T est

6.

I used to feel I was beirig held back by “my lack o f confidence.”

7. 9.

He felt proud that he “h ad achieved his goal o f ed ucation.” His father always “loved him very m u ch .”

10.

A real man “is ed u cated .”

12.

The worst things about women “are th e ir laughing habits.”

15.

To get along in a group, you “have to com prom ise.”

19.

7 could hate a person who “beats people up .”

20.

His earliest memory of his mother “was very loving.”

21. 28.

I was most depressed when “ I was on my own.” When they talked about sex, I “don’t listen.”

38.

The kind of people 7 liked best are “sm art guys who know alot abo u t pol­ itics and stu ff.”

42. When I am criticized, I “som etim es accept it.” 44. He felt he couldn’t succeed unless “he ch eated .” 61.

Sexual intercourse “increases the p o p u latio n .”

63.

Whenever he does a poor job, he “gives up.”

65.

7 felt most thwarted when “1 was in d ep en d e n t.”

86.

7 could lose my temper if" I get beaten up.”

87. 91.

I am afraid ( / “g ettin g m ugged while rid in g the train to M an h attan .” Sometimes I feel that my boss “worked m e a little too h a rd .”

118 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

SCHIZOPH RENIA, UNDIFFERENTIATED, CHRONIC U ntil recently, Mr. L, a 17-year-old high school stu d en t, h ad been living in Florida w ith his older b ro th e r an d sister in the family’s home. His father w anted to move the family n o rth in the hope th a t closer contact with his clients would help revive his faltering business as a m edical supplies dealer. His children (Mr. L, his brother, an d his sister) h ad ag reed to stay b eh in d so th a t th e ir Florida house would be occupied while it was u p for sale. Mr. L was happy to comply w ith his fath er’s wishes. A fter his p aren ts left, he d ro p p e d o u t o f high school an d spent his days loafing aro u n d the house an d h a n g in g o u t at a local beach by him self. Living this way was a relief and he was glad to be able to remove him self from school an d the com pany o f friends. Academic an d social pressures were beyond him . For some tim e he h ad been ex p erim en tin g with d ru g s, p articularly hallucinogens, an d now with the household incom e entirely at his disposal, he beg an to seri­ ously abuse hallucinogens and m ariju an a. O ne m onth prior to admission, his m other received a late night call from him . She said he h ad sou n d ed “strange an d frig h te n e d .” M uch o f w hat he said to h er she found incom prehensible. His father flew to Florida an d finally tracked him dow n at the local beach w here he h ad sp en t the last few nights. He was disheveled, poorly fed, an d unable to give a coherent account o f his activities over the last few days. T h e house was filled with dirty dishes, partially eaten food, and unw ashed laundry. His o lder b ro th er an d sister had moved o u t two weeks previously, disgusted with the state o f the house an d un ab le to stop th eir younger b ro th er from soiling it faster th a n they could clean it. His fath er learn ed th a t Mr. L’s o lder b ro th e r was living with his girlfriend. Mr. L d id not know the w hereabouts o f his b ro th er an d was su rp rised to h ear th a t he h ad moved out. He ag re e d to re tu rn hom e with his father. A t hom e, his m o th er found him d istan t an d rem oved. A lthough he did not seem frightened, she still had trouble m aking sense out o f much th at he said. Mr. L went with his m o th er to consult a local psychiatrist who recom m ended th at he be hospitalized. Seeing th a t he d id not im prove at home and given no assurances that he would improve with o utpatient treat­ m ent, his p aren ts finally d ecided to have him hospitalized. His m ental status exam ination at the time o f admission revealed a poorly nourished, disheveled young m an with long hair. He stated th a t his reason for seekin g adm ission was th a t “ I th in k I’ve got a problem o f incoherency. I like to laugh.” A lthough polite and willing to answ er questions, he felt little anxiety about his present condition an d related to the ex am in er w ith a detached, distant air that m ade it difficult to gath er any p ertinent historical data. His accounts o f recent events and o f his own experience were generally

Schizophrenias / 119 p resented in such vague an d abstract term s th a t it was o ften difficult to determ in e w hether his responses bore any relationship to the questions he was asked to answer. He was able to com plete the m ore form al p arts o f the exam ination and d id dem o n strate some curiosity about why he was being asked to do certain tasks. However, w hen given an explanation, he seem ed not to com prehend w hat he was told an d sm iled at the ex am in er with an air o f detach ed puzzlem ent. He acknow ledged th a t he h ad recently ex p e­ rienced both visual an d auditory hallucinations, b u t given his extensive, recent use o f hallucinogens, it was impossible to determ ine if these phenom ­ ena h ad o ccu rred outside the context o f his d ru g abuse.

D SM -III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV : V:

Schizophrenia, u n d ifferen tiated , chronic None None M ild— parents moved to a new city Very p o o r— m arked im p airm en t in both social relations and academ ic functioning

Treatment and Hospital Course Mr. L’s initial weeks o f hospitalization involved a tho ro u g h medical workup and extensive efforts to g ath er additional inform ation from his fam ­ ily reg arding his personality and functioning over the last few years. In light o f his extensive d ru g abuse, pharm acological trea tm en t was delayed in o rd e r to provide a perio d o f d ru g -fre e observation. Initial concerns were focused on the possibility o f significant cerebral im p airm en t related to his d ru g abuse and a prior history o f electroencephalographic (EEC) anomalies. C om puterized tom ography (CT) and EEC studies were ordered by his treat­ ing psychiatrist. T he C T results were reported as showing “considerable dis­ tu rb an ce o f w hite an d gray m a tte r p attern s, especially noticeable in the frontoparietal region,” suggesting “diffuse white m atter disease.” T h e elec­ troencephalographic exam ination revealed a “diffusely abnorm al EEC with­ o ut focal features." In reviewing his past m edical records, his present EEC findings were rep o rte d as showing no significant ch an g e from the results o f the exam ination o f a few years ago. His hospital psychiatrist was able to learn that Mr. L had a family history o f m ental illness. Both his paternal g randm other and his older brother had received hospital treatm en t for “depression.” No o th e r family mem ber,

120 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning including his o th e r five o lder siblings, was rep o rted to have received any psychiatric o r psychological care. His p aren ts an d his siblings all d escribed him as a distan t and seclusive individual who h a d always kept to him self and seldom participated in family affairs. Periodic concerns about his poor academ ic o r social functioning had prom pted the family to seek psychiatric consultation for him on two previous occasions. However, his lack o f interest an d the absence o f any positive findings h ad discouraged the family from insisting th a t he p u rsu e any exten d ed course o f treatm en t. He h ad always been pleasant, if distant, an d his parents h ad m ost o ften felt th a t he, like his o ld er siblings, simply w ouldn’t “come into his own an d blossom ” until later in life. T hey h a d been aware o f his d ru g abuse, b u t n ot o f its m ag ­ nitu d e, and h ad n ’t considered it a significant problem . T hey h ad n ot been aware o f his d ro p p in g out o f school; on learning o f it from his brother, they h ad attem p ted to dissuade him from it. D u rin g th e initial p erio d o f observation, Mr. L continued to rep o rt auditory and visual hallucinations which he found entertaining an d com ­ forting. He sp en t m ost o f his tim e in his room a n d involved him self with o th e r patients o r activities only upon d irect request o f the hospital staff. He was cooperative with, b u t puzzled by, these requests and would occasionally offer a m ild com plaint a b o u t having to p articip ate in such activities since, as he saw it, the sta ff “d id n ’t u n d erstan d w hat my life is ab o u t.” A fter the first m onth o f hospitalization, w ith no discernible im provem ent in his clinical state, his hospital psychiatrist decided to begin a trial o f an ti­ psychotic medication to determ ine if his hallucinations could be alleviated. H e ag reed to th e trial, b u t the only positive effect he could rep o rt at the en d o f the next m on th was th a t the m edication h elped him to sleep b ette r a t night. T h e re was no o th e r ch an g e in his m ental state. A rep eat C T scan failed to confirm the earlier findings o f disturbance in white and gray m at­ te r p a tte rn s although his EEC rem ained diffusely abnorm al.

Psychological A ssessm ent In light o f his medical findings and his failure to improve on medication, the hospital sta ff requested a psychological consultation to assist in d iffe r­ en tiatin g betw een a schizophrenic syndrom e an d an organic syndrom e. They also requested assistance in helping to form ulate additional treatm ent goals for him . H e was given the VVAIS, Bender, R orschach, TAT an d SCT in o rd e r to evaluate th e interplay o f intellectual, cognitive, and em otional factors and th e ir contribution to his present clinical state. Mr. L ap p ro ach ed the psychological evaluation with m uch the sam e a tti­

Schizophrenias I 121 tu d e re p o rted d u rin g his initial m ental status exam ination. He arriv ed for testing dressed in a som ew hat slovenly m a n n e r an d although he was coop­ erative an d polite, he was not always attentive. Q uestions and test in stru c­ tions h ad to be rep eated occasionally because he “d rifte d o f f ’ into his own thoughts. H e stated th a t he enjoyed the testing because it gave him “som e­ th in g to d o .” O n the VVAIS, Mr. L achieved a full scale IQ o f 95, with both verbal and perfo rm an ce IQs o f 96. D espite the sim ilarity in his IQs, inspection o f the range o f subscale scores reveals extremely variable functioning. His subscale scores ranged from the mentally defective (Comprehension) to superior (Block Design) levels. His good verbal an d nonverbal concept form ation abilities are inconsistent with the possibility o f a d iffu se cerebral im p airm en t. He possessed a good fu n d o f general inform ation and d em o n strated superior abilities to analyze an d synthesize visual designs. H is social ju d g m e n t, on the o th e r h an d , was grossly im paired. He concluded th a t if he found a sealed an d stam p ed letter in th e street th a t “I ’d send them o ff a tem porary note ju s t to let them know th e letter was sent, so they would get a re tu rn letter”; bad com pany was eq u ate d with “unsocialized youth” who could m ake one irritable; taxes are paid because o f the “fanfare o f com m odities”; child labor laws are n eed ed “to in fu riate you . . . to keep the principle o f the w orking m an’s life in o rd e r so the youth can’t take over”; to find his way out o f the forest “I ’d use my own instincts.” His p ecu liar langu ag e an d fluid and idiosyncratic th o u g h t were perva­ sively in evidence on both the Rorschach an d TAT. He began the Rorschach by describing the “com ing to g eth er o f a mass with two h ands stretching o u t” and also described the lower h alf o f the in tern al detail o f card I as a wrotnan because “it looked like it was a dress on her, the o u ter p a rt. Call it the outskirts.” Card 111 was described as “an inform al setting for a h ead .” Card VIII seem ed to him to be “a lion step p in g across a stone p ath , I guess, kind o f in a continental way. It signifies a ferocious beast all over the continent.” O n the TAT, his already tenuous hold on reality com pletely evaporated. By the 10th card , he told the following story to card 7BM, a card with an older male figure in the background an d a younger m an in the foreground. T h is card typically elicits stories re g a rd in g the older m an giving advice to the younger. Mr. L’s story contained som e o f these elem ents: “You know, I can tell you ‘You’re right,’ an d I can tell you ‘You’re w rong’ an d you ju s t sit there. You can look as h a rd as you want b ut I know you want the sam e infor­ m ation, no less an d no m ore. You can find your way ou td o o rs if you like, b u t rig h t now you’re here in prison. I f you want to m ake it on your own, you’ve got to be able to stand u p for yourself an d speak the tru th . All I can say is th a t I ’m m ad at all o f you. W hy d id you pick on me? T h a t’s all.” It

122 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning was im possible to tell w hat private m eanings he h ad draw n from this card and inquiry on the p a rt o f the ex am in er d id not clarify them . Mr. L’s strongly m etaphorical an d at times allegorical ap p ro ach to b oth the Rorschach and TAT was pervasive. His m etaphors and allegories, un fo r­ tunately, often obscured w hat he had p e rh a p s set o ut to clarify. His responses gave the im pression th at th ere was m ore d e p th th a n m eets the eye, b u t Mr. L found o rd in a ry speech a p o o r vehicle for conveying all th at he th o u g h t an d experienced. He could n ot struggle th ro u g h th e layers o f m eaning he dim ly perceived, he could only allude to the m any impressions w hich he glim psed as they briefly passed by. D u rin g the course o f th e ex am ination, he a g reed th a t o th ers would ce r­ tainly have difficulty u n d e rstan d in g him . H e was aware to some d eg ree o f the peculiarities in his th in k in g a n d in his speech, b u t he was n ot troubled by this. He simply recognized th a t o th ers d id not think and feel as he did. H e also m ad e it clear th a t he h ad no desire to rectify the difficulty. T h e S entence C om pletion Test provided a n o p p o rtu n ity for him to record his responses to com m on, everyday situations. Even in this reality-oriented con­ text, he retained his idiosyncratic m odes o f expression. He w rote that he often wished he could “relate tru e to know ledge”; he felt proud that “he u n d e r­ sto o d ”; mother was all right when “I know h e r” ; after he told them how he felt, he “knew them ”; most of all I want “to be.” Absent from the SCT is any sense o f volitional action (e.g. when they told him what to do “I looked o n ”). In its place he has substituted an intellectual state o f merely being where an osten­ sible tran scen d en t know ledge has its own rew ards an d is sufficient. Such abstruse intellectualization ap p eared to be his deepest desire (he noted, for exam ple, th a t love is “auspiciously intellectual”) and seem ed to be sought for its ability to release one from tension. He used to feel down in the dum ps w hen “I was tense” an d noted th a t the cause of his failure was “tension.” Mr. L’s peculiar and idiosyncratic th in k in g , his inability to d ifferentiate p erception an d association, his convoluted intellectualized m a n n e r o f dis­ tancing him self from reality, and especially his acknowledgm ent o f and lack o f concern over this difficulties were th o u g h t to be m ore in keeping with a functional rath e r th an an organic in terp re tatio n o f his difficulties. T h e absence o f anxiety, turm oil o r sustained efforts to rem edy these difficulties suggested these problem s were o f long stan d in g an d although p e rh a p s e n h an ced by his recent hallucinogen abuse, were nevertheless indicative o f a chronic condition. As th ere was no indication in the test reco rd o f any desire to deal w ith a n d alleviate his problem s, the ex am in er was u nable to suggest any therapeutic goals which could be used to form a treatm ent alli­ ance with Mr. L. It was recom m ended th at, in light o f his im p aired social ju d g m e n t, he be placed in a protective treatm en t settin g w here he could be given an o p p o rtu n ity to en gage in some productive work th a t would not

Schizophrenias / 123 overly tax him emotionally. T h e psychologist also suggested th a t he be strongly encouraged to abstain from any fu rth e r d ru g abuse.

Treatment P lanning and Outcom e Mr. L an d his family were inform ed o f the outcom e o f the psychological evaluation an d accepted the recom m endations o f the hospital treatm en t staff. A rrangem ents were m ade to d ischarge Mr. L to a ru ral, residential care facility w here he would be able to spend an h o u r o r two each day engaged in small jo b s to help in ru n n in g the facility. He and his family vis­ ited the facility prior to his discharge. He found the facility quite acceptable and looked forw ard to living in a quiet setting w here he could “relate to the plants an d anim als.” He continued to take his m edication with the u n d e rsta n d in g th a t it would help him to rem ain in touch with things o u t­ side him self. A t the tim e o f his disch arg e th ree m onths after his adm ission, Mr. L was given a g u a rd ed prognosis. However, he had no difficulty with the transition an d settled com fortably into the routine o f the new facility. Several m onths later, he w rote th at he was glad to be living a useful life an d c o n trib u tin g to his own upkeep. H e had m ade a friend at the facility with w hom he enjoyed discussing various ways in which knowledge could be acquired. He seem ed content with his present life and he has not retu rn ed to the hospital.

124 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

EXHIBIT

I.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

Persistent hallucinations for three-four months

Im paired reality testing

Speech persistently vague, ellipitical and impoverished

Peculiar language, syncretistic and loose thinking

Deterioration from previous level o f functioning

D ropped out o f school; grossly im paired selfcare

Poor hygiene

Duration o f illness (including pro­ drom al phase) of six months or more

Social withdrawal and isolation with marked im pairm ent in role functioning and hygiene; vague speech followed by active symptoms

Absence o f anxiety despite recognizing his im pairm ents

None

No capacity for sustained effort

Adequate fund o f infor­ mation; im paired judgm ent

Average intelligence grossly im paired ju dgm ent

None

Sweepingly dependent on an intellectualized approach

Cooperates with plans m ade for him

Functions best with high degree o f external structure

D ropped out o f high school; no work history

None

No social relationships and uninterested in them

No interest in social relationships

Symptoms/Diagnosis Schizophrenia, widifferentiated, chronic Prom inent halluci­ nations and incoherence

11. Personality Factors III. Cognitive Abilities

IV'. Psychodynamics

V. T herapeutic Enabling Factors VI. Environmental Demand and Social Adjustment

Schizophrenias / 125

EXHIBIT

2

W A IS -R S u m m a r y

Verbal Subtexts In fo rm a tio n C o m p reh en sio n A rith m etic Sim ilarities D igit S p a n V ocabulary

Scaled Score 12 2 9 11 10 9

Performance Subtests D igit Sym bol P icture C o m pletion Block D esign P ictu re A rra n g e m e n t O bject A ssem bly P erfo rm an ce Score

6 7 13 9 I1 46

Verbal IQ Perform ance IQ Full Scale IQ

96 96 95

R o rsch a ch Sum m ary

N u m b e r o f R esponses R ejections P o p u la rs O rig in als A verage R /T ch ro m atic A verage R /T ach ro m atic F% ¥+% A% H% W :M M :S um C m :c V III-X % FK + F + Fc% (H + A ):(H d :A d )

18 0 6 1 35" 20" 39 56 28 44 4:5 5:2 1:3 33 39 10:3

126

/

Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o r sc h a c h S um m ary

Apperception

W D d D d+S

28% 44% 28% 0%

Schizophrenias I 127

EXHIBIT

3

Ro rschach Sum m ary

Response

Inquiry

1. H m m . . . I don't know. All I can see is it’s the com ing together o f a mass.

1. (Coming together?) At first I d idn’t know w hat to think o f it, b ut then I saw it as m ountains. (Mountains'?) A h, ju s t this, I ju s t came from a rt therapy and I was d oing some painting, and th a t’s generally how I paint. (Mountains?) It was a quick glance and 1 h a p ­ pened to notice it. (Coming together?) (P) Ah, it's a com ­ ing together o f a . . . well, the line was significant, I guess, thinking about it. Kind o f like a center point.

DmF-Ldsc Fab.comb.

2. With two hands stretching out. T h e lines are signifi­ cant, b u t it doesn’t really relate to, ah . . .

2. (Hands?) Yeah. (Stretching out?) U h-huh.

dM H d

3. Probably be a woman. That's all I can see.

3. (Woman?) Ah, ju s t from the, ah, the lower point, the lower h alf looked like the lower p a rt o f a woman. But past th at point, I really couldn’t see th at well. (How remind?) Ah, ah, ju s t because it looked like it was a dress on her. T h e, ah, the outer, call it the outskirts (L). Womb o f the woman. (Certain?) By her navel, can’t fully read this.

DFHP Peculiar verbalization

Scoring

I.

128 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P lanning

R orschach Sum m ary

Response

Inquiry

Scoring

1. Ah . . . two Japanese ladies, in kimonos, with their heads down . . . ah, with th eir hands together. T h a t’s basically it. Probably be, 1 don’t know, some sort of ritual if I’m not m is­ taken. Yeah. T h a t should be it.

1. 1.{Japanese}) T h e kimonos and the h air and the colors. (Kimonus?) Just the colors com ing thro u g h . (Ritual}) Ah, ju s t cause, you know, it was, ah, ju s t because o f th eir stance.

W M -FCHP

2. You could call it a joyf ul, no, I don’t know, I d m ake it out as a bird. W here the hands come together, there’s a bird. T h a t’s all.

2. 1.{Bird}) T h e bird because o f the beak. A nd because it was spread out like a plane but more in the shape o f a bird.

d(S)F-A

1. (Smiles) I don’t know . . . the m ore I look at it . . . an inform al setting for a head. Because, ah, it shows a lot o f distinct qualities o f p eo ­ ple. I don’t know, it’s ju st . . . there are a lot o f heads in

1. (Heads')) Yeah. Ah. just from th e distractive points. (Distractive points}) T h a t’s ju s t from a line and how a jag g ed line forms a head. Kind o f cartoonist (Else}) N othing so distinctive. Except for the colors. They cam e together again. T he same inform ality as the one before, ju s t as distinctive.

D(S)F-Hd Peculiar verbalization

2. It comes together with a bowtie and the distinction is th at there is no head for the bowtie. I couldn’t really get any m ore thoughts out o f it.

2. (Bowtie}) Yeah. A nd it’s kind o f left alone. (Left alone}) An, ju s t cause it, I couldn’t relate a head to it. Kind o f C onfounding a fearful thought th at there’s supposed to be a head there and there’s no head there (L). (Boivtie}) Ah, ah, ju s t it’s distinctions. It ju s t came tog eth er to me to look like a bowtie.

DF C lothing Aut. Log.

II. 7"

III. 45"

Schizophrenias / 129

R orschach S um mary

Response

Inquiry

1. A giant m andrill. (Smiles) With two big feet. Ah, that's all I can get o ut o f it really. T aking big footsteps, though.

1. (Mandrill}) Yeah. (What is}) O ne o f those . . . it’s an ape in South America. Color­ ful, too. T hey’ve got color­ ful noses b u t black. (Remind you}) Ah, ju s t the . . . 1 saw a face. I like to see faces in pictures. I seen the face in it. Just from the top o f my head, it came to me. A nd being o f a massive size. Seems like it takes up the whole picture.

W M -FC'A

1. (Men}) Ju st cause, ah, the hair. Ju st because o f the big shape o f them . They look ra th er bold with their shape. Ah, playing a m an­ dolin. (P) C ould have been a flute, though. (Mando­ lin}) Ah, well, actually I thought it was a flute at first but then it came to me to be a m andolin. It seem ed rath er pleasant to me. T h e flute rem inded me o f a picture my m other painted. A h, th a t’s all I could get out o f it except for the butterfly.

de(S)M H,O bj.

Scoring

IV. 10"

V. 43" (Shakes head, looks puzzled) 1. Ah, two m en playing a m andolin. A h, side by side.

130 1 Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

2. With a butterfly essentially in the background. T h a t’s it.

2. (Butterfly?) Well, actually I thought o f it as a moth at first because it was gray, but ah, ah, it ju st, you know . . . (Else?) Yeah. (What}) Nothing else really. T he picture’s not too significant really. Didn’t stand out too well.

WFAP

1. (Lagoon}) Ah, just, ah, a water-type setting. (Water}) Ah, ah, how did I think reflected? (Explain}) I seen a picture before that rem inded me o f it. (Set­ tings}) Just cause of, ah, the black outline o f the whole thing. (P) Uhm, ju st, ah, if I could point it out it would be more distinct. I see two islands coming together and I guess it m ade me think o f where I used to live, in the C hannel Islands there.

DcF.C'F-Ldsc Peculiar verbalization

VI. 10" Can I turn it any way I like? (Okay) (PP) 1. It’s more like a lagoon-type picture. And it comes across as two island settings coming together at one point where the sun should be. But it isn’t. Kind o f a reflective type work. I don’t know. It ju st hit me to tu rn it to the side, you know.

Schizophrenias / 131

R o rschach Sum m ary

Response

Inquiry

1. Two women with their bel­ lies coming together. (Bel­ lies coming together?) Yeah. Actually they should be pregnant. (P) Ah, th at’s all I can think o f it.

1. (Women?) Ah, ah, just, ah, the out-stretch (sic) o f their whole bodyies. Ah . . . (L) . . . ah, it ju st looks like their whole bodies coming together at the bottom. Like a slouch cause the bodies were kind o f thin and then fat at the bellies. (Pregnant}) Just cause, ah, ah, ju st cause o f their bel­ lies in p art and their stom­ achs coming together.

W MHP Aut. log.

1. It’s a lion stepping across a ah, stone path, I guess. (P) Ah, kind o f in a continental way, it signifies a ferocious beast all over the continent. Cause o f the colors. Kind o f like an atlas-type stuff.

I. (Lion}) Ah, ju st kind o f m ade me think o f a m oun­ tain lion on top o f a boulder.

WFMAP Contam

2. A path here.

2. (Path}) Like a path because o f the shadow on its foot. Yeah. (More}) Ah, just kind o f a, looked like it was on the ru n , with a lope. With spots below its foot.

DFc-Geo

I. (Ixigoon}) Ah, ju st the colors, you know. I couldn’t think o f anything length­ wise or edgewise.

dr(S)CF-geo.

Scoring

VII. 23"

VIII. 50" T here I go turnin g it again.

IX. 48" Try to think o f it this way. Ah, it’s colorful. 1. Ah, this is another like lagoon-type scene. This more than one when I look at it. (P)

13 2 I Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R o rsch a ch Sum mary

Response

Inquiry

2. With a crab com ing out o f it this way.

2. {Crab}) Ah, ah, ju st ’cause it was round and it had feel­ ers. At first 1 was trying to think o f an astrological sign, Cancer.

Scoring DF-A

X. 25" 1. Kind o f a Sgt. Pepperstype scene. But it comes out with, ah, a confrontation o f some sorts. Looks like they’re trying to head off, head off, ah, 1 don’t know.

1. (Sgt. Peppers}) Ah, Sgt. Peppers. Just the colors com ing together. A nd, ah, I don’t know. (L) Maybe a face th at was in the album cover. Oh yeah, 1 was th inking English-type, London bob­ bies. (Bobbies}) Ah, ju st the m oustaches and th eir hats. Kind o f English-style chaps. (Head off}) A h, ah, I guess it ju st cam e together th a t th eir heads were tog eth er and they were looking for som ething tog eth er th a t they were tu rn e d away from.

DW FC-H Confab.

2. T hen in oth er ways 1 can get a w rangler with spurs on, but the two times don’t meet. T h a t’s about it, except I can see the place where they’re protecting kids. I don’t know, it’s kind o f abstract.

2. {Wrangler}) No, not a thing. (Don’t know now}) Ju st an attitude. (Protecting kids)) O h yeah. It was a, ju s t two kids sitting down. Like youngsters. (Kids)) Just th eir restlessness, you know. Just from the projec­ tion point o f view.

SF-Hd Pec. verb. Confab,

Schizophrenias I 133

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 1 2 " I was w ondering if this lesson wasn’t m ade for me. I’d rather be outside playing than playing this violin. I don’t know, I’m ju st bored sick, I have b etter things to do. Mom said I should play it b ut I still ju s t don’t have the e a r for it. (PP) I don’t know. T h a t’s abo u t it. (Come out?) He’s going to think it over. He’s going to look at the violin, th en look at the page, try to figure out the ends o f it. (Ends?) Ends o f it. How to get it over w ith. How to play it, I guess. Looks a little bit d istu rb ed really. 3'. CARD 13MF 12" Just woke u p this m orning, an d perceive m yself to be an early riser. W onder how I slept in my clothes. I know I’m tired but I couldn’t have been that tired. All I h ad was one d rin k . M ust have been 3 AM. T im e to go to work now. M ust leave, b ut should I wake up this lady? O r should I let h er sleep? Well, I’ll take my time. G et my head together. T h a t’s all I can think o f really. 1'55". CARD 6BM 12" Sorry th a t it ever h a p p en e d . You tell me I shouldn’t of, b u t I went ah ead an d d id it. T h a t loan you gave m e was all the money I had. I don’t know, I ’ll get by somehow. H ope you can m ake it your own way. Sorry it ever h a p p en e d , b u t the money I used was my only risk, b u t it was a risk at g ettin g m yself in my own m ode o f living. Now we’re b o th at a loss, aren’t we? (P) C ould have th o u g h t o f m ore to say. (Wait.) (Okay.) T h a t’s all I have in m ind. 2'14". CARD 7BM 20" You know, I can tell you, you’re right, an d I can tell you you’re w rong, and you ju s t sit there. You can look as h a rd as you w ant b u t I know you want the sam e inform ation, no less an d no m ore. (Wait.) You can find your way outd o o rs if you like, b u t rig h t now you’re here in prison. I f you w ant to m ake it on your own, you’ve got to be able to stand up for yourself an d speak the tru th . (Wait.) All I can say is th a t I’m m ad at all o f you. W hy did you pick on me? T h a t’s all. 2'18". CARD 3BM 18" Well, I m ight as well sleep rig h t here. Looks like a cozy place. Too tired to pick u p my keys. (Wait.) Seems like things are going to be different. Ah, m ight as well wake up and get my keys. Ah, not to mention I m ight as well get th a t book I was going to read. I’m too tired for all o f this. Maybe I’ll go back to sleep. 1'57". CARD 4 8" No, don’t leave yet. You’re going to m ake it on your own, b u t ju s t don’t leave me yet. (Wait.) M ight w ant to find your own time,

134 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

T h e m a t ic A p p e r c e p t io n T e s t

m ig h t w ant to d o your ow’n th in g , but you seem ready to go w ithout m e. (Wait.) You’re g o in g to, ah , look for your own way, b u t why w ithout me? W hy can’t I go? I see you’re a n a d v en tu re r at h eart. (Wait.) A h, b u t I guess I ’m g o in g , reg ard less, because I am an a d v en tu rer. T h a t’s all I can th in k of. 2 '.

Schizophrenias / 135

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e st

2. He often wished he could “relate tru e to know ledge.” 5. When she refused him, he “left.” 6. I used to feel I was being held back by “oppression.” 8. Av a child my greatest fear was “crying.” 11. A person who falls in love “knows the m eaning.” 23.

Sometimes he felt that “sex pro h ib ited .”

27.

The cause of his failure was “tension.”

32. Love is “auspiciously intellectual.” 37.

I dislike to “take o rd ers.”

40.

After he made love to her, he “said hello.”

45.

I used to feel “down in the dumps” when “I was tense.”

47. 50.

When I fail, I ’m “awe st ruck (sic).” Mother was “all rig h t w hen 1 know (sic) her.”

51.

After he told them how he felt, he “knew th em .”

52.

Most of all / want “to b e.”

57.

,4 man ivho masturbates “b ette r relate it.”

58.

The trouble with marriage is that “it (sic) not all together.”

61. 65. 69. 79.

Sexual intercourse “relates.” I felt most thwarted when “I ’m spectacled.” / feel guilty about “m yself.” His greatest worry was “him self.”

82. 93.

When I try to get things off my chest, I'm “uneasy.” The worst thing a person can do is “go crazy.”

136 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

DISCUSSION O u r two cases of schizophrenia include Mr. S, a 19-year-old adolescent who lives at hom e with his a u n t an d m other, and Mr. L, a 17-year-old m ale who has been residing writh his siblings. B oth are quite young, about the age o f the first episode o f illness for m ale schizophrenics. Both have a m ix tu re o f the positive sym ptom s o f schizophrenia, such as hallucinations an d d elu ­ sions, an d the negative sym ptom s of schizophrenia, including social w ith­ drawal an d apathy. T hey differ, however, with re g a rd to th e ir subtypes. Mr. S presents with prom inent paranoid sym ptom atology including ideas o f ref­ erence an d delusions o f influence and control. Mr. L, on the o th er han d , m ore closely resem bles the u n d ifferen tiated subtype. He seem s ra th e r d if­ fusely disorganized an d quite autistic in both his th in k in g an d his social interactions. N evertheless, for both these schizophrenic patients, the psy­ chological testing is h elpful in p lan n in g treatm en t interventions, especially aro u n d th re e areas of concern: reality testing, the presence o r absence o f paranoid ideation, and social skills, prem orbid social com petence, and qual­ ity o f interp erso n al relations. T h e testing indicated th a t Mr. S was fu nctioning at an average level o f intellectual ability, b u t with great variability across different cognitive areas. H e retained the capacity for abstraction, while at the sam e tim e his po o r reality-testing ability in terfered with accurate perception o f details in the environm ent. N ot surprisingly, th e test d a ta indicated an extensive im p a ir­ m ent in reality testing at the tim e o f testing. Secondly, consistent with the diagnosis o f p aranoid schizophrenia, he d id manifest paranoid thinking. He not only attended to details in the environ­ m ent in an idiosyncratic way, b u t gave responses th a t suggested th a t he wished to m ask him self and hid e from his interactions w ith others. T h is suggests th at in treatm ent planning one would have to go about developing a th erap eu tic relationship with this m an in an extrem ely cautious, careful, an d m easured way. Finally, treatm en t p lan n in g for schizophrenic patients always dep en d s upon som e assessm ent o f the p atien t’s prem orbid capacity for h u m a n rela­ tions, b o th in term s o f the p otential quality o f the p atien t’s life and the potential for a tru stin g th erap eu tic alliance. H ere, the test d ata are som e­ w hat discouraging and suggest th a t this p atien t’s custom ary capacity for and level o f relating to o th ers is poor. As noted previously, this is suggested by the low Picture A rran g em en t subtest score on the intelligence scale, his bland projective stories, and the absence o f h u m an and movement responses in the projectives. T h u s, treatm en t p lan n in g for this young m an with a chronic condition would em phasize a structured, b u t not intense, treatm ent

Schizophrenias / ¡37 pro gram . 'I'he th erap ist would have to cautiously build a relationship with this suspicious and distant individual, going slowly from casual but regular contact to o th e r m odes o f interacting with him . T he cu rren t thinking about schizophrenia is that it involves a vulnerability to cognitive overload, especially with stimuli o f an intense emotional nature. T his young m an would very likely flee any intense contact an d escape into isolation. It is m ost likely th at, as he had in th e past, he would accomplish this escape th ro u g h illicit d ru g s. T h e issue o f the m anagem ent o f his d ru g abuse is im portant an d any attem pt to keep him out o f acute episodes must involve control o f his substance abuse. Possibly a psychoeducational app ro ach to this issue would be helpful. Like Mr. S, Mr. L is a very d istu rb ed young m an who tends tow ards iso­ lation an d d ru g abuse. Mr. L seem s to have been m ore involved in d ru g abuse th an Mr. S, an d th e referral for psychological testing was focused on the n a tu re o f his cognitive im p airm en t, including the hypothesis th at his d ru g abuse had p erm an en tly com prom ised his cognitive functioning. O nce again, the testing revealed very poor reality testing. Mr. L’s thoughts were characterized by loose and idiosyncratic associations. H elpful for treat­ m ent plan ning, however, was the fact th at the n a tu re o f this cognitive m al­ functioning was more consistent with functional rath er than organic causes. His idiosyncratic productions were filled with m etaphorical an d allegorical m eaning n o t readily u n d erstan d ab le to others, b ut also giving evidence o f vocabulary skills th a t seem ed h ig h er th an his tested IQ. In contrast with Mr. S, fran k p aran o id ideation was absent. However, Mr. L seem s en rag ed at his p arents and o th e r auth o rity figures whom he sees as controlling. Mr. L’s prem orbid social com petence an d the quality o f his in terp erso n al rela­ tionships are im p o rtan t to his treatm en t planning. U nfortunately, the inform ation gathered through his psychological assess­ m ent leaves m any questions unansw ered. At th e tim e o f the testing, he was so overwhelmed by his florid psychotic state th a t his verbal productions were often h ard to interpret. H e does refer to others in his world, a positive sign, b ut testing at a later d a te would probably yield a m ore valid indication in this area o f concern. M anagem ent o f this p atien t’s extensive d ru g abuse would be central in m ain tain in g some h u m a n contact with him .

B. SCHIZOAFFECTIVE BIPOLAR A N D DEPRESSIVE TYPES Schizoaffective d iso rd e r is a d ebated classification th at comes and goes. W hile this classification was not present in D SM -III, it has been articulated with specific criteria in D SM -III-R u n d er the general heading o f Psychotic D isorders Not Elsewhere Classified. T h u s, it is g ro u p ed with b rie f reactive

138 / Psychological Assessment, Psychiatric Diagnosis, and. Treatment Planning psychosis, schizophreniform disorder, induced psychotic disorder, and aty p ­ ical psychosis. A ccording to D SM -III-R , this category is a p p ro p ria te for individuals w ho at one point in tim e have met criteria for both a schizo­ phrenic disorder and a m ood disturbance and at ano th er point in time have m anifested psychotic sym ptom s w ithout m ood sym ptom s. T h e construct and discrim inative validity o f schizoaffective d iso rd e r is only tentative. D S M -III-R notes th at in family studies the d iso rd er b ears a close relation­ ship to schizophrenia. O u r two cases provide a com parison o f a schizoaffective, b ipolar type w ith a schizoaffective, depressed type. In con trast to o th e r cases in this vol­ um e, the testing was called for to help solve a specific diagnostic dilem m a: Was this patient schizophrenic o r affectively d istu rb ed ? In o th e r cases in this volume, we have noted that the DSM criteria were adequately addressed by the clinical interview an d history, an d psychological testing was utilized to address treatm en t plan n in g issues not covered by the diagnosis itself. Given the d isp u ted n a tu re o f schizoaffective disorder, it is interestin g to review the diagnostic criteria to see which ones would lend themselves to assessment by tests. T here m ust be signs o f affective disorder, either a m ajor depression or m ania, in the presence o f schizophrenic sym ptom s. T hese schizophrenic sym ptom s would include psychotic behavior such as d e lu ­ sions, hallucinations, loosening o f associations, o r flat o r in a p p ro p ria te affect. In addition, the criteria note th at schizophrenia itself has been ruled out; th a t is, the affective episodes have not been b rie f in d u ratio n relative to the d u ratio n o f the psychosis. It is this latter d u ratio n criterion th a t c an ­ not be decided by cross-sectional testing. T hus, we are looking for a battery w hich would include signs o f psychosis as in schizophrenia plus prom inent signs o f m ood disturbance.

SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Ms. N, 26 years old, single, R om an Catholic, and o f Italian-A m erican descent, h ad been in the em ergency room o f the local hospital a b o u t one year ago. She h ad been m u g g ed an d badly beaten while o u t late one n ight sixteen m onths ago, and was taken to the hospital with a fra c tu red pelvis and a deep head wound. She rem em bered being “o ut o f her m ind” an d had claim ed at the tim e th a t she was a dog. She was therefore ad m itte d to the hospital for observation an d treated with antipsychotic m edication which she found extrem ely unpleasant. Now h er p aren ts h a d b ro u g h t h er to the hospital again. T h e doctors w anted h er to take the m edication again and to ad m it h erself for a n o th e r perio d o f observation. She fled the em ergency room in a panic an d was

Schizophrenias / 139 escorted back to the hospital by the security guards. With the consent o f her parents, the d o cto r p etitioned for h er to be hospitalized ag ainst her wishes an d she was tra n sfe rred to a nearby hospital th at accepted involun­ tary adm issions. Ms. N was angry a b o u t the hospitalization. For the last few weeks, she had been p rep arin g for h e r m arria g e to an elderly, widowed m an whom she had “d a te d ” o ff and on for the last two years. H er older sister had gotten m arrie d a few m onths earlier and was now ex p ectin g h e r First child. A lthough Ms. N ’s in ten d ed spouse was unaw are o f h er m arria g e plans, she felt com pelled to p u rsu e them nonetheless. She believed she had been im p reg n ated by the Holy S pirit and did not wish to give birth to the child out o f wedlock. O ver the last few weeks, as her parents h ad learn ed o f the plans she was m aking and her reason for them , there had been m any violent arg u m en ts and she h a d b oth verbally and physically abused h er m other. She h ad form ed the opinion th a t h er parents were plotting against h er to stop the m arriage. She accused h er m other and sister o f adultery and attem p ted to exorcise them o f “evil spirits.” H er family h ad seen h er in sim ilar states before. She was always going o ff on the sp u r o f the m om ent in pursuit o f some whim. This time, however, she seem ed m uch more disorganized than usual. In the last week, they had been called by the police on several occasions w hen she h ad been found preaching against the sins o f infidelity at a local shopping mall. Such behav­ ior was clearly out o f c h aracter for Ms. N, whose sexual life could best be characterized as one o f casual promiscuity. She seem ed to need very little sleep and often w andered around the house and the neighborhood at night. At times, her family had found her speech incom prehensible b ut she would refuse to slow down an d explain h er thoughts. Finally, they d ecided to take m atters into th e ir own hands. For years h e r parents h ad been trying to get their d au g h ter to see someone for her problems. She had occasionally com­ plied for b rief periods, b ut these treatm ents had w rought little change. Now that things had gotten worse, they were p rep are d to have h e r hospitalized against h er will, if necessary. W hen seen at the hospital to which she was tran sferred , she was found by the exam in in g psychiatrist to be an attractive, w ell-groom ed, casually dressed w om an who a p p e a re d som ew hat anxious. H er speech was mildly p ressu red , b u t th ro u g h o u t the interview, she rem ained eng ag ed with the psychiatrist and m ad e good eye contact. T h e co ntent o f h e r speech was notable for exam ples o f ideas o f reference. She felt certain th a t m uch o f w hat she heard on the television referred in some way to the sexual infidelity o f h er sister an d m o th er an d th a t she could avoid the im p en d in g p u n ish ­ m ent for h er own sim ilar transgressions by m arry in g a n d giving b irth. She described exam ples o f th o u g h t b roadcasting and som atic delusions, but

H O / Psychological Assessment, Psychiatric Diagnosis, arul Treatment Planning d enied any hallucinations. H er affect was ju d g e d to be in ap p ro p ria te at times. H er intellectual functioning, as ju d g e d from h er fu n d o f know ledge and abstracting abilities, the latter slightly circum stantial, indicated at least average intelligence an d seem ed consistent w ith h er high school education and cred it for some college courses.

D SM -IU -R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV: V:

Schizoaffective disorder, bipolar type None None No a p p a re n t stressor— no recent changes in h e r life Very Poor— m arked im pairm ent in both her social and occu­ pational functioning

Treatment and H ospital Course Ms. N was initially resistant to the idea o f m edication. She com plied with the treatm en t only after h e a rin g o f h er parents’ wishes th a t she comply a n d learn in g th a t the hospital sta ff had d eem ed h e r a risk to herself and would proceed to treat h er against her will if necessary She was treated with increasing doses o f a potent neuroleptic, b ut showed lit­ tle im provem ent in h er delusional sym ptom s. She was o ften active in a rath er disorganized way, had great difficulty form ulating plans and suc­ cessfully executing them an d easily becam e fru strated an d an g ry at the sm allest setback. H er em otional irritability an d lability, as well as her rather entitled stance reg ard in g others’ rights, seem ed consistent with a manic com ponent to h er illness. Consequently, d u rin g the second m onth o f h er hospitalization, the hospital staff considered a d d in g lithium to h er m edication regim en. W hile the diagnosis o f schizoaffective d iso rd er seem ed to sum m arize her com bined sym ptom s o f cognitive and emotional disorganization and instability, the hospital sta ff continued to be divided over th e issue o f w'hether this was an exclusively affective illness, p e rh a p s an atypical bipolar disorder, or an u n a d u lte ra te d schizophrenic disorder. In an effort to seek clarification o f this differential, she was referred for psy­ chological testing.

Schizophrenias / 141

Psychological Assessment Ms. N was seen by the exam in in g psychologist at the start o f h er second m onth in the hospital an d d u rin g the first week o f her lithium treatm ent. She was given som e o f the subtests o f the WAIS-R, the M M PI, Rorschach and SCT, a n d an abbreviated n u m b e r o f TAT cards. D uring the exam ination, she expressed the hope that the exam iner could “p u t in a good w ord” for h e r in o rd e r to sp eed up h er discharge. Despite her wish to m ake a good impression so as to evoke the exam iner’s assistance in sp e ed in g up h er discharge, she was restless to the point o f distraction. She laughed often for inexplicable reasons and often san g to herself betw een tasks. H er WAIS-R perform ance on the subscales adm inistered indicated a p ro ­ rated level o f intellectual functioning in the Average range. However, h er subscale scores ran g ed from Borderline levels to High Average levels o f intel­ lectual functioning. H er unevenness o f functioning seemed likely to extend beyond the WAIS-R tasks at h an d an d was likely to be characteristic o f her behavior in situations o u tside the testing situation. Ms. N ’s efforts to present herself in a positive light (K scale), as well as h er pressured and p e rh a p s erratic behavioral propensities (scales 8, 9 and 4), were also reflected in h e r MMPI profile (K-FL 8 '9 4 7 -6 /J/5 0 :2 ). She acknow ledged h er irritability an d unusual experiences and idiosyncratic th in k in g (scales 9 and 8) while strongly den y in g any significant depressive sym ptom atology (scale 2). H er overall defensiveness (K scale) suggested her efforts to m inim ize these tren d s in h er self-report and deem phasize the am o u n t o f distress she felt. W hen asked to express herself in a less stru ctu re d form at, her idiosyncracies becam e m ore a p p a re n t. For exam ple, her SC T contained a n u m b er o f item s with extrao rd in arily elliptical content. She rep o rted th a t she often wished she could “have seen h im ”; the ideal matt “is one with silver”; the ideal women “are these kind ” ; I used tofeel down in the dumps when “I d id n ’t receive any p ictures”; people seem to think that I “am the p o stm an ”; 1 could lose my temper if "I knew otherw ise”; when I think of marriage “I think o f you.” T h e sense o f these responses is th a t she has som ething personal in m ind that is very poorly conveyed by her choice o f w ords— p erh a p s p u rp o sefu lly so. In any case, there u n doubtedly existed a poorly integrated sense o f self as reflected in such contradictory experiences as h er father always telling her “No,” while her earliest mem ory o f her father “is a good one” and when her father cam e home she “cried first, then laughed.” Likewise, in reference to h er m other, she rep o rted th at h er earliest m em ory o f h er m o th er was “one o f nastiness,” but th at when with her mother, she felt “quite good” and

142 I Psychological Assessment, Psychiatric Diagnosis, arul Treatment Planning w hen h er m o th er cam e hom e, she felt “relieved.” An air o f conflict and, as before, poor integration was also ap p aren t in her sexual impulses. She notes on the SC T th a t she “closes h er e a rs” when sex is discussed while at the sam e tim e describing h er sexual desires as “som ew hat u n ta m e .” O n the R orschach, she stru g g led to in teg rate contradictory associations which a p p e a re d in th e context o f fluid percepts. For exam ple, h er first response to card II involved “two little p antom im e p eople” who, because o f costum es which hide th eir h u m a n shape, m ight be people p an to m im in g seals or, alternatively, they m ig h t be seals dressed up as people. O n card III, the looseness o f h er thinking, here m anifest as a fluidity o f perception, p er­ haps provides a clue to her vacillation and uncertainty. T h e percept o f “pyg­ mies in A frica . . . playing congos” is partially ju stifie d , and to her su p p o rted , by a later perception o f the congos as “flarin g nostrils . . . like som eone’s nose, m aybe th e nose o f one o f the A frican people.” As was h er languag e on the SCT, h e r language on the R orschach was m arked by a n u m b e r o f peculiarities. O n card I, she re ferred to “outside form s”; on card II she spoke o f the “positiveness an d negativeness o f the d raw ing” to ju stify h e r perception o f “a cat’s face” and later referred to “a certain m easure w ithin th e crab ” to indicate a vagina percept. A dditional exam ples included card V w here she rep o rte d “two people leaning against each other very extremely,” and on inquiry, “doing one particular act known as leaning” and, with considerable projection, describes the people as “underg ro u n d type o f people,” m eaning, she explained, detectives o r crim ­ inals o r “quiet people like nuns that slightly smell o f secrecy”; card VI where the p uppy d o g “was very o u treach ed ” ; card VIII w here she finds “two eyes th a t looked like sunglasses”; card IX w here a “space” becomes a “space-age movie” because “both sides o f th at, o r p a rt, were like retaliating, m aking way for w hat was going to come betw een those two sides.” T his sort o f elliptical an d symbolic speech, often carry in g a w eight o f m eaning that is ju s t out o f reach o f ordinary com prehension, illustrates the fragm entation o f experience on which her delusional ideation m ight be said to rest. However, am idst this f ragm entation, she could occasionally step back from the ongoing experience o f fluidity an d disintegration to acknowledge the unusualness o f w hat she saw: for exam ple, com m ents such as “wordy, very w ordy” (card /), o r references to h er skills as an a rtist th a t help ed h er to see things in certain ways (card VI). Feeling as flimsy and vulnerable to destruction as the “tissue p a p e r” she saw on several R orschach card s, she vacillated betw een intellectual distancing reflected in h er “geom etric shapes” and espousing an innocent, childlike p o stu re like the “angels” she saw on the first card o f th e Rorschach a n d children playing at a b irthday p arty on the last card. In h er TAT stories, Ms. N carries over the sam e air o f u n usual novelty

Schizophrenias I 143 and w onderm ent that was evident on her Rorschach. She told a story to card 13 o f a m an who “ju s t h ad an encounter with a space c re a tu re ” who is u nab le to decide w heth er o r n ot to a tte m p t to pro fit from “som ething very special” th a t was “revealed to h im .” H ere, as on the Rorschach, a certain am ount o f idiosyncratic thinking and elliptical thought perm eated her rec­ o rd . H er last story is told to card 4 an d in it, a wom an is a b o u t to take her “big chance” to show the m an th at she loves him only to conclude th a t “he will give h er the tim e o f day.” Som ew hat m ore usual b u t slightly offbeat stories also a p p e a re d . Card 3GF pro m p ted a story o f a woman whose h u s­ band died when she thought hed get better and card 13MF revolved around a rap e an d subsequent apology because “he realized th e m ean in g o f w hat he d id .” In the exam ining psychologist’s report, Ms. N ’s emotional lability, extrem e counterdepressive tendencies, grandiosity, an d sexual preoccupation were considered indicative o f a m anic state. W hen these features were taken in conjunction with the severity o f h er disorganized thinking and im pairm ents in reality testing, the test evidence was rep o rted as su p p o rtin g a diagnosis o f schizoaffective disorder, b ipolar type.

Treatment P lanning and Outcom e Partly as a result o f the psychological consultation, Ms. N ’s pharm acolog­ ical regim en was revised to include augm entation o f h e r lithium treatm en t and her neuroleptic treatm ent was gradually reduced over the next month. H er clinical condition h ad noticeably im proved by the en d o f the m onth. A lthough h er m ood rem ained somewhat labile, her delusional thinking had resolved and she was actively participating in several hospital activities. Her free tim e was prim arily occupied with read in g , which she enjoyed and seem ed able to concentrate on for progressively longer periods. She cam e to see her delusional experiences as expressing h e r wish to “settle dow n” an d lead h er own life. D u rin g h er psychosis, this h ad m eant becom ing a wife an d a m other an d h e r attem p t to achieve these goals th ro u g h an im m aculate conception ap p aren tly had been a way o f p u ttin g h er life on a new footing u n m a rre d by the sexual excesses o f h e r past. As she slowly recovered from h er psychosis, she was able to en gage in m ore ap p ro p riate efforts to establish h e r own, indep en d en t life. To help her consolidate h er recovery, she was tran sferred to an in term e­ diate care unit and, as h e r condition im proved, she was enrolled in the hos­ p ital’s vocational services pro g ram w here she could receive train in g consistent with h er goal o f p u rsu in g part-tim e clerical work upon discharge. As h er condition fu rth e r im proved, she stru g g led to com e to g rip s w ith the

144 / Psychological Assessment, Psychiatric Diagnosis, ami Treatment Planning discrepancy between her parents’ high expectations o f her and her siblings’ achievem ents an d h er own dif ficulties an d m ore realistic aspirations. For a time, she considered living in a stru c tu re d residential setting upon dis­ charge, but her parents’ vehement opposition to having her live “with those people” and h er own wish to re tu rn to live in fam iliar su rro u n d in g s ulti­ m ately d ecided the m atter. A t the tim e o f h er discharge, 5 ‘/2 m onths after h er adm ission, she h a d been accepted into a day hospital treatm en t p ro ­ g ram w here she could continue with h er vocational training. She re tu rn e d to live at hom e an d was involved in both individual an d family p sychother­ apy with h er hospital psychiatrist and social worker. O ver the next several m onths, Ms. N continued to slowly improve. She com pleted the train in g pro g ram at th e day hospital an d succeeded in acquiring part-tim e work as a typist. H er neuroleptic medication was finally discontinued. She continued to take lithium which she found helpful in con­ tain in g h er m ood swings. At one-year followup, th ere had been no rec u r­ rence o f h er psychosis an d she rep o rted that she was m aking steady progress for the first tim e in h er life. H er parents were also pleased with h e r progress and in add itio n , h ad becom e increasingly realistic re g a rd in g h er abilities an d difficulties.

Schizophrenias / 145

E X H I B I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

i. Symptoms/Diagnosis Schizoaffective disorder, bipolar type A. Schizophrenia — grandiose, reli­ gious delusions

Believes she has been im pregnated by the Holy Spirit

Poor reality appreciation and peculiar and fluid ideation

Mania— euphoria and irritability and:

Easily angered; has been assaultive

None

— restlessness

Unable to sit still

Restless

— pressured speech

Pressured speech

Pressured speech and verbosity

— grandiosity

Delusional impregnation

Idiosyncratic associations often having hidden meanings

— decreased sleep

Needs little sleep

None

Maintains capacity and desire for relationships

Enjoys and seeks out others

Average intelligence

Average resources but present use is ineffi­ cient and compromised by affective instability

Conflicted relationship with parents

Identity conflicts involv­ ing self and parental expectations. Vacillates between intellectual distancing and child­ like compliance.

II. Personality Factors III. Cognitive Abilities

IV Psychodynamics

Conflicts over sexuality as a means o f expressing and achieving closeness and immoral behavior which invokes punishm ent V. T herapeutic E nabling Factiors

None

Capacity for some self-reflection

1 4 6 / Psychological Assessment, Psychiatric Diagnosis, an d Treatment P lanning

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

VI. Environm ental D em and and Social A djustm ent

Extensive history of poor social adjustm ent

Cooperativeness com pro­ m ised by suspicious­ ness an d rebelliousness

Seldom accom m odates to im posed constraints

Dif ficulty accepting limits

Schizophrenias I 147 E X H I B I T

2

WAIS-R S u m m a r y Verbal Subtests Inform ation C om prehension A rithm etic Sim ilarities Digit Span

Scaled Score 9 11

7 11 12

Performance Subtests Digit Symbol Picture C om pletion Verbal IQ Performance IQ (est.) Full Scale IQ (est.)

7 6 101

76 87

MMPI S u m m a r y K-FL7 8 '9 4 7 -6 /3 150:2 R o rsc h a ch S um mary

N u m b er o f Responses Rejections Populars O riginals F% F+% A% H%

O bj% W :M M :Sum C m :c V III-X % FK + F + Fc% (H + A ):(H d + Ad)

48(-5) 0 10

0 44 88 31 31 25 16:9 9:8 5:8 38

50 2 2 :8

148 I Psychological Assessment, Psychiatric Diagnosis, arul Treatment Planning R o rsch a ch Sum m ary

Apperception

W I)

d Dd+S

33% 54%

6% 6%

Schizophrenias / 1 4 9

EXHIBIT

3

R orschach Sum m ary

Response

Iiujuiry

Scoring

1. I see two outside forms. Two little angels and they’re both kind o f m eeting each o th e r— like this o r holding onto each o th e r’s hands and they’ve got their knees— the th in g in the m iddle— I really don’t see— th eir feet are on a ru n g o r som ething. Do you know w hat I m ean?

1. T h eir wings prim arily and, uh, their profile and they facilitate considering them angels for some reason. (Facilitate angels}) I think it’s the fact th a t their wings are so— th eir wings are the main thing, and that makes them look like angels. If they weren't in profile they probably wouldn’t look like angels.

W M(H)

2. It almost looks like a pelvis— you know like one huge pelvis o f a woman and instead o f these angels as the outline o f a h u m an being. Wordy, very wordy.

2. Just looking at the whole o f it— the o u ter most p arts— their shape. (Huge}) Did I say that? O h not huge what I m eant was contrary to seeing two little angels— the entire draw ing looked like it was som ething.

WFAt

3. A nd the center— it looks like a woman w earing— som ething like from an 18th century gown with a very tight waist and she’s raised both hands up and she’s missing a head.

3. T he pinched in waist or how could I p ut that? T he waistline looking like a cor­ set and uh how can I say the rest o f her outfit also— like w hat’s above and below the corset also. (Head}) All there was— was no collar but no head above the col­ lar, however, there were two hands stretching up above the shoulder.

DMH

I.

1.50 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Plan ning

R o rschach Sum m ary

Response

Inquiry

1. I see like two little p an to ­ mim e people. A nd they’re both going like this— they’re touching th eir left or right hands tog eth er as they do a dance and they’re w earing grey outfits, grey gowns and they’ve got two red hats on— like two little seals doing a dance.

1. They kind o f look like seals too because the way th eir heads are bent over— the way seals tend to look— look like dressed up seals. (Do you see them as seals or people?) I would say dressed u p seals really. Both o f them equally. Feel strongly for both cases cause people doing pantom im e— they can look so differen t any­ way. Sometimes pantom im e people do seem d ifferen t— like they're different spe­ cies o f some sort. (Dressed up seals'?) It has to do with their po stu re such as in the neck region they’re kind o f bending forward and also the way the entire body is po stu red — it makes them look like seals th at have clothes on and if not seals— they look like two hu m an beings im itating som ething like a seal.

2. I see a cat’s face in the u p p e r p a rt o f this blotch. How can I refer to this? Blotch or blot. (Either)

2. Well the u p p e r p a rt o f the design has two white parts and the whiteness and the curvature o f line make it look like a cat’s face. It has to do with the positiveness and the negativeness o f the draw ing and not ju st the ink. P art o f a picture can be the white spaces that you find in the draw ing.

Scoring

II. W FM -FC'FC(A), C lothing

S(D)FAd

Schizophrenias I 151

R o rsch a ch Sum m ary

Response 3. I see a butterfly in the bot­ tom p a rt o f this and some kind o f

Inquiry I'he wings.

Scoring DFAP

4. seashore or like a crab or som ething— o r some sea­ shore anim al besides a crab.

4. In that case— in the case o f the crab— whatever was draw n in — yeah w hatever was wherever the ink showed u p — th at was d efi­ nitely considered p a rt o f the draw ing b ut if you want to know specifically I saw two feelers com ing o ut and I came to the conclusion th at it looked like a crab because ju d g in g from the shape that the ink p ro ­ duced this was not a case o f positive and negative like with the cat so it was his feelers and his shell which the ink showed for me and th at’s about it. His back shell o r his vertebra or som ething.

DFA

5. Vagina down here in the lower p a rt o f this design— elem ents o f— not the whole thing b ut parts of, innerm ost.

5. (Parts of vagina?) (Pi. laughs) T h ere was a certain m easure within the crab, it would have been let's say the spine o f the crab and that resem bled to me the p art o f the female known as the vagina, ju s t the innerm ost p art, like some­ th in g from an anatom y book.

ddF-Sex,At. Peculiar verbalization

1.52 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R orsch a ch S um mary

Response

Inquiry

1. T hese look like two pyg­ mies in Africa. A nd they’re playing congos, got their re a r sticking up in the air and they’re bending down low to play their congo drum s.

1. I’ll say A fricans— it's more general— I’m not sure if pygmies could be A fricans— too primitive people— could you say that? (Primitive?) T he way the head was shaped, their postures and the fact that they had congo d ru m s with them — the shape o f the head was definitely what m ade me m ake up my m ind cause it’s different from w hat people’s heads are shaped like.

W M H ,obj.,P

2. Butterfly.

2. T he shape and the red color.

DFCAP

3. Looks like rose colored paper. T h e kind they make p a p e r flowers out o f— so th a t’s the butterfly — it’s both th a t and p a p e r flower m aterial and two red blotches on the side look like, well one o f them .

3. Ju st the light— the tra n s­ parency o f it o r the light­ ness o f color, ju s t looked both like a tissue in a way— light and fluffy, like a tis­ sue. T h a t is tissue p ap er th at they use by the way, only it’s colored.

DFC-cF Obj.

4. Looks like a musical note or suggestion o f a musical note.

4. T he stain and this roundish p a rt here look like a note.

DF Obj.

5. Also their congo d ru m s look like someone’s flaring nostrils. Seen as a whole looks like someone’s nose. Maybe the nose o f one o f the A frican people. They definitely look A frican— I m ean it’s am azing.

5. Maybe th e kind o f nose th at is indicative o f the race o f the people. (What about the blot made it look that way?) T h e blackness o f the ink in two circular shaped forms.

DFC-Hd

Scoring

III.

Schizophrenias / 153

R orschach Sum m ary

Scoring

Response

Inquiry

6. T he red butterfly in the center could also be a red bowtie.

6. T he shape is the sam e as a bow tie.

DFC C loth P

1. Look like two heels— two boots with, uh, heel touch­ ing the floor and the toe up in the a ir— toes, toe p a rt u p in the air.

1. I'he heel section and the toe section. T h e way the heel section p a rt seem ed to be d u g into the g ro u n d and the rest was up in the a ir— it looked like a kick or som ething.

DM H d, Cloth P

2. Also see the letter M in here. A nd

2. It has the “M” shape.

DF Obj

3. I also see a giant person who’s looking down from u p w here he is.

3. T h e fact th at u h the fact th at like w hen you look at him his head is so far away from w here you are and you would be closest to his shoes an d the rest o f him seem ed so far away. His lower p a rt such as his boots were larger in com parison to his head.

W M (H)P

154 / Psychological Assessment, Psychiatric Diagnosis, an d Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

Phew! Again I see two people and they’re kind o f two people leaning against each o th er very extrem ely— 1 m ean the only thin g touching on them are the shoulders and the head area.

1. W hat m ade it look like two people leaning— I don’t know how to explain it. It ju s t did, th e bodies look like two hu m an s and the bodies were do in g one p a r­ ticular act known as lean­ ing. (What sort of people?) Each was w earing a black cape or some kind o f black outfit in the form o f a cape and they may have been like u n d erg ro u n d type o f people, like detectives, crim inals o r ju s t quiet p eo ­ ple like nuns th at slightly smells o f secrecy o r any­ th in g like th at (patient laughs) some kind o f secrecy, doesn’t m atter who, som ething unspoken.

W M -FC'H Peculiar verbalization

J see an insect— some kind o f a fly with big wings and I see two little antennae and two little feet on this fly. Do you have any idea when I m ight be discharged?

2. Well the wings looked like wings an d , uh , anytim e th ere are two short lines ju ttin g out from som ething I always o r very often tend to view them as anten n ae o r little legs. T h e antennae o r th at p a rt is a big thing in d eterm in in g w hether it’s an insect o r not.

WFAP

Schizophrenias / 155

R orschach Sum m ary

Response

Inquiry

Scoring

1. First th in g I saw was uh violin. Next th in g I see is

1. Um, the long neck, the upright position o f it. It ju s t looked very u pright and prim and p ro p er with the long neck and I associ­ ate prim and p ro p er with violins. I m ean I associate violins with those characteristics.

WFObj.

2. a puppy dog with his m outh all the way up. He could be looking u p to his m aster or calling out.

2. (Looking up or calling out?) T he only time a puppy dog is going to p u t his head up like th at is w hen he’s look­ ing at som eone a lot taller when he’s sitting o r if he’s crying for some reason. Fie was very outreached. It was a position o f outreach. His m outh really comes before any p art, before the eyes too. (Puppy dog?) I’ve seen oth er puppy dogs th at look like th a t picture before. I’ve seen th a t before and also the uh the hairs, the fu r com ing out from the jaw area. You know d o g fur.

DFM-FcA

1 see two profiles o f the h u m an h ead — two profiles— one on each side, o f a h u m an being with a long nose by the way.

3. Well the nose was very outstanding. I don’t know, could I look at it again? I was ju s t going, I was ju s t generalizing from the o u t­ line o f the forehead I noticed eyes, pronounced nose and probably chin th a t’s w hat m ade it look like a profile.

DFHd

VI.

156 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R orschach Sum mary

Response

Inquiry

Scoring

4. I see a highway with a line in the m iddle to show separation.

4. Oh I saw two parallel lines— two dark parallel lines with uh littler, very thin line in the center and I thought o f some kind o f highway as seen from an aerial view or photo. It’s really two dark lines with the line in the center repre­ senting the dividing line— you know whatever they call that thing—

diFkRoad

I see the soles o f two feet and the calves o f those feet, o f the person. And what else do I see?

5. (Patient grimices) It was the shading o f the feet, cause as an artist I know that there are certain parts o f the feet that are lighter than others and I know that heels are lighter so I thought o f heels.

dFcH d

6. I see a geometric shape. I don’t know if you’d call it an octagon or what. It’s the one with ten sides, not an octagon. It’s the next one up.

6. Well I saw, I don’t know how to answer this I saw many different sides, the sides you would see if look­ ing at a hexagon let’s say or octagon— they were symmetrically assem­ bled to look like one large geometric shape. Don’t even have to say large, not necessarily large, one whole geometric shape.

WFObj

1. (Patient laughs) T he shape.

SFObj.

VII. I. Well 1 see uh vase with the front line across is missing. Like a vase with artistically (patient sighs) a horizontal line missing.

Schizophrenias / 157

R o rschach Sum m ary

Response

Inquiry

Scoring

2. I also see two women facing each other. I see two women doing some kind o f a dance o r in some kind o f a funny pose.

2. T h eir profiles. (Dancing?) Position o f th eir arm s (patient laughs)

WMHP

3. And I think o f a seashore anim al also but I can’t think o f w hat I ’m looking at, lobster o r som ething. Also I see som ething stick­ ing out o f these women’s head like feather com ing out o f the hat or som ething.

3. Som ething in the jagged edges o f it th at rem inded me o f that.

WFA

4. Rear end sticking up in the air like the m oon— m oonies— and with the rectum showing also.

4. (Patient laughs). Well, there are two very ro und surfaces you m ight say th at m ade me think o f a rear end. Also, the rectum seem ed to be like a black hole. T here was like a black hole in the m iddle of, in the m iddle, a slit.

D FC '-H d

5. Also, I see two clown’s faces.

5. T h e big noses, I think.

DFHd

1. two polar bears o r w hat do you call th at group o f ani­ mals th at includes rats and mice, (Rodents?) Two rodents, yeah.

1. They had the pelt and the shape o f polar bears. (Pelt?) (Patient sighs) O h the little (patient sighs) lines (patient laughs).

DFMAP

2. I see a geographical m ap an d I see those rodents try ­ ing to clim b some kind o f stru ctu re. (Patient sighs)

2. T he color green. It looked like a geographical map.

DC/FAP

VIII. O h G od. Well here I see

15 8 / Psychological Assessment, Psychiatric Diagnosis, atul Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

3. I see lhat colored tissue p a p er th at is used to make flowers and these anim als have one leg up and an o th er one stuck to some kind o f substance. (Patient laughs) T his could go on and on.

3. T he color o f the p rin t— colors, nam ely pink and orange. (Stuck}) O ne o f th eir legs was not with the o th e r leg— it was left b ehind in some kind o f trap.

WcF.CF Obj,A

4. 1 also see an o th er face here. All right I think we have enough. It's very dec­ orative. T h e whole thing that doesn’t count as a statem ent does it? (Patient begins singing to herself)

4. T here was a goatee and there were the two eyes that looked like sunglasses. Made good eyes and then I ju st filled in the rest. It was mainly the goatee and the eyes that m ade the face. (Coatee}) T h e way it h u n g down in the front.

D FHd

1. Looks like a space, rem inds me o f a space, rem inds me o f a space age movie like a new movie o f some sort, oh dear, let's see.

1. T h e fact th at both sides o f th at o r p a rt were like retal­ iating m aking way for w hat was going to come between those two sides, ju s t looked like a big bubble com ing in the m iddle o f those two sides. Ju st looked like they were being taken aback by som ething th a t was h appening.

W mF Movie Confab

2. I see two ice cream cones.

2. T h e shape o f ju st, the round shape and the point of, the point o f trian g u lar shape together.

d F Food

IX. O h brother.

Schizophrenias / 1 5 9

R o rschach Sum m ary

Response

Inquiry

Scoring

I see two beings trying to m ake contact with u h each o th er with their arm s.

1 see little not necessarily people. 1 m ean you could see— it’s like living organism s— like fauna b ut from the movie aspect it didn’t have to be fauna, could be ju s t shapes th at are moving aro u n d and you get a new shape from them .

W Fm(A) Confab

4. Um w hat do you call those little lanterns that you have to p u t oil in to get them going. Not oil lanterns but som ething like that. Well, I see som ething in here th at rem inds me o f one o f those lam ps that we have, a little oil lantern.

T he filter or flint, the wick m ade it, there was a p art, there was a line in the cen­ ter o f the lan tern which represents the wick.

I)F Obj

5. I see a salt, a salt or p ep p er little you know, shaker and oh well I can go on and on but I d ra th er not.

5. 'Fhe shape o f the outside o f the salt o r p e p p e r shaker, the shape o f the form th a t I saw.

d F Obj

6. I see two people m eeting and they’re exchanging either a candle o r they’re ju s t m eeting to talk and they’re using a candle to help light th eir way.

6. I ju s t thought that. It was two people since I have it on my m ind to m eet with someone an d talk about im p o rtan t m atters. I tran s­ lated th at to w hat I saw. Just what I had on my m ind I don't know how to put it. Ju st looked like two little stick figures m eeting over an im p o rtan t matter. Either exchanging the can ­ dle o r having it out o f necessity.

DM H,Obj.

16 0 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch S um mary

Response

Inquiry

Scoring

1. M erry-go-round.

1. T here was one o u tstanding shape th at d om inated over the o th e r shapes and it gave m e the im pression o f som ething at a merry-goround, it gave me the im pression o f som ething that would be in a merrygo-round. (Merry-goround?) T h e colors and the shapes.

WCFsym. Obj.

2. I think o f a children’s b irth ­ day party. (Patient latigks) I think o f children playing m erry-go-round with th eir hands, they play merry-gorou n d with their hands, don’t they? C hildren in a circle playing pocketful o f posey or w hatever those dances are.

2. O h there was a lot o f it, ju st looked like all the shapes and uh th at would be p art o f an excitem ent th a t would be p art o f children playing those kind o f games.

W M.CFsym., Obj.

3. chickadees. Yellow chicka­ dees and I think o f two

3. They were small and the color in the smallness and the exact color.

DFCA

4. crabs again. I see two

4. Not really ju s t an im pres­ sion, they rem inded me o f crabs b u t you w anna know why? T hey’re ju s t scattered and disorganized looking. (patient laughs)

DFAP

5. (lowers. I think o f the

5. They literally looked like two yellow little roses.

DFCP1

X. O h boy I think of, uh

Schizophrenias / 161

R orschach Sum m ary

Response

Inquiry

6. Eiffel Tower and w hat else.

6. It’s pointedness and the grey color. By point I m ean, literally headed toward the sky. O h by the way I think also th a t it was the first thing on th e top o f the page. If it was found anyw here else it wouldn’t have been.

DFC A rch, Autislic Logic

7. Two little worms like for bait, w hat do you call those?

7. They look like worms.

DFA

8. Seahorses like you find them on the beach. Yeah I see two seahorses here. They’re teeny really small, OK th a t’s it. Want m e to show you everything. This is a bright round.

They definitely looked like seahorses. T h e shape and the size.

Scoring

DFA

162 ! Psychological Assessment, Psychiatric Diagnosis, ami Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 3G F H er n am e is M she’s very upset because she ju s t found o u t th a t h er husband died. She d id n ’t expect him to. H e was very sick an d she th o ught he’d get b ette r b ut he died. (Laughs). C A R D 4 A aah. Lovers— um , this is her big chance to show him how m uch she loves him but she d id know if she hopes th at he’ll give h er enough tim e and attention to show it cause he’s looking the o th er way. (Feeling}) She’s feel­ in g g reat cause she’s with him (Laughs) (Next}) I th in k they’ll get it to g eth er an d he’ll show her th a t it is w orth the togetherness, he will give h er the tim e o f day. L et’s put it th a t way. See th a t’s a big m om ent for her. C A R D 13M F He ju s t rap ed this woman and I th in k felt sorry for w hat he did (1). It’s a weird th in g cause he realized the m ean in g o f w hat he d id an d he felt very bad. (Next}) Process o f— he’ll apologize to h er b u t he can’t count on w hether o r not he’ll accept the apology, naturally. I m ean really. CA R D 14 H m m m . (Light inflection of tone) He looks like he’s y earning to go outside an d m erge with the rest o f the world b u t he still has to deal with certain problem s in the life th a t he’s leading rig h t now. But he’s p re p arin g to go out and mix with o th e r people. C A R D 15 T h is is spooky. He ju s t had an e n co u n te r o f a space creatu re an d he’s tra p p e d as to w h eth er he’s going to talk abo u t it o r keep it to h im ­ self. (Feeling}) He’s feeling sneaky because he doesn’t know w hether he’s enti­ tled to know w hat he does but somehow som ething very special was revealed to him and he doesn’t know w hether he could profit from letting o th er peo­ ple know it so he kind a feels tra p p e d . (Do}) I t’s not for m e to know o r say w hat he’ll do.

Schizophrenias I ¡63

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e st

2.

She often wished she could “have seen h im .”

9.

M y father always “u sed to tell me n o .”

10.

The ideal man is “one w ith silver.”

20.

Her earliest memory of her mother “was one o f nastiness.”

21.

The ideal women “a re th ese k in d .”

28.

When they talked about sex, I “closed my e a rs.”

33.

My earliest memory of my father is “a g o o d o n e .”

45.

/ used to feel 'down in the dumps' when “ 1 d id n ’t receive an y p ictu res.”

49.

People seem to think that 1 “am th e post m a n .”

53.

My sexual desires are “som ew hat u n ta m e .”

70.

When my father came home, I “cried first, th en la u g h e d .”

76.

When my mother came home, I “felt relieved.”

86.

/ could lose my temper “if I knew o th erw ise.”

92.

When I think of marriage I “th in k o f you.”

94.

When with her mother, she “felt q u ite g o o d .”

164 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE Ms. R, a 22-year-old, single, Irish Catholic woman, ag reed to h e r th ird psy­ chiatric hospitalization in six years after atte m p tin g to throw h erself o ut h er parents’ a p artm e n t window. U ntil th e last m onth, she was d o in g well. H er last hospitalization was over two years ago and there had been no recur­ rence o f her hallucinations, delusions o r paranoid thinking. She had begun takin g courses at a com m unity college an d was d o in g well in h er day hos­ pital treatm en t pro g ram an d volunteer jo b . She was well-liked an d seen as a productive m em ber o f the day hospital com m unity and consistently had been given good reports on h er jo b behavior and perform ance. She had been steadily d a tin g a young m an an d b oth she an d h er parents d escribed this relationship as a “w arm and caring" one. She h ad been d o in g so well th a t th ree m onths prior to h er rehospitalization, she had sto p p ed taking h er medication, with her doctor’s approval, and had accom panied her fam ­ ily overseas to visit relatives, experiencing no difficulty despite the fact that the visit was p ro m p ted by the d eath s o f two relatives. However, on h er re tu rn , Ms. R and h er boyfriend “broke u p ,” m uch to h er fam ily’s surprise. W ithin a few days, she becam e increasingly paran o id an d despondent. She rep o rted feeling th a t people were p lan n in g to h arm h e r in some unspecified way an d also told h er family th at she w anted to die. As she p u t it, “ I’ve been feeling worse. I feel as if I’m so u p set a t hom e all I can th in k about is try in g to take my life. I em b arrass my family and 1 believe I shouldn’t be aro u n d so I w ouldn’t em b arrass them anym ore.” W hen ad m itted to the hospital, Ms. R was described as a neatly dressed, attractive young woman whose m an n er was g u ard ed . H er m ood alternated betw een anger, anxiety, fear, an d sadness. H er anxiety occasionally p ro m p ted in ap p ro p riate, nervous laughter. She ad m itted to auditory hal­ lucinations, b u t would not describe th e ir content. H er speech was at times incoherent and her th in k in g was described as loose an d tangential. She acknow ledged h er suicide a ttem p t, b u t a d d e d th a t “if som eone would help m e and 1 w ouldn’t have to be hom e with my family, I w ouldn’t w ant to kill m yself.” H er concentration, insight, a n d ju d g m e n t were described as p oor an d h er intelligence was estim ated to be in the low average range.

DSM -III-R D iagnosis Axis I : Axis II:

Schizoaffective disorder, depressed type Rule o ut Obsessive Com pulsive d iso rd er D ependent personality d iso rd er

Schizophrenias ¡ 1 6 5 Axis III: Axis IV: Axis V:

None M oderate— death of two distant relatives and recent breakup with boyfriend Fair— A lthough functions well in highly stru c tu re d setting, has been unable to move beyond this setting; has a close rela­ tionship with a boyfriend, b ut otherwise no close relationships except with family

Treatment and Hospital Course U pon her adm ission to the unit, the staff rapidly learned o f Ms. R’s com ­ pulsive handw ashing and showering and much attention had to be devoted to stru c tu rin g her tim e aro u n d h e r visits to the b athroom . She took hourlong showers an d m ad e dozens o f trips to the b ath ro o m to wash her hands if u n atten d ed by the staff. H er past difficulties in tolerating a n u m b er o f neuroleptics and a lack o f previous response to eith er antidepressants, lith­ ium , o r electroconvulsive therapy p e rsu ad ed the staff to rein stitu te her recently discontinued m edication despite past problem s with hypotension when this neuroleptic was initiated. She did develop tran sien t hypotension bu t as she rem ained asym ptom atic, no im m ediate change in h er p h a rm a ­ cological regim en was m ade. H er m ental status, however, showed little ch ange on the m edication. She d id rep o rt feeling “safer” in the hospital and was able to reveal th at h er vis­ ual hallucinations consisted o f seeing “dead bodies.” She acknowledged that she had auditory hallucinations, b ut would not reveal th eir content o th er th an to say th at occasionally she recognized the voice as th a t o f her cousin. H er m ain concerns focused on o th er patients on the un it and her occasional feelings th a t they “d id not like h e r” and p e rh a p s would h u rt her. She could give no reason for these feelings, b ut often looked scared an d anxious. She acknow ledged th a t w ashing h elped h er to feel less anxious. At o th e r times, she presented as inappropriately cheerful and optimistic, but easily shifted over into a m ood o f sadness and feelings o f hopelessness w hen discussing h er present difficulties and fu tu re plans. Shortly after h er adm ission to an acute intake service, Ms. R was tran s­ ferred to a longer-term treatm en t unit for additional treatm en t an d dis­ ch arg e p lanning. T h e treatm en t sta ff there, afte r a b rie f p erio d o f observation, felt that her dram atic fluctuations in mood an d the appearance o f sleep difficulties, decreased appetite, and preoccupations with d eath and feelings o f guilt w arranted consideration o f a schizoaffective diagnosis and requested psychological testing to help in assessing the relationship between h er psychosis and h er affective sym ptom s.

166 / Psychological Assessment, Psychiatric Diagnosis, arul Treatment Planning

Psychological A ssessm ent Ms. R was seen in consultation over a th re e week p erio d d u rin g which she was exam ined by two psychologists using a wide variety o f self-report, interview, clinical psychological and neuropsychological m easures. She received some o f the subtests o f the WAIS-R, the Rorschach, TAT, and SCT, am ong o th e r tests. In ad d itio n to th e results o f the present evaluation, the results o f h er evaluation two years previously d u rin g her second hospital­ ization were available for com parison, as well as stan d ard academic achieve­ m ent m easures an d o th e r school records. She h ad achieved a full scale IQ o f 72 on h er first WAIS-R testing at age 20 d u rin g h er second hospitalization. W ith the exception o f Digit Span, w here she ea rn e d an average score, she achieved scaled scores o f 4-5 on all o th er subscales. O n subsequent retesting d u rin g the present hospitalization at age 22, she received scaled scores o f 7 on th e Information, Arithmetic, an d Similarities subscales an d scaled scores o f 10 an d 4 on th e Digit Span an d Picture Completion subscales, respectively. H er full scale IQ, estim ated from these subtest scores, was 86, placing h e r in the low average ran g e o f intel­ lectual functioning. This estim ate seem ed more consistent with h er prem or­ bid intellectual abilities as estim ated from h er school records an d achievem ent testing a n d suggested th a t at the present tim e h er intellectual efficiency was less profoundly influenced by h e r functional im pairm en t than previously. Nevertheless, she m aintained her earlier p attern o f substan­ tial intratest scatter, suggesting th at her psychological difficulties continued to in terfere with h er intellectual functioning. O n the R orschach, Ms. R o ffered a total o f 18 responses, with consider­ able encouragem ent from the examiner. T h e record was rem arkable for the com plete absence o f whole responses, a feature consistent with h er generally lim ited organizational abilities. H e r m ost consistent ap p ro ach to the blots involved the perceptio n o f some edge o r e x tru d in g detail, giving rise to a ra th e r p o o r response justified on th e basis o f indefinite, m inor features. For exam ple, h er responses to card I are “a fro g ,” seen in the to p p a rt o f the central detail, because o f “the hands, the feet and the shape o f the face” and “an alligator,” seen in the lower portion o f the central detail, suggested prim arily by “the face, the way it cam e out. L ong.” She m an ag e d only two pop u lar responses (card II, the “baby b ears” and card VIII, the “tiger o r cat”) and one very unusual h u m an response (card VII). T h e easily perceived, and popular, h u m an figures on card III were seen by Ms. R as “chim ps,” in part because o f their “brownish” color and th eir “hym en.” Although the inquiry failed to elicit any clear p ercep tu al su p p o rt for the “hy m en ,” she ad h ered to the association and related it to the “backside, back torso, rig h t?.”

Schizophrenias / 167 H er overreliance on anim al detail responses, p o o r (usually vague) form level, n ear total absence of any o th e r d eterm in an ts, a n d idiosyncratic asso­ ciations and logic were consistent with a psychotic process. It was noteworthy t hat although she d id not respond very m uch to color, which taps em otion­ ality, she spontaneously characterized several anim al responses som ewhat inappropriately and incongruously as “b eau tifu l” an d “ad o rab le,” alm ost as if she were endeavoring to w ard o ff dysphoric feelings. Ms. R’s TAT stories were m ost notable for th eir pervasive atm osphere o f sadness an d passive hopefulness. For exam ple, h er first story, told to card /, focuses on the boy “thinking” which is “kind o f h ard on him . He’s feeling sad and d isap p o in ted because he can’t p u t it together.” D espite these tra ­ vails, she ends on a slightly optim istic note by indicating th at “he’s going to try to work on it an d build his confidence an d streng th . He’ll work on trying to rem em ber w hat he has to rem em ber.” These themes recu r on card 2 where, again, everyone is “thinking” an d she hopes for “som ething good” for the two women lost in thought. Acknowledging the same feelings in card 3BM, she concludes the story on a patently d ep en d e n t note: “I hope som e­ one will com e an d com fort her, I hope she gets over it, I hope she’ll be alrig h t.” A lthough she m anages to organize an affective them e for each o f the cards, it is invariably disconsolate. This affect seems immobilizing since no one is described as tak in g steps to alleviate the vague but im p en d in g tragedy. In h er SCT, Ms. R m akes it clear th a t effective action is beyond h e r cap a­ bilities. At bottom , she finds she lacks confidence in herself, a quality she wishes she h ad in g re a te r abundance. As she notes, she often wished she could “gain self confidence” a n d attrib u tes her lack o f success to “h er lack o f confidence in herself.” She feels unable to effectively persist in p ursuing h er goals. She “gives u p ” o r “som etimes sighjs]” if she ru n s into difficulty in g etting w hat she wants. W hile she retains a desire “to succeed,” she feels th at she needs certain things from o thers in o rd e r to do so: “protection” from a lover; good cheer from h er m other; the backing o f those in a u th o r­ ity; an ab u n d an ce o f “help and love,” generally. T hese reactions o f others affirm h er own ef forts and help h er to achieve h er own happiness by m ak ­ ing “o th er people happy.” However, this receptive m ode o f relating to o th ers thw arts h er attem p t to p u rsu e h er own goals. W hen confronted with opposition, she prefers to w'alk away. Yet, she worries abo u t “losing my te m p e r” since she feels guilty about “g ettin g angry.” T h e extent o f h er guilt and concern in this m atter is p e rh a p s best judged by h er com m ents to the ex am in er d u rin g the TAT (card 12M) w here she becam e concerned that the exam iner m ight be either “scared" o f h er o r “an g ry ” at h er since she felt she h ad a reputation am ong the staff a n d o th er patients as being “an angry perso n .”

168 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning I n the report, the exam ining psychologist noted her propensity to be eas­ ily moved by both affect and unrealistic fantasies and th a t in the face o f h er generally poor organizational abilities, a psychotic disorder with signif­ icant affective features was most likely. T h e ex am in er detailed h er desire for warm, supportive relationships and indicated th at this m et her personal needs for direction and appreciation, as well as reflecting som e realistic appreciation o f her lim itations. U nfortunately, her p rim ary m eans o f elic­ iting the su p p o rt she n eed ed req u ired h er to com prom ise h er in g rain ed Catholic morality reg ard in g sex and love. T hus, her active heterosexual life h ad left h er with a b u rd en o f guilt she could not m anage except th ro u g h o u trig h t denial.

Treatment P lanning and Outcom e O n the basis o f these results, Ms. R’s treatm en t team elected to help her p u rsu e h er goal o f sep aratin g from h er family in o rd e r to en courage her efforts to establish an indep en d en t life for herself. H er family, as d id the treatm en t team , h arb o re d some reservations ab o u t her ability to function independently. She and h e r family were p resented with a carefully fo rm u ­ lated discharge plan involving a halfway house placem ent an d productive em ploym ent in a stru c tu re d work setting ap p ro p ria te to h er intellectual abilities. A lthough Ms. R and h er family were easily p ersu ad ed o f the value o f the plan, all agreed th a t add itio n al effo rt would need to be directed at im prov­ ing h er clinical state. In an effo rt to do so, h er m edication was increased. T his ch ange, however, provoked the previously expected clinical problem s with h er hypotension. For the next few weeks, h er treatm en t team attem p ted to find a suitable m edication to little avail. She becam e severely constipated and was repeatedly worked up for various intestinal an d abdom ­ inal pathologies, with no significant findings. She began to feel increasingly hopeless about h er im provem ent and h e r anxiety and h er attem p ts to con­ trol it with h er com pulsive w ashing both increased. Efforts on the p a rt o f the sta ff to restrict h er access to th e bath ro o m led to an g ry outbursts. She tu rn e d to a male patient on the u n it for su p p o rt an d becam e involved in a clandestine sexual relationship which, w hen finally b ro u g h t to light, left h e r feeling betrayed an d guilty enough to m ake a suicide gesture. At this ju n c tu re , she expected the treatm en t team to revise th eir dis­ charge plans, b u t was astonished to learn th a t she had been accepted at both her favored halfway house program and jo b placement. Moreover, she found h er family firm ly resolved to help h er p u rsu e these plans an d to su p p o rt her in do in g so in w hatever way they could. A final ch an g e in h er m edi­

Schizophrenias / 169 cation regim en began to b rin g about a satisfactory resolution o f her psy­ chosis. She was allowed to m ake several visits hom e w here she b egan to feel the pull to retu rn to her dependency on her family, but now witnessed their firm insistence th at she d o things for herself. As her clinical condition continued to im prove, the treatm en t team was able to work with her and her family to delineate appropriate responsibilities and expectations for h er which she seem ed willing an d able to shoulder. Consequently, when it was learned that there would be an unavoidable delay in adm itting her to her halfway house, she and her family were able to work out an interim living a rra n g e m e n t for her so th a t she could e n te r h e r jo b program . A followup contact several weeks after her discharge revealed that this interim arran g e m e n t was working satisfactorily.

1 7 0 I Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

EX HIBI T

1.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

Symptoms/Diagnosis Schizoaffective dis­ order, depressive type Believes other people Schizophrenia— persecutory delu­ wish to harm her; sions with auditory Claims boyfriend & visual raped her; sees dead hallucinations bodies; hears cousins voice Depression— dysphoric mood

Poor reality testing with prom inent autistic and bizarre thinking; poor self-other boundaries

Is often sad or anxious

Preoccupied with sadness

— poor appetite

Poor appetite with mild weight loss

None

— insomnia

Has difficulty falling and staying asleep

None

— feelings o f worth­ lessness and guilt

Feels she is a b urden to her family and they would be better o ff with­ out her

Feels dam aged, ineffect­ ive and inadequate. Frustration stimulates anger which is projected

— wishes to be dead and suicide attem pt

Wants to die and tried to ju m p out a window

Demoralized and sees self as unable to effect change

D ependent and infantile personality features

Relies on others for sup­ port and guidance

II. Personality Factors

Remains passively hope­ ful although demoralized I II. Cognitive Abilities IV. Psychodynamics

V. T herapeutic Enabling Factors

Average intelligence

Low average intelligence

Enjoys but feels guilty about her heterosexual activity

Sees her sexuality as nec­ essary to her self­ esteem and at odds with her self-image

History o f compliance with past treatm ents

Relies on ju dgm ent of others when convinced they understand her abilities and limitations

Schizophrenias / ¡71

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

VI. Environm ental D em and and Social A djustm ent

A spirations are realistic

Realistic aspirations b ut doubts h er ability to follow through

Stable and consistent p e r­ form ance in stru ctu red settings

Able to use consistently applied limits and expectations

Capacity for w arm th in h er relationships

Capacity for close rela­ tionships m arred by fears of denigration

172 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests Info rm atio n D igit S pan A rithm etic Sim ilarities

Scaled Score 7 10 7 7

Performance Subtests Picture Com pletion

4

Verbal IQ (est.) Full Scale IQ (est.)

86 8 0 -9 0

R o rschach Sum mary

N u m b er o f Responses Rejections Populars O riginals Average R /T chrom atic Average R/t achrom atic F% F+% A% W :M M :Sum C m :c V III-X % FK + F + Fc% (H + A ):(H d + A d ) A ppercep tio n W 0% D 58% d 21% Dd + s 21%

19 0 1 0 43" 43" 37 74 89 0:1 1:1.5 2:8 32 63 11:8

Schizophrenias / 1 7 3

EXHIBIT

3

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

I. 3" 1. A frog.

1. T h e hands, th e feet, the sh ap e o f the face. (Else}) No. T h e eyes, b u t 1 d o n ’t th in k so.

DFA

2. A n alligator.

2. T h e face, th e way it cam e o u t long, the nose, the feet a n d the sh ap e o f the body. T h e eyes. (Else}) T h e color a n d sh ad in g m ake it look like alligator skin.

DFc-A

3. Some kind o f a deer. I'he face, th e face o f a deer. 1 don’t th in k it looks like a deer, b u t related to a deer. No, 1 can’t see a deer. T h a t’s all.

3. W here? I can't see it. Som e­ th in g about th e shape. T h e e ars a re like a d e e r’s ears.

dFAd

1. T h e ears, sh ap ed like a cub, a baby bear. Really cu te ad o rab le like a baby bear, a p a ir o f them . Small a n d fat a n d cute, you know?

DFAP

II. 98" I have no idea. I d o n ’t see a n y th in g to tell you th e tru th . (Lookfurther}) I can't see an y th in g . 1. These are the only th in g 1 can see, m aybe a bear.

1 7 4 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum mary

Response

Inquiry

Scoring

III. 8 Sea horse maybe. It’s kind of ugly for a seahorse.

1. I’d say the way it was sh ap e d . (Else}) S h a rp edges. (?) Color was red (?) No. O n the sea horse there’s like a long a rm stretch e d b u t I d id n ’t say an y th in g because I d id n ’t know if a seahorse has an arm .

DFCA

2. C h im p an zees I would say, kind of like monkeys. Two of them . T h a t’s all.

2. T h e ch im p an zees were shape. The hym en an d the face. (Hymen}) Back side, back torso, right? (Else}) T h ey ’re brownish.

DF-A,Sex

IV. 43" Even if 1 d o see things, 1 don’t know w hat they are called. (Describe it?) 1 don’t see an y th in g in this picture. 1. T h ere’s so m ethin g here but 1 don’t know w h at it’s called. T h e face of an an i­ m al . . . (rubs blot unth index finger). I don’t know w hat it’s called. (Any kind}) A beau tifu l anim al but 1 d o n ’t know w hat it’s called.

1'he black a n d w hite color­ ing like the coloring o f a skunk. Its b eau tifu l, b u t n ot a skunk. A g o at maybe. I’m not su re w hat 1 saw. Maybe it is a skunk. It looks soft. (Soft}) Ju st looks nice. T h e colors look nice, like it feels nice, too.

d F C '.F c,A d

Schizophrenias / 175

R o r sc h a c h S um m ary

Response

Inquiry

Scoring

V. 42 I really don’t . . . I. A seal or a walrus but I think it looks like a seal. The face and the shape o f it, the way it has its head looking down. T hats what I’d say. Can’t think o f any­ thing else.

1. Just the shape o f the thing.

dFM-A d

1. I’d say the nose, the way the face was shaped. The nose protruded.

ddFAd

2. The moustache made it look like a man. T he eyes were nice and eyebrows. (N ice eyes?) The eyebrows. (Else?) No. (H um s “M a ry h ad a little lam b ” to herself)

dFc-Hd

VI. 90" Can’t figure them out. N othing in here. 1. 1 see a dog, face o f a dog.

2. I see a man with a mous­ tache. That’s all.

VII. 36 Wow! I don’t see too much in this picture. (Keep looking?) Well, it

176 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

I. looked like two people, one o f them was holding onto som ething they were sh ar­ ing. Two people, a m an an d a female, a male and a female.

They were faced backw ards so you couldn’t see their faces. O ne was holding onto a long stick or a h a n ­ dle. They were kneeling like in a prayer in a church. I hey were kneeling together, two people. (Stick?) A long candle o r a stick. It wouldn’t be a stick in ch u rch . A long candle. Maybe they weren't even in a church. I’m tired. Maybe I’ve been sleeping too m uch. T h a t’s horrible. (Sleeping too much?) Yes.

diM H , Obj.

2. I think I see a horses head. Yeah, a horse’s head right here. T h a t’s about it.

T he nose, the color, the d ark er spot. A nd w hite col­ oring. Looked like a horse to me. Beautiful. (Else?) It was spotless, like the nose.

dF C 'A d

3. T he ears flopping down, face like a collie. Beautif ul. It doesn’t necessarily have to be a puppy but it looked young. A lot of dogs aren’t puppies b ut they look young. Looks furry.

drFcA d

3. I see a dog, a puppy o f a dog. T h e face o f a dog, cute.

VIII. 15" 1. I think this is some kind o f tiger o r jag uar. It doesn’t have stripes or nothing, but it’s like a tiger. T hat's all I can see. (Keep looking'?)

T he way it was stretched out and the length. T h a t’s all the legs, the shape of a tiger. (Else?) No. T h e face but the whole thing looked like a tiger to me, face and everything. They are beau­ tiful, the shape of a tiger.

DFMA

Schizophrenias / 177

R o rschach S um mary

Response

Inquiry

Scoring

T hat's all. T here’s two of them , of course. T h a t’s all I can see. T h e way it’s stretched out is like when a cat stretches with legs stretched out. IX . 45" I see anim als, a lot o f ani­ mals, but 1 don’t know what they are called. T h a t’s all 1 can think of. (Animals}) Yeah, how m any? 1. O ne, just one. T h e re are two o f them .

1. Just a face. (Animal}) Face, more like eyes. And the nose is the shape of a moose. (?) Just one eye and the color, the bluish color, is nice. (Where might you see an animal like this}) Don’t know. 1 think I saw a pic­ ture o f one in a book once. Nice coloring.

DFCAd

X. 48" Wow! T his has some crazy stu ff in it. I don’t know w hat it is. 1 really don’t see anything. T here’s nothing 1 see. Except I see som ething over here. I don't know what it is though. Wow! H ere and here I see a rab ­ bit. Som ething like that. T h e ears come out o f the top o f this head p ro tru d in g out.

T he ears. (Else?) No, if there is, I don’t remember.

DFA

1 7 8 I Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R orschach Sum m ary

Response 2. Lobsters, some kind o f thing with an ten n a here.

Inquiry

Scoring

2. I saw a n ten n a but 1 don’t know if it was a lobster. I guess it was.

DFA

3. Looked like curly hair. It didn’t look like a regular dog. Looked like a poodle. It ju st did. (Else?) It looked like a poodle to me so all I can see was curly hair. T he face. T h e hair didn’t look so Hat (?) (Laughs) It wasn’t the hair, it ju s t looked like a poodle.

DFcA

4. The goat because the color is black a ro u n d the eyes. T he coloring o f the face, the fur. (fur?) T he coloring.

drF C 'F cA

(Keep looking.) T h a t’s all I see. 3. Maybe a dog, a poodle.

T hat's all I see. 4. A nd here are sheep. A goat, some kind o f goat. E ither sheep o r goat. Some kind o f goat, it’s beautiful. T h a t’s all.

Schizophrenias / ¡79

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 Looks like he’s sort o f given u p — he’s th in kin g an d it’s kind o f h ard on him he’s thinking too hard and it’s kind o f h ard right now (Feeling}) for m e o r for him . He’s feeling sad and d isap p o in ted . (Why}) Because he can’t p u t it together, get it together. (Happen}) He’s going to try to work on it and build his confidence and strength. Work on trying to rem em ber what he has to rem em ber. CARD 2 I rem em b er this one. This lady is looking o ff in the distance thinking about som ething also. A nother one is thinking. O ne is sad thinking about som ething that h u rts. The o th er is th in k in g about som ething from a b etter p o in t o f view. I'he m an is ju s t looking o ff in the distance at the trees in sam e direction in th e house— not the house b ut looking o u t th at way. (Feeling}) L ady seem s kind o f sad, b o th ered . T h e o th er is th in k in g som ething h a p p ie r an d isn’t b othered. (Happen}) W hat do you m ean h a p ­ pen? I don’t know, som ething good for b oth o f them , all o f them I hope. He looks like he has no problem s. He m ight have problem s, b u t noth in g there. CARD 3BM A h. Poor baby. She’s crying over— she’s sad she’s upset about som ething so she’s bent over thinking about som ething, upset. She’s sad, she’s upset. (Happen}) I don’t know I hope som eone will come and com fort her. 1 h ope she gets over it, I hope she’ll be all right. CARD 4 She’s very pretty. T h is looks like a movie scene. Well they’re very happy to g eth er she loves him . She may n ot look m arrie d b u t she is— he looks like he’s going to be in a fight. She’s holding on to him to keep him from getting in a fight. T h e way his teeth is looks like going to get into trou­ ble. (Feelings}) She loves him a lot and he loves her too an d he wants to go som ew here because he has to leave, he has som ething to do. Come to think o f it the shad in g isn’t too good his m outh, lips are closed. (Happen}) He’s going to go. (?) She’ll feel bad, sad because she w anted to hold him back an d couldn’t. He m ight get h u rt o r he m ight beat up on the person. CARD 12M T his m ight be a priest who’s not dressed u p who is p u ttin g a good word over h er o r blessing her because she’s ill. (Happen?) H opefully she’ll be all right. A re you all right? (Pardon me}) Are you all right? (Yes. Why}) I th o u g h t you m ight th in k I ’m an g ry an d be afraid th e word is going aro u n d the unit th a t I ’m an an g ry person. (?) I don’t know I’m scared I

180 / Psychological Assessment. Psychiatric Diagnosis, and Treatment Planning

T h e m a t ic A p p e r c e p t io n T e s t

ju s t th in k you m ig h t be scared th a t I ’m a n g ry at you? O r m aybe you’re a little an g ry a t m e. C A R D 14 Well, I th in k u in n im .. . . this p erson is in the d a rk and he wants light so he’s o p e n in g u p th e w indow — w ants lig h t to com e in, w ants to see th e light anyway because he’s in th e d a rk . (Feel?) H e ju s t w ants light, to see th e light, he’s in th e d a rk (Happen}) n o th in g really, he’s g o in g to o p en th e light, get som e light. 1 don’t knowr why it’s so light out an d pitch d ark inside.

Schizophrenias I 181

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e st

2.

She often wished she could “gain self-confidence.”

11.

A woman who falls in love “feels very protected an d b eau tifu l.”

22.

When people made fun of her, she “walked away.”

25.

If I think the job is too hard for me, I “eith er give up o r d o som ething

27.

d ifferen t.” She fell her lack of success was due to “h er lack o f confidence in herself.”

41.

I f I cant get what I want, I “som etimes sigh.”

42. 60.

When 1 am criticized, / “ feel b ad .” My mother always “cheers me up.”

69.

/ feel guilty about “g ettin g angry.”

73.

People in authority are “h elp fu l.”

74. 83.

/ feel happiest when “I m ake o th er people happy.” More than anything else, she “needed help and love.”

87.

/ am afraid of “losing my tem per.”

182 / Psychological Assessment, Psychiatrie Diagnosis, and Treatment Planning

DISCUSSION T he 26-year-old Ms. N was clearly psychotic in her fantasized rom ance and fertility with an unknow ing older male and/or the Holy Spirit. T his suggests a desperate yearning for an adult relationship with a male, and concom itant verbal an d physical abuse against a m o th er whom she saw as th w artin g this striving for independence. 1'he hospital staff were deadlocked over w hether this patient was suffering from schizophrenia or an affective disorder; psy­ chological testing was requested. H er behavior d u rin g the testing involved laughing and singing to herself, suggesting both m ood and cognitive deficits. H er p erfo rm an ce on the p ro ­ jective tests clearly illustrated her f rag m en ted experience an d perceptions, accom panied by elliptical speech an d fluidity. In the cross-sectional testing it seem ed clear that signs of a manic state, including affective lability, g ran ­ diosity, and sexual preoccupation, coexisted with severe disorganized think­ ing an d im pairm en ts in reality testing. T h e testing was influential in red irecting the treatm en t tow ard g re a te r attention to the affective sym ptom s. In contrast to Ms. N ’s m anic picture, Ms. R, a n o th e r young single adult w oman, presented with depression and psychosis. She, too, was referred for testing to clarify a com plicated diagnostic picture. H er behavior included com pulsive handw ashing an d show ering in ad dition to fran k psychotic m aterial with visual and auditory hallucinations, but com bined with prom ­ inent depressive features. T hese depressive sym ptom s seem ed to arise on the heels o f a significant and positive relationship with a boyfriend. T h e testing revealed a woman o f Low Average intellectual functioning. T h e tests were characterized by a depressed m ood, a paucity o f thought m aterial which seem ed consistent with depression and interpersonal themes o f sadness and pervasive powerlessness and passivity. Psychotic thinking was suggested in her poor form level and absence o f the ability to integrate p er­ cepts an d focus on extraneous details. O ne m ight ask how this record can be distinguished from psychotic depression. In this case, the results o f the second exam ination, carried out after p artial rem ission o f h er m ore acute sym ptom atology h ad been achieved, were very useful. Despite an im provem ent in her intellectual func­ tioning, she rem ained quite prone to u nusual an d idiosyncratic m odes o f th o ught. At the tim e o f the second testing, these could no longer be con­ sidered consistent with a concom itant d istu rb an ce in m ood an d were more consistent with the schizoaffective diagnosis finally offered.

CHAPTER 4 ❖

Major Affective Disorders

A. MAJOR DEPRESSION W ITH MELANCHOLIA A N D W ITH PSYCHOSIS M ood diso rd ers in D SM -III-R are subdivided into b ipolar diso rd ers an d depressive disorders. T h e depressive d iso rd ers are two: m ajor depression and dysthym ia. T h e m ajor depressive syndrom e includes some o r m ost o f the following sym ptom s for a m inim um o f two weeks: depressed m ood, dim inished interest o r pleasure in m ost o r all activitites, significant weight loss or gain, insom nia o r hypersom nia, psychom otor agitation or re ta rd a ­ tion, fatigue o r loss o f energy, feelings o f worthlessness and guilt, dim inished ability to think o r concentrate, recurrent thoughts o f d eath and suicidal ide­ ation o r attem pt. Since the individuals who become depressed are quite var­ iable in strengths an d weaknesses, and since the p recursors to depression arc multiple, psychological testing is often instrum ental in fu rth e r defining the treatm en t plans to fit th e individual case.

MAJOR DEPRESSION, SINGLE EPISODE, W ITH MELANCHOLIA Mr. F, a 24-year-old, single, w hite m ale o f Italian-R om an Catholic back­ gro u n d , had moved to a new city to begin his g ra d u ate studies earlier in the fall. It was his first experience living away from home and he had trouble adjusting to a bachelor’s routine. As a serious student, he resented his room ­ m ate’s m ore lackadaisical approach to his studies. He h ad tried to accom ­ m odate his room m ate’s un tid y habits an d irre g u la r ho u rs an d h ad even m ade an effort to be friendly to the seemingly endless parad e o f girlfriends w ho cam e by to visit. As his schoolwork began to suffer, he h a d retreated to the solitude o f his own room w here he h oped to ignore the distractions o f his room m ate and get on with his studies. 183

184 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning His school perform ance continued to d em an d more a nd more o f his time. Increasingly distressed over his inability to excel in the classroom, he sought psychiatric consultation. A fter a few visits, the psychiatrist recom m ended a leave o f absence from school an d Mr. F re tu rn e d hom e w here he contin­ ued in an outpatient treatm ent with a local psychiatrist. He was bitterly dis­ ap p o in te d in him self an d was convinced th a t his family was equally d isap p o in ted in him . A lthough his psychiatrist enco u rag ed him to get out o f th e house m ore, he was u nable to face his old frien d s an d sp en t most o f his day at home. O ver the next few weeks, he becam e increasingly agitated and upset over his w ithdraw al from school an d his psychiatrist recom m ended a b rie f hos­ pitalization at a nearby private hospital for a diagnostic w orkup a n d initi­ ation o f pharm acological treatm e n t o f his anxiety an d agitation. H e was beg u n on a m edication to h elp control his anxiety, b u t his guilt a n d distress continued to m ount an d his family ag reed to let him re tu rn hom e against his d o cto r’s advice. A fter several days o f increasing agitation an d sleepless nights, Mr. F an d his family ag reed to a hospital adm ission at a pro m in en t local teaching hospital. At adm ission, his agitation an d distress were im m ediately obvious. W hen asked about himself, his rep o rt clearly revealed th a t in the last m onth he had experienced a pervasive disinterest in his usual activities, progressive social isolation, an d a deterioration in his ability to function autonom ously. His ap p e tite h ad declined an d he was not sleeping well. In a tense and worried m anner, he attem pted to give a clear account o f his experience, b u t h a d difficulty concentrating, which he expressed as his difficulty in “th in k in g clearly.” He was preoccupied with feelings o f guilt and worthlessness and rep o rted re c u rren t th o u g h ts o f his d eath . H e could not rid him self o f a nagging concern th at he may be a hom o­ sexual. H e h ad recently en g ag ed in hom osexual practices which he found “disgusting.” A lthough preoccupations with his sexual orientation were not new, he h ad becom e increasingly self-conscious abo u t the m a t­ te r as his room m ate h ad becom e involved in heterosexual relationships and his educational c u rricu lu m directly exposed him to sexual issues. H e gave no evidence o r history o f hallucinations o r delusions, b u t did express a fear th a t he was losing his m ind.

DSM III-R D iagnosis Axis I: Axis II: Axis III:

M ajor depression, single episode, with m elancholia None None

Major Affective Disorders / 185 Axis IV : Axis V:

M oderate— beginning a new school year, revealing his sexual concerns to classmates Fair— good academ ic functioning b ut no close friends

Treatment and H ospital Course Im m ediate m anagem ent o f his agitation and distress was attem p ted w ith a neuroleptic and a benzodiazepine. T his treatm en t regim en was unsuccessful in alleviating his sym ptom s and he developed several nonorganic physical complaints. In the second week following his admission, b e n z o d ia z e p in e s w ere d is c o n tin u e d a n d h e was b e g u n on an antidepressant. Despite adequate serum levels, he failed to improve and two weeks later was referred for psychological testing. Following comple­ tion o f the testing, Mr. F atte m p ted to injure him self on several occa­ sions, either by asphyxiation or electrocution, and was referred for ECT. In the next seven weeks, he received a total o f 19 unilateral treatm ents and showed substantial im provem ent. He was d ischarged on a lower dose o f an antidepressant, with plans to live in a stru ctu re d residential setting w here he would be involved in an o u tp atien t treatm en t and engage in a volunteer jo b .

P sychological Assessm ent Mr. F was referred for psychological testing to help in establishing his diagnosis a n d provide an assessm ent o f his intellectual an d personality stren g th s an d weaknesses. His failure to respond to an tid ep ressan t tre a t­ m ent, the slightly bizarre n a tu re o f his atte m p te d suicide by electrocution, and a persistent, interm ittent and mild thought d isorder provided the basis for the diagnostic referral. T h e diagnostic differential suggested by the referrin g th erap ist was betw een a m ajor depression w ith melancholic and perhaps psychotic features and a schizophreniform disorder. An intellectual assessm ent was requested to ascertain if the p atient h ad sufficient intellec­ tual ability to undertake his grad u ate education. T h e assessment o f his p er­ sonality strengths an d weaknesses was requested to aid in d e te rm in in g an ap p ro p riate psychoth erap eu tic strategy once his acute difficulties could be b ro u g h t u n d e r control. Although cooperative and motivated d u rin g the testing, he was clearly distressed and anxious. He was aware o f his difficulties in concentration and o f a decline from his previous high level o f functioning in o th er areas as well, and frequently sought reassurance from the exam iner that

186 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning he was not “o ff the wall.” His evaluation consisted o f a com plete WAIS, a R orschach, TAT, DAP, a p artial B ender (copy only), an d the O bject Sorting Test. T h e test results repeatedly reflected Mr. F’s acute anxiety an d distress. T h ere was considerable variability in his WAIS subscale scores, which ran g ed from low average to superior, with num erical reasoning am ong the lowest, a pattern which confirm ed his concentration difficulty. A test which entails simple rote mem ory o f num bers, and so requires less cognitive effort, yielded a better perform ance. Finally, there is evidence o f m uscular tension, a com ponent o f anxiety, in his reproduction o f the geom etric designs on the Bender. T h e clinical history clearly revealed a recent, a b ru p t decline in fu n ctio n ­ in g a n d was indicative o f some strain betw een this young m an’s aspirations an d his abilities. A lthough his verbal IQ o f 122 suggested th a t despite his c u rre n t distress, he had the intellectual ability to perform adequately in a p o stg rad u ate p rogram , personality factors were clearly lim iting his full em ploym ent o f these intellectual abilities. This sam e inefficiency due to p e r­ sonality factors h am p e re d his R orschach p erform ance, which was ch arac­ terized by a paucity o f com plex, in teg rated responses, a restricted ran g e o f associations (A% and multiple determ inants) and an overreliance on p o p ­ ularly perceived, un elab o rated responses (P%). Strong depressive them es and a considerable level o f personality d iso r­ ganization co n trib u ted m ost prom inently to his inefficiency. His TAT con­ tained stories ab o u t people who are “frig h ten ed by the com plexity o f life” an d seek “re fu g e ” in the security o f family an d home. Life in the larg er world is fraught with danger, particularly the d an g er o f having one’s “im per­ fections” revealed. His awareness o f his cognitive difficulties on the WAIS, perceived as “im perfections,” provoked significant anxiety and contributed to an erratic pattern o f subscale scores. However, the quality o f his responses to the structured WAIS items as well as to the more u n stru ctu red Rorschach indicated retention o f the capacity to adequately test reality despite frequent lapses in critical ju d g m e n t an d intrusion o f fantasy m aterial. T h ro u g h o u t the test record, th ere was a b u n d a n t evidence o f the toll taken by his efforts to ad h e re to reality constraints an d , as suggested by the TAT, o f a desire for a simpler, m ore tru stin g relationship with o thers, uncom plicated by the strife o f ad ulthood. T h e m ain psychological issues an d personality factors which com pro­ m ised his intellectual an d em otional fu nctioning seem ed clearly related to the developm ental tasks o f early ad u lth o o d . He experienced conflict betw een his high need for n u rtu ra n c e and su p p o rt an d his d esire for in d e­ pendence a n d achievem ent. T h e form er th reaten ed to shade into a passive d ep endency linked with a hom osexual orientation, while the latter were at

Major Affective Disorders / ¡87 times confused with hostility an d aggression. At eith er pole, his idealized view o f the ad u lt m an as strong, am bitious, and com petent, yet loving and sensitive to his family, was in d a n g e r o f crum bling. W hile struggling to integrate these aspects o f himself, he apparently alter­ nated betw een experien cin g him self as “a ro b o t” (Rorschach card IX) o r as a small and insignificant anim al (squirrels on Rorschach card VIII). His rigid self-control seem ed designed to contain an d b lu n t the th re a t o f aggression he experiences, reflected, for example, in his Rorschach percept “someone with boxing gloves on.” Yet, these efforts at denying its existence to him self and others left him filled with a loneliness th at was “intense and agonizing.” T hese concerns were heig h ten ed by the task o f sep aratin g from his family and establishing an in d ep en d en t existence an d identity. In achieving the goal o f separation, ef forts to help both the patient and his family to accept his am bitions an d his lim itations seem ed likely to be rew arded.

Treatment P lanning and Outcom e I'he results o f Mr. F’s psychological assessment were reviewed by his treat­ m ent team and, as a result, the p atie n t’s treatm en t plan was revised to include twice weekly sessions with his family. T hese family sessions were included to directly address th e issues o f separation an d the family’s denial o f the patient’s present limitations. Each family session was immediately fol­ lowed by individual psychotherapy sessions to co u n ter the potential for regression b ro u g h t on by the discussion o f these issues. As a result o f these changes in his treatm en t plan, the patient was able to sustain his im provem ent following ECT. Although he continued to strug­ gle with feelings o f depression an d anxiety, these feelings a p p e a re d more realistically related to his im m ediate concerns an d present limitations. His af fect was generally b e tte r m odu lated and his feelings were m ore success­ fully integrated with his ideas such th at he was neither isolating his feelings nor becom ing overw helm ed by them . T h e work with the family a n d the patient h elped them to u n d erstan d his need for continued treatm ent in a structured setting. Application to halfway house program s in his home area and to program s in the city where he had been d o in g his g rad u a te study were m ade. At the time o f the p atien t’s dis­ charge, he h ad been referred for continued individual and family therapy, was accepted at a halfway house p ro g ram in the local area, an d had o b tained a tu to rin g position w hich would engage him in a few hours o f work each week. H e had not decided on w hether to re tu rn to his g rad u ate studies, b u t h ad ag reed to continue to discuss this issue as p a rt o f his o u t­ p atient treatm ent.

188 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

E X H I B I T

I.

A rea of

C l in ic a i.

A ssessm ent

E x a m in a t io n

1 P s y c h o l o g ic a l E x a m in a t io n

Sym ptom s/D iagnosis Major depression, single episode, with melancholia Dysphoric m ood and loss o f in ter­ est and pleasure

No interest in any o f his usual activities

Depressive themes and im poverishm ent o f intellectual resources

Poor appetite

Fats poorly; has lost a few pounds

None

Insom nia

Difficulty falling and stay­ ing asleep

None

Psychom otor agitation

Paces, cannot sit still

Tense and restless

Feelings o f w orth­ lessness, selfreproach and guilt

Berates self for hom osex­ ual feelings and experiences

Feels unable to live up to idealized m asculine im age

Difficulty concentrating

Has trouble following conversations; seems distracted

Difficulty utilizing intel­ lectual resources u n d e r m oderately effortful conditions

Suicidal ideation

Has considered ending his life

Despairs o f achieving his goals and living up to expectations o f him self and others

Ambitious, interested in m astery

M otivated by aspirations, achievem ent oriented

None

Above average intelligence

II. Personality Factors III. Cognitive Abilities

Cognitive inefficiency due to acute distress IV Psychodynam ics

Conflict over dependency/m astery

Ambivalent about success and the price it exacts

Aggressive feelings con­ sciously rejected but feels guilty

Wishes to be rid o f baser h um an feelings

M ajor Affective Disorders ! 189

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Fearful o f intimacy

V.

T herapeutic Enabling Factors

None

Equates closeness with passivity and dependency Intelligence Capacity for self-observation Achievement history and orientation

VI. Environmental Demand and Social Adjustment

D em anding educational environment and feel­ ing o f failure

Usually mobilized by dem and given his high need for achievement

Poor sexual adjustm ent

Desires for strength to compensate for u n d er­ lying homosexual concerns

190

/

Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

E X H I B I T WAIS-R

2

Sum m ary

Verbal Subtests Information Comprehension Arithmetic Similarities Digit Span Vocabulary

Scaled Score 15 14 12 13 15 13

Performance Subtests Digit Symbol Picture Completion Block Design Picture Arrangement Object Assembly Verbal IQ Performance IQ Full Scale IQ

13 8 9 8 11 122 98 112

R o rsc h a c h Su m m ary

Number o f Responses Rejections Populars Originals Average R/T chromatic Average R/T achromatic F% F+ % A% H% W:M M:SumC m:c VIII-X% FK + F + Fc% (H + A):(Hd + Ad)

19 0 6 0 7" 7" 42 79 47 32 8:5 5:1 6:0 37 42 13:2

Major Affective Disorders R o rsch a ch Sum m ary

Apperception

W 42% D 42% d 0% Dd + S 16%

/

191

192 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment Pla n ning

EXHIBIT

3

R orsch ach Summary

Inquiry

Response

Scoring

I. 2" 1. T h e front p a rt o f a ship with oars on eith er side.

1. Shape.

VVF-Obj.

2. Butterfly.

2. It’s shaped like it.

3. An anim al th a t’s on its front legs and its back legs are out.

3. (Kind of animal?) Not really a cow, like a goat o r som e­ thing. (Goat}) Ju st seem ed that the back p a rt was up kicking.

VVFM-A

1. Puppies looking at each other.

DFMAP

2. (Jet or plane}) Shaped like one and the red would be the smoke com ing o ut the back. (Smoke}) It ju st was red and seem ed like fire burning.

SFmObj DCF'.mF Fire, Smoke

I . W earing a tuxedo. (Tux­ edo}) T h e way the front parts stick o ut and the back p art was longer.

W M H, Cloth P

VVFAP

II. 10 1 I think I see the head o f two dogs facing each other, probably puppies. T h a t’s it. Do you want m ore th an one response? (Whateveryou see) T here’s som ething— it seem s like it’s a je t o r a plane going this way.

III. 10" 1. T his looks like two butlers facing each o th e r and carrying dishes. T h a t’s it. (Look longer) T h a t’s it. IV. 15" 1.

Looks like two boots th at are leaned up against a wall, back to back. Here’s one boot, the other, the heel and the toe.

Shaped like boots and they’re leaning. (Leaning}) Looks like they are bal­ anced there on th eir heels. They are tilting back a bit.

WFm Cloth

M a jo r A ffective Disorders / 193

R orschach S um mary

Scoring

Response

Inquiry

2. A n o th er possibility would be an anim al with w ings a n d a n te n n a e over here. T h a t’s it.

2. (Kind of animal?) S o rt o f like an insect. (Insect?) T h e head p a rt with the an ten n a e.

WF-A

1. Ju st the shape.

WFA

1. Seem s like two people lying dow n with th e ir arm s up a n d yelling o r talk in g . . . a n d they m ig h t be In d ia n s if this is a feath e r com ing o ut o f th e head . H ere are the heads, m ou th s, arm s, legs. T h e h ead is n e a r me.

1. (Yelling or talking?) T h e way the m outh was open.

DM H .O bj.

2. T h is looks like a penis over here.

2. T h e way it’s sh ap ed .

d iF Sex

1. T hey’re looking at each o th e r an d seem an g ry because o f the sh ap e o f the jaw.

WMHP

V. 5" 1. A gain, it looks sort o f like an insect w ith w ings— here’s th e h ead , a n ten n aes, two wings. T h a t’s it. V I. 10"

V II. 5" 1. A gain, it looks like two p eople, this tim e two w omen, facing each other, w ith th e ir h a ir up, have ponytails th a t a re u p in the air. T hey m ust be m ad because th e ir jaw is out a little. H ere’s the hair, nose, jaw.

194 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R o rsch a ch Sum mary

Response

Inquiry

Scoring

1. 1 see two animals, probably squirrels o r beavers or som ething. Here are the legs, tails.

1. Die shape o f the figures. T h a t’s all.

DFAP

2. 1 see arm s reaching out to them , here are the arm s and the fingers.

2. (Kind of arms}) T he arm part. (Op) A person.

drM H d

1. I see like a robot— here’s the head part, the body part, wheels on bottom.

1. It’s shaped that way.

D(S)F(H)

2. The possibility that this is someone down here with boxing gloves on. (Demon­ strates) Here are the eyes and the outstretched arm s with boxing gloves on.

2. (Boxing glows}) They just seemed to be very large in comparison to the rest o f the body. They seemed to predom inate and extend out.

D(S)M-Hd, Obj.

1. I see two spiders here and here.

1. Legs o f spiders.

DFAP

2. This looks like two lions over here.

2. They seemed to be proud, with the head up. (Anything else}) T he front part o f the body was very strong.

DFMA

3. This looks like two frogs. Am I completely o ff the wall?

3. The legs seemed to be outstretched.

DFMA

VIII. 5"

IX. 10"

X. 2"

Major Affective Disorders / 195

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 T h e p aren ts o f a little boy b o u g h t a violin for th e ir son and wanted to give him lessons on this instrum ent. He would take the violin and sit at his desk in his room , d o se his eyes, an d think o f the day when he would be a g reat violinist. T h ro u g h the years he sp en t m any a day playing and enjoying the music he created w ith his violin. In tim e he becam e a g reat violinist an d b ro u g h t joy to all who h e a rd him play. CA R D 3BM T h e crippled girl sat alone often in the coniines o f h er home. T h e tragedy o f the accident she experienced years before h ad left h er w ith a broken body and a broken spirit. T h e loneliness o f h e r world was intense and agonizing. She would sit with her head buried in her arm s and wonder why this tragedy was necessary. She wouldn’t see th e things th at were h a p ­ p en in g aro u n d h er b u t would isolate h er feelings in the m attress th a t she was clinging to. T h e o th e r people in h er life tried desperately to remove the loneliness b u t were un ab le to p en e tra te h er world o f agony. She died on her m attress w ith h er arm s an d h er h ead b u ried in the graveyard o f h er room . (How die}) W ith a broken heart. (Agony?) B eing alone (Others try to penetrate) she would ju s t close herself o ff (Why?) she ju s t couldn’t accept h er­ self and h er im perfections. C A R D 4 T h e two ch ild ren , th e girl and th e boy, grew up to g eth er in the small town beside the sea. T hroughout the years they developed a fondness th a t was transform ed in to love. As they got o ld er they sensed th a t they need ed each o th e r an d decided to live in the cottage whose backyard ran up to the sea. T hey led a life th a t was difficult b ut satisfying and they were sustained by th eir love and by th e ir devotion to each other. T h e ir life was invaded by the cruelty and insanity o f war. T h e husband was called to serve in the arm ed forces o f his cou n try an d was asked to leave his hom e for far away lands. But his wife cannot un d erstan d his d e p a rtu re from her life and she attem pted to stop h er husband from leaving. T h e m an was to rn between the two w orlds but d ecided th a t it was necessary for him to leave. He did re tu rn though and the tranquility an d love in th e ir lives increased even more. C A R D 6BM T h e m an woke u p th at m o rn in g an d went on with his daily work and activity. T he phone was used to contact associates for his very suc­ cessful com pany. O ne m o rn in g the phone ra n g an d his m o th er asked him to com e to the hom e th a t he grew u p in. His m o th er said th a t she n eed ed him w ith h er because his fath er h ad d ied. He cam e hom e an d stood with

196 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t i o n T e s t

his m o th er beside the bed o f his deceased father. T hey stared o u t the w in­ dow an d his m other would cry an d wish for th e days th at she spent with her husband. (Son feels}) Very sad. CARD 7BM T h e train moved slowly to its destination to New York, to Bos­ ton, from New York to Boston. T h e tim e seem ed long for th e two men who were anxious to re tu rn to th eir hom es d u rin g the holiday season. T hey sat on the train and talked o f th eir families who were aw aiting th e ir arrival at the train station. T h e o th er m an had experienced a longer life th a n the young m an who sat beside him . H e saw in his com panion a p art which he had experienced 20 years earlier. He saw the u n certain ty an d th e b u rd en o f responsibility in th e young m an’s eyes. He assured his com panion th at he should enjoy all those things, his family, an d life, th a t he h ad taken for granted d u rin g his own lifetime. T h e friendships, the disappointm ents, and the situations he had ex perienced w hen he was younger becam e very real to him as he listened to the w ords o f the younger m an beside him . He becam e m ore aware o f his present an d would re tu rn hom e with a g reater appreciation o f his family, an d o f his life. CARD 10 T h e boy was frig h ten e d by the com plexity o f life an d found refuge by his p arents an d the rest o f his family. He would seek the reas­ surance an d the power o f stren g th th a t his m o th er an d fath er provided. T hose th in g s th a t frig h ten ed him an d m ade him seek his parents’ reassu r­ ance, thing s th a t he eventually could cope with an d u n d ersta n d . (What?) Ju st the com plexity o f life. I sort o f th o u g h t a b o u t m yself there. (Wlui's in the picture?) Me an d my father, I guess. I don’t know why I ’m m aking such abstract stories ra th e r th a n saying “a boy fell on his knee an d ran to his father.” CARD 13MF T h e m an and the woman shared a small a p a rtm e n t in the h e a rt o f the busy city. Beyond the noise an d confusion o f life outside, they experienced a oneness in this love an d devotion to each other. But fate could not be stopped even w ithin the haven o f their home and tragedy and death occu rred . W hile they b o th slept th ro u g h the night, he felt the coldness o f h er body and knew th a t she died peacefully. H e went on with his life b ut no longer found the security and com panionship in his lost partner.

Major Affective Disorders / 197

MAJOR DEPRESSION, RECURRENT, W ITH PSYCHOSIS Mrs. D is a 47-year-old, recently divorced m o th er o f a teenage son and a nine-year-old daughter. She has been hospitalized twice in the last two years. H er ex-husband has been carrying on an affair with his secretary for several years before th eir divorce. Even afte r the divorce, he d enied Mrs. D ’s accu­ sations o f infidelity, telling h er th a t she was “crazy.” She tried to take her life on th re e previous occasions. H er two m ost recen t suicide attem p ts were provoked by h er d esp air over being un ab le to regain control o f her e x -h u sb an d ’s affections. H er life h ad been devoted to h er family an d she h ad few interests o r friends outside o f h er home. O ver the past m onth, she grew more depressed. She sent her son and her d a u g h te r to a n o th er state to live with h er sister for a few weeks. She had trouble falling asleep and staying asleep. She spent m uch o f the night pacing h er b edroom . She cried frequently and was upset a t the slightest inconven­ ience. She was eatin g poorly an d lost 15 p o u n d s over the last m onth. She was fearful o f leaving the house an d unable to keep her appointm ents with her psychiatrist or regularly go to work. She m anaged to call the psychiatrist periodically and in th eir last conversation told him th a t she h ad p u rch ased a g u n with the intention o f using it to en d h er life if she d id n ’t begin to feel b etter soon. H er psychiatrist persuaded her to come to the hospital despite h er fears th a t she would be “poisoned by m ore d ru g s while th e re .” W hen ad m itted , Mrs. D was d escribed as a “thin , very anxious, tearfu l, depressed woman who w rings h er hands and becomes easily agitated.” She was preoccupied with the idea th at the hospital staff would h u rt her, feeling th at past hospitalizations h ad been h arm fu l to her. She recognized th at she was “nervous and depressed” and noted th at “I haven’t been sleeping well.” She attrib u ted her recent difficulties to her failures as wife and m other and altern ated betw een an agonizing guilt over these failures and ram bling descriptions o f how h er ex-h u sb an d an d children h ad continually p erse­ cuted h er over the last few years. She denied any present suicidal intentions, b u t m ade it clear th a t she felt she had few o th e r options th a n to take h er life.

DSM -III-R D iagnosis Axis I:

M ajor depression, recu rren t, with psychotic features

Axis II:

D ependent personality d iso rd er with possible paranoid features

198 I Psychological Assessment, Psychiatric, Diagnosis, and Treatment Planning Axis IV :

M oderate— conflict with her sons; recent divorce

Axis V:

Fair— m o d erate im p airm en t in social relations an d o ccupa­ tional functioning

Treatment and H ospital Course Mrs. D was ad m itted to an acute care u n it with the expectation th a t she could be re tu rn e d to h e r previously effective m edication regim en and quickly discharged to the care o f her referring psychiatrist. D uring previous episodes o f illness, it had been established that she could not tolerate p h a r­ m acologically effective doses o f m any com m on antidepressants because o f blood pressure problems. D uring h er most recent prior hospitalization, she h ad been effectively treated with a com bination o f lithium an d a m ono­ am ine oxidase inhibitor. T h e hospital sta ff rein stated this d ru g regim en, but despite several adjustm ents she rem ained tea rfu l, depressed, an d fear­ ful th a t the hospital sta ff would h a rm her. She was tran sferred to an ex ten d ed care u n it a fte r one m onth w ith a rec­ om m endation for a réévaluation o f h e r diagnosis an d treatm en t plan because she h ad failed to im prove. D u rin g th e th ird week following her transfer, h e r hospital psychotherapist requested a psychological consulta­ tion. T here had been some im provem ent in her depression but she rem ained preoccupied with h er “failures” an d continued to deny the severity o f h er illness.

P sychological Assessm ent Mrs. D was given a WAIS-R, R orschach, DAP, SCT, an d B enton Visual Retention Test d u rin g the seventh week o f h er hospital stay. I'he specific referral questions included a request for a form al assessm ent o f h er intel­ ligence, the severity o f h e r suicidal ideation, an d h er capacity to utilize either a supportive or insight-oriented psychotherapy. W hile she cooperated w ith the exam ination, h er m a n n e r was described as “obsequious” in th a t she was constantly concerned over w h eth er she h ad given the ex am in er “w hat he w anted.” D espite h er desire to cooperate, it was necessary to ex ten d the exam ination over 10 days as she tired quickly an d would com ­ plain o f fatigue an d nervousness. O n the WAIS-R, Mrs. D o b tain ed a full-scale IQ o f 88 with verbal an d p erfo rm an ce IQs o f 88 an d 89, respectively. H er scaled subtest scores ran g ed from below average (Similarities, Picture Completion an d Digit Symbol)

Major Affective Disorders / 199 to average (Vocabulary). A lthough evidencing only a modest degree o f inter­ test scatter, she invariably m issed o r received only p artial cred it for some o f the easiest item s on each o f the subtests. T h is p a tte rn o f early misses raised questions abo u t h e r intellectual efficiency an d concerns about pos­ sible im p airm en t o f h er reality-testing abilities. H er WAIS-R profile indi­ cated th a t h er p erform an ce was frequently d isru p ted by anxiety an d th a t she had difficulty in m aking any sustained effo rt o r in easily focusing h er concentration. Mrs. D ’s approach to the m ore u n stru c tu re d tests in the b attery revealed h er intense needs for an o rderly and predictable world in which affection an d d eco ru m were the m ainstays o f h u m a n relationships. W hen conflict e ru p te d , she was left feeling annoyed, guilty an d un ab le to cope. H er SCT responses traced this progression in the context o f h er m arria g e and divorce. She believed th a t a woman who falls in love “should know h er m an an d love him ju s t the way he is and not w ant to ch an g e h im .” Believing th a t most men “are honest, hardw orking, and faithful,” she seem ed secure in real­ izing h e r d aydream abo u t “having a w onderful family o f father, mother, a n d sons.” U nderstandably, th en , she rep o rted th a t I was most annoyed when “my ex-husband was not tru th fu l to m e” an d th a t / could hate a person who “lies an d uses o th e r p eople.” Surprisingly, she felt guilty ab o u t the divorce d espite com ing to believe th at “I d id all I could to m ake it work an d it d id n ’t work.” T his them atic progression suggested th a t she h a d few in tern al resources for coping with conflict. Instead, she relied on obedience to a hopefully benevolent external authority, a p a tte rn ad o p ted early in life (e.g. When they told her what to do, she “usually always obeyed because she w anted to please her parents.”). C u r­ rently, she feels quite d am ag ed by the events tra n sp irin g in h er life, not unlike the “cat that someone ran over and the po o r th in g is squashed” which she perceived on card VI o f th e Rorschach. H er lack o f internal resources an d her reliance on external structure were evident in h er R orschach responses. She gives five p o p u la r responses an d nine easily perceived anim al responses in a total reco rd o f 19 responses. H er percepts were most often highly congruent with the consensual reality o f the inkblots (F + = 88%), yet she repeatedly em phasizes the “fantasy,” “exaggerated” o r “cartoon-like” qualities o f the blots to justify h er percepts. T hese qualities were typically invoked in o rd e r to deal w ith h er self­ u ncertainties as well as to distance herself from h er em otional reactions to h er percepts. H er em otionality may precipitate tran sien t lapses in reality testing as dem onstrated in h er response to card III. She reports “. . . fantasy anim als here. It looks like two chickens w ith the beak a n d the neck and one leg, and it alm ost looks like the leg has a high heel on, and I would say it would be two women chickens, because they got a little plum e dow n here,

200 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning so m aybe they’re excited about going o u t on a d a te — you know, how they have it on the cartoons. A nd this bow m ight represent their heart, each one’s heart, th a t they’re excited about w hat they’re go in g to d o .” H er need for em otional distance also a p p e a re d in the context of the p e r­ ception o f th e “d an g ero u s” qualities o f h er percepts. For exam ple, on card IV she reported a m onster “like Bigfoot because he has huge feet and a large tail and tiny arm s and a tiny head." As she continued, she noted th a t the h ead is “like an alligator, so he could be d an g ero u s” an d su m m ed up by saying th a t “so th a t’s basically w hat 1 see this as— a cartoon monster, and I would call him B igfoot.” D u rin g the inquiry, she continued to rationalize an d to distance h erself from the p ercep t by ascribing the origin o f the p e r­ cept to w atching T V with h er child ren w hen they were little, statin g th a t “th ere was a m onster sim ilar to th at on a C hristm as show, a snow monster, and my son used to get afraid o f th a t m onster an d we used to have to tu rn it off.” T h e som ew hat p aran o id sense o f cold, om inous d a n g e r th at p erm eates this response reap p eared on card VIII. Two polar bears were seen as “trying to clim b u p the side o f a glacier, a snowy m o u n tain , to the top.” In the inquiry, she responded th a t “im m ediately they resem bled p olar bears; not so fantasy-looking, like real polar bears . . . and it looks like they had a h ard tim e g ettin g u p to th e icy top.” T h e response contained an im plied success o f the p o lar bears’ effort. T h e Sentence C om pletion Test also revealed a focus on being successful. T h ere were assertions o f h er desire for greater independence and the success h a rd work brings. She states th a t w hen she was com pletely on h er own, she “becam e very in d ep en d e n t,” b u t ascribes h er lack o f vocational success to a “lack o f h a rd work.” She is asham ed th at “I was not strong in my convictions.” A lthough she asserted th at com m itting herself to such achievement goals and p u rsu in g them with determ in atio n represent a viable alternative for her, they are presented more as attitudes likely to win approval th an as moti­ vating an d sustaining beliefs. H er inability to in teg rate these two aspects o f h er self-representation— on the one han d , obedience an d subm ission, and on the other, am bition and self-fulfillment— was ap p aren t in her figure draw ings. Both the m ale an d fem ale figure draw ings are childlike rep re­ sentations draw n with smiling, open faces an d arm s, but with stiff and rigid postures. H er self-portrait lacks any sexual specificity despite the im plica­ tion o f ad u lth o o d derived from its la rg e r size. T h e figure is p resented with short h air and billowing, knee-length trousers, with butto n s placed down the m iddle o f the shirt an d at th e cuffs. Unlike the m ale an d fem ale figure draw ings which are filled in with heavy sh ad in g reflecting ap p rehensive­ ness, h er m ore idealized self is an o pen figure with only the short h air receiving any shading. T h e childlike qualities o f the p icture she drew o f

Major Affective Disorders / 201 herself seem m ore in keeping with h e r wishes to be n u rtu re d a n d d irected; by contrast, the asexual b u t som ew hat m asculine qualities a p p e a r to be an a tte m p t to honor h er a ttitu d es concerning am bition an d self-assertiveness, b u t at the price o f rejecting h er femininity.

Treatment P lanning and Outcom e In review ing the results o f th e psychological testing w ith the hospital treatm en t team , the im plications o f h er intellectual level, tran sien t d isru p ­ tions in reality testing in th e context o f psychosexual an d aggressive th e ­ m atic content, and reliance on ex tern al authority were the m ain elem ents o f h er assessm ent b ro u g h t to b ear on h er treatm en t plan. H er p h arm aco ­ logical regim en rem ain ed u n c h an g ed in light o f the depressive ch aracter­ istics im p lie d by h e r p re o c c u p a tio n w ith th e d iv o rc e a n d h e r disp ro p o rtio n ate guilt-feelings in relation to it. In view o f h er history o f reliance on external authority and her presently lim ited capacities to cope with in tern al distress, a supportive ap p ro ach to h er psychotherapeutic tre a tm e n t was recom m ended. W ithin such a su p ­ portive fram ew ork, she was en couraged to develop realistic jo b aspirations in line with h er intellectual abilities. She was also enco u rag ed to widen her netw ork o f social sup p o rts an d to share m ore equitably the b u rd e n o f rais­ ing h er two children with her ex-husband. O ver the next six weeks, Mrs. D’s mental status continued to improve. She becam e less preoccupied w ith h er divorce a n d h e r guilt ru m in atio n s as her depression resolved. K eeping pace with this positive developm ent was a grow ing sense th a t th e present treatm en t plan, in which she actively p a r­ ticipated, was effectively designed to assist her and she gave u p her concern th at the treatm ent staff would h arm her. She was, in fact, able to coordinate the care o f h e r child ren with h e r ex-husband an d felt reassu red th a t she could rely on his help m ore th a n she h ad previously. She successfully nego­ tiated a re tu rn to work with h er form er employer, who was able to keep h er in h e r present position an d provide the additional stru ctu re an d guidance on the jo b th a t she needed. At the end o f h er th re e m onth hospital stay, Mrs. D was d isch arg ed from the hospital and retu rn ed to the care o f her referring psychiatrist. He found the recom m endations m ad e by th e hospital treatm en t team useful an d was able to provide for h er care after discharge.

2 0 2 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

EXHIBIT

I.

A rea oe

C l in ic a l

A ssessm en t

E x a m in a t io n

1 P s y c h o l o g ic a l E x a m in a t io n

Symptoms/Diagnosis Major depression, recurrent, with psychotic features Depressed mood and sad affect

Dysphoria related to divorce and mistrust verging on paranoia

Lost 15 pounds in last month

None

Insomnia

Initial, m iddle and term i­ nal insomnia

None

Psychomotor agita­ tion or retardation

Agitated, hand-w ringing

Psychomotor retardation

Excessive guilt

Feels to blame for divorce despite objective evidence

Preoccupied and guilty regarding divorce

Im paired concentration

Easily returns to p er­ severation regarding m istreatm ent by hus­ band and sons

Difficulty concentrating with im paired intellec­ tual efficiency

Suicidal ideation/attem pt

Past attem pts and present ideation

None

Psychotic delusions o f harm congru­ ent with themes o f personal inad­ equacy and guilt

Fears being poisoned by treatm ent staff

Transient im pairm ent in reality testing in the context o f sexual or aggressive themes

None

Optim al functioning with high external structure

Dysphoric mood and loss o f pleasure At least four symptoms Poor appetite/ weight loss

II. Personality Factors

Childlike need for nurturance and support III. Cognitive Abilities IV. Psychodynamics

None

Low average intelligence

None

Limited ability to cope with emotional distress

M ajor A ffective Disorders / 2 0 3

A rea of

C l in ic a l

A ssessm ent

P s y c h o l o g ic a l E x a m in a t io n

E x a m in a t io n

Tends to externalize internal conflict; ratio­ nalization is a major defense V.

T herapeutic E nabling Factors

VI. E nvironm ental D em and and Social A djustm ent

None

Responds positively to benevolent authority

Feels unable to m anage her children

Expects com pliance with authority

Few friends

None

Recent divorce; conflict with ex-husband

Feels abandoned and betrayed by ex-husband

204 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning E X H I B I T

2

WAIS-R S u m m a r y Verbal Subtests Inform ation C om prehension A rithm etic Sim ilarities Digit Span V ocabulary Performance Subtests Digit Symbol Picture Com pletion Block Design Picture A rran g em en t O bject Assembly Verbal IQ P erfo rm an ce IQ Full Scale IQ

Scaled Score 8 7 10 7 8 6

6 9 9 8 6 88 89 88

R o rschach Sum mary

N u m b er o f Responses Rejections Populars O riginals Average R /T chrom atic Average R /T achrom atic F% F+% A% H% W:M M :Sum C m :c V III-X % FK + F + Fc% (H + A ):(H d + Ad)

19 0 5 0 36" 7" 42 88 47 26 8:2 2:4 3:2 53 42 13:1

Major Affective Disorders / 205

R o rsch a ch Sum mary

A p p erc e p tio n

W 42% D 58% cl 0% D d + S 0%

2 0 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

3

Rorsch a ch Sum mary

Response I. 11" 1. It looks like it alm ost could be a cat’s face. It th a t all you want, one thing? I think definitely it looks like a cat’s face, when they are hissing, th eir ears go out and th eir back goes up, because he’s afraid. I’d stick with that.

II. 30" 1. I guess w hat I’d get o ut o f this is two cartoon people touching hands, OK? W hat else do you want me to describe? T hey’re exagger­ ated cartoon people because they have a pointed head, and stripes which would be their backs, and definitely an eye on each creature, and a lit­ tle m outh and nose and a neck, with an exaggerated body, and each one is touching a h and, and as the body comes dow n, the red p a rt would be a leg, and they have an o th er leg in back, and the b u m p in the m iddle would be the tail.

Inquiry

Scoring

1. T h e en tire picture ju s t looks like, is a cat’s face; a black cat th a t got frig h t­ ened, the ears kind o f go u p like they do, and the m outh is kind o f exagger­ ated, an d th a t was my im m ediate thought was a black cat’s face. (?) Ju st d ef­ initely the whole entire shape; the eyes, ears, nose; ju s t a com plete picture o f a cat. (Frightened or hissing?) I'he ex aggerated m outh and ears kind o f sticking o ut ra th er th an up, like cats usually are. It’s an exagger­ ated picture, b ut th a t’s how I’d describe it.

W FM .FC'Ad

1. Just the n a tu re o f it; it was m ore fantasy-type inkblot: I couldn’t get anyth in g realistic o u t o f it, so it b ro u g h t to m ind cartoons for children.

W M (H)P

M ajor A ffective Disorders / 2 0 7

R o rsc h a ch Sum m ary

Response

Inquiry

1. T hey’re all so . . . All I do is see all these fantasy an i­ mals here. It looks like two chickens with the beak and the neck an d one leg, and it alm ost looks like the leg has a high heel on, and 1 would say it would be two women chickens, because they got a little plum e down here, so maybe they’re dressed to go out, and this red bow in the m iddle, so maybe they’ie excited about going out on a d a te — you know how they have it on the cartoons, and this bow m ight represent their heart, each one's h eart, that they’re excited about w hat they’re going to do.

1. (Chickens}) They ju s t look like chickens to me, having watched so m any cartoons with the kids, it ju s t resem ­ bles chickens. (Women chick­ ens}) Like leg had high heel and the plum e, like they were dressed lip to go out, the shape looks like a plum e in each o f their hands. (Red bow}) Repre­ sented each o f th eir hearts, so their hearts were excited, they were going out. (Hearts}) Just the fact that they were dressed up and excited and it kind o f had the shape o f a heart, and they were connected, and sometimes 1 say 1 wear my h eart on my sleeve, so th a t’s how 1 use that.

WM(A) DF Cloth DFC Cloth P Confab.

1. Just because o f watching from when the kids were little— there was a m onster sim ilar to that on a C h rist­ mas show— a snow m on­ ster, and my son used to get afraid o f th at m onster and we used to have to tu rn it off. (Anything eke) No, ju st the whole blot itself, like the story we used to watch.

WF(A) Fab.

Scoring

III. 36"

IV. 5" 1. 1 see n o th in g but cartoons (Laugh). Is that unusual? I know you can’t say. T his also looks like a m onster feature, and 1 would say this is like bigfoot, because he has huge feet and a large tail and tiny arm s and a tiny head, but a head like an alligator, so he could be dangerous. So th a t’s basi­ cally w hat I see this as— a cartoon monster, and 1 would call him bigfoot.

2 0 8 / Psychological Assessment, Psychiatric Diagnosis, a m i Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

1. T h is looks like a butterfly, definitely, w ith th e long w ings an d a n te n n a e an d head , an d a little p a rt th a t com es out a t the e n d o f the butterfly. It’s ex a g g erated , because it’s n ot perfect like a butterfly, b u t it rem in d s m e o f a butterfly.

1. T h e whole th in g — a b u tte r­ fly w ith th e w ings sp rea d open.

W FM A P

T h e h ead m ad e me th in k it was a cat, an d it b ein g flat­ tened o u t an d o p en e d up m ade m e th in k it was in an accident a n d som eone ran over it, because it w ouldn’t be in th a t sh ap e if som e­ th in g h a d n ’t h a p p e n e d to it b u t still alive.

W FM (A)

(Women}) T h e h ea d s— definitely very fem inine looking heads. (Hair}) T h e way it was sta n d in g straig h t up, a n d p u ffy the front.

YVMHP

Scoring

V. 7"

VI. 3 ' 1. O h G od, here we go again with m ore anim als. T h is is sad, b u t it looks like a cat th at som eone ra n over, and the p o o r th in g is squashed, a n d we’ve got the h ead with th e little w hiskers com ing out, an d the neck, a n d his w hole body has been o p en ed a n d sm ashed, an d it rem in d s m e o f a cat th at som eone ran over— very sad. VII. 10" 1. O h , gosh. (Laugh) O K , this one ag ain looks like two women th at are d ancing. T hey’ve tu rn e d a ro u n d to look at each other. You see the long h a ir fixed so it stan d s stra ig h t up, the puff o f h a ir on th e forehead, the nose, m o u th , one h an d . T hey ’re d a n cin g from the side. T h is is like a th eatrical play w here they’re d an c in g a n d they’ve kind o f backed in to each o th e r a n d they tu rn e d to face each other. You can see one h a n d an d one foot. O f co u rse it’s ex ag g erated , b u t basically th a t’s it.

M ajor A ffective Disorders / 2 0 9

R orschach Sum m ary

Response

Inquiry

Scoring

VIII. 37" O h, wow! H m m m . T h a t’s in color. H m m , let’s see. OK. H m m . . . 1. OK, this to m e looks like two polar bears trying to climb up the side o f a gla­ cier snowy m ountain to the top, which is the gray area, the snowy area and you definitely see four legs and the shape o f a polar bear and the head, and on the left one an ear. They’re try­ ing to climb up to the snow peak, which is the gray area.

(Polar bears}) Im m ediately they resem bled polar bears; not so fantasylooking; like real polar bears, and going u p to the gray area, the snowy area.(Why polar bears}) Just because I think o f the real cold, and it looks like they h ad a h a rd tim e getting up to the icy top, and the gray area looks like snow, so th a t’s why I picked polar bears.

DFMAP DFC’Ldsc

(How do you see it}) Just as a fantasy creature, like in a cartoon, like from o uter space, th at would ru n around and do silly things. (Anything else}) Just the horns on the nose and the pointy head; those rem ind me o f things th a t you see on those o u ter space car­ toons th at they watch, you know, media.

DF(H)

IX. 25" O h, wow— I don’t know if I see anything. W hat h a p ­ pens if you don’t see anything? 1. T h e only thin g I would say is th at it would be a very exaggered cartoon crea­ tu re with a pointed head, and eye, a m outh, an d a big long nose th at comes o ut in several kinds o f pointers or antlers, and it’s got a funny balloon-shaped body. I really can’t get anything out o f the o th er two . . .

DC Color

2. T h e aqua and the pink; they ju s t look like blobs, blobs o f color. I can’t say I see anythin g in those. 3. Also, as I look at it I see a dust m op, with the handle and the m op part.

3. (Dust mop}) T he handle was right there, and it was the shape o f a d u st mop, and they do some in various colors, so it could definitely be a d u st mop.

DFCHObj.

2 1 0 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R orschach Sum m ary

Response X. 50" O h G od, you got lots on here. H m m , O h G od. OK. Hmmm. I would say this is . . . real fantasy, OK, but it rem inds m e o f sum m er, and

the two pink objects could rem ind you o f seahorses, and this blue out here on each side could be coral th a t you find at the beach, and.

4. the gray up at th e — again, as I said, this is m ore fantasy— could be, some­ times you see those crabs at the beach? 5. A nd dow-n here this green, green area could be an exaggerated fantasy cater­ pillar because it has two bodies but one head. So he’s a fantasy caterpillar.

Inquiry

1. {Summer}) First o f all, the b rig h t colors, and the fantasy seahorses, crabs, and caterpillar, an d su m m er is my favorite season; I think a lot o f the pastels they used in the picture rem ind me o f sum m er, and a lot o f the things you see at the beach. 2. (Seahorses?) T h e shape.

3. {Coral}) T h e way it was kind o f broken and spread ap art, because the coral you find can be sharp and you have to be careful with it. 4. T he sand crabs— the gray crabs at the beach resemble the ones at the top o f the picture. 5. {Caterpillar}) T h e head an d the coloring, and it looks like a caterpillar, and the two bodies m ade me say a fantasy caterpillar, and they do shed when they become a butterfly anyway, so . . . (?) So they lose one body and get another. (?) He’s definitely a fantasy caterpillar, because you only see real caterpillars with one body.

Scoring

WCsym. S um m er

DFA

DFCoral

DF-A

DFCA

Major Affective Disorders ! 211

EXHIBIT

4

S e n t e n c e C o m p l e t io n T e st

1.

When she was completely on her own, she “b ecam e very in d e p e n d e n t.”

3.

It looked impossible, so she “trie d even h a rd e r to accom plish th e task .”

5.

When he refused her, she “felt very re je c te d .”

8.

As a child my greatest fear was “th a t so m eth in g m ig h t h a p p e n to my

9.

My father always “a very c a rin g a n d loving m a n .”

fath er.” 10. The idecd man "is on e w ho loves you ju s t th e way you a re!” 11. A woman who falls in love “should know h e r m an a n d love him ju s t th e way he is a n d not w ant to c h a n g e h im .” 12.

I was most depressed when “my e x -h u sb an d took m y c h ild ren out o f

13.

My first reaction to him urn “th a t 1 will not let him get me d ep ressed

state ju s t because I was in the h o sp ita l.” again. I will be stro n g a n d take legal action.” 14.

When he turned me down, I “was rejected a fte r m an y reconciliations b u t 1 am now stro n g .”

16.

Most fathers “are very loving an d protective o f th e ir c h ild re n .”

19. I could hate a person who “lies a n d uses o th e r p eo p le .” 20. Her earliest memory of her mother was “a very loving a n d friendly p e rs o n .” 21.

The ideal women “is w ho loves a n d cherishes h e r c h ild re n b u t shows th em they have choices.”

24.

When I think back, I am ashamed that I “was not stro n g in my convictions.”

27. She felt her lack o f success um due to “lack of h a rd w ork.” 29. I used to daydream about “hav in g a w o n d erfu l fam ily o f father, m o th e r a n d sons.” 30. Most men “are honest, h a rd -w o rk in g a n d fa ith fu l.” 34. / was most annoyed when “m y ex -h u sb a n d was not tr u th fu l with m e.” 35.

When she thought of her mother, she “th o u g h t o f a very loving a n d c a r­ ing p e rs o n .”

36. Taking orders “helps you in later life.” 37. I dislike to “h u r t p eo p le if it’s not necessary.”

212 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning S e n t e n c e C o m p l e t io n T e s t

43.

Shefelt she had done wrong when she “d id n ’t listen to the o th e r persons

44.

She felt she couldn't succeed unless she “started to p u t m ore effo rt into

sides o f the story.” h er jo b .” 48.

When she failed the examination, she “was an g ry because she d id n ’t study.”

55.

She felt she could murder a woman who “w ronged her. I feel you could

62.

Responsibility “I feel 1 am a very responsible p erso n .”

never m u rd e r a w om an.” 64.

She felt blue when “th e boy she w anted to ask h er to the dance asked som eone else.”

69.

I feel guilty about “divorce b u t I have com e to believe I d id all I could

73.

People in authority “a re necessary to m ake jo b s, schools, hospitals, etc. ru n in an o rd erly m an n er.”

74.

/ feel happiest when “I am with my ch ild ren and we are ju s t enjoying

to m ake it work an d it d id n ’t work.”

81. 84.

each other.” Most women act as tlwugh “they m ust be in d ep en d e n t an d su p p o rt them selves.” Most people are “nice an d honest until they prove themselves d iffe r­ en t to m e.”

91. 100.

Sometimes I feel that my boss “m akes a lot o f d em an d s on my personal life.” I feel sad about “b reak -u p o f my family b u t divorce is a fact o f life an d I am strong an d I will raise my c h ild ren a n d have a g o o d a n d happy life with th em .”

Major Affective Disorders / 213

DISCUSSION W hile b o th Mrs. I), a 47-year-old, divorced m o th er o f two, and Mr. F, a 24-year-old g rad u ate stu d en t, ex perienced agitated, melancholic dep res­ sions severe en oug h to w arran t hospitalization, the sim ilarities en d there. Mrs. D was depressed over a n u m b er o f m onths in a p p a re n t reaction to a clear stress, the loss o f the attention an d affection o f h er h u sb an d who h ad recently left her. A personal equilibrium th a t h ad been working prior to this stress was destroyed. She suffered some o f the classical signs o f depression with m elancholia: d istu rb ed sleep, freq u en t crying spells, and p oor appetite with a loss o f weight. At times her fears th at others (including the hospital staff) would h a rm h e r reached p aran o id proportions. She was not responsive to a b rief hospitalization an d reinstatem ent o f her previously effective medication regimen. T hus, in the context o f her failure to respond to acute treatm en t, she was referred for a m ore extended hospital stay. Psy­ chological testing was requested to help assess h er intellectual abilities and h er capacity to utilize eith er a supportive o r an expressive psychotherapy. Mr. F also experienced growing sym ptom s o f depression, including exces­ sive guilt, psychom otor agitation, p oor sleep, an d disinterest in his usual activities. His th in k in g was d istu rb ed , an d he rep o rted confusion an d was preoccupied with being hom osexual. Like Mrs. D, he failed to respond to a b rie f hospitalization an d m edication. It was in this context th a t psycho­ logical testing was requested. T h e ch ief referral question concerned the extent an d severity o f his th o u g h t disorder. T h u s, in both cases, the assessm ent o f a p atient with depression who d id not exhibit the expected, positive response to acute hospitalization and m edication form ed the background o f the referral for psychological testing. Developmental issues were m ore pronounced with Mr. F, as he was relatively young an d preoccupied w ith sexual identity issues. Mrs. D was older, with a previous history o f adequate functioning, including a connection to a hus­ band and two children. In b oth cases, the referral question req u ired a weighing o f strengths and weaknesses in o rd er to plan an optim al treatm ent for som eone not resp o n d in g to an a p p ro p riate m edical tre a tm e n t strategy. Mr. F’s testing revealed a bright (I.Q. o f 122) but frightened and anxious young m an w ith psychotic th in k in g an d m ajor dynam ic them es involving his fear o f the developm ental tasks o f young a dulthood. His needs for su p ­ port and n u rtu ran ce conflicted with his desire for independence and auton­ omy. T his conflict was reflected in his fear o f homosexuality. Both o f these test features led to the recom m endation o f a structured intervention, at least for the present, and family therapy to assist in a m ore p lanned an d artic­ u lated em ancipation from the family o f origin.

214 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning In contrast, Mrs. D’s test results revealed an I.Q . o f 88. In u n stru ctu re d situations, she relied on unim aginative responses, and seem ed to possess little internal organization on which she could draw. H er th in k in g was less overtly disturbed than th at o f Mr. F. H er ut icon dieted and ego-syntonic reli­ ance on external authority and structure, plus her relatively low-normal I.Q., led to the treatm ent recom m endation o f a supportive rath er th an an expres­ sive psychotherapy. In both cases, the sym ptom s o f depression were clear an d well evaluated before the referral for psychological testing. T h e testing was not used to d iagnose depression, but to clarify the personality stren g th s an d w eak­ nesses, the defensive styles, the dynam ic them es an d preoccupations, an d the intellectual resources o f th e patients. Especially u n clear in b o th situ ­ ations was the level o f intellectual an d cognitive functioning: present func­ tional I.Q., and the extent and severity o f thought disorder. This additional inform ation from psychological testing in b o th cases led to m odifications in the psychosocial intervention.

B. BIPOLAR M ANIA: PRIOR TO A N D DURING A MANIC EPISODE Patients with bipolar d iso rd er have experienced one o r m ore m anic epi­ sodes, an d most have also ex perienced episodes o f depression. Manic ep i­ sodes are characterized by an expansive an d elevated m ood, accom panied by such behaviors as restlessness, talkativeness, flight o f ideas, grandiosity, distractibility, an d excessive involvement in activities th a t can be h a rm fu l an d /o r self-destructive, such as buying sprees an d sexual indiscretions. Differential diagnosis relevant to treatm ent planning involves distinguish­ ing bipolar disorder from schizoaffective disorders and cyclothymia. Espe­ cially relevant to treatm en t p lan n in g are the personality features, both diagnostic (Axis II) and nondiagnostic. These features can assist in planning the form at o f treatm e n t as well as predicting an d sustaining functioning betw een episodes.

BIPOLAR, MANIC, W ITHOUT PSYCHOTIC FEATURES Ms. G is a 23-year-old, single Jewish woman employed for seven m onths as an actuarial train ee at an insu ran ce company. Ms. G ’s family h ad en c o u r­ aged h er to take this jo b after she gained 25 p o unds a n d becam e increas­ ingly lethargic, sp en d in g all h er time at hom e with h e r parents and five y ounger siblings w atching television. With the continued encouragem ent o f h er fam ily and friends and the im pact o f h e r work routine, she was able

Major Affective Disorders / 215 to begin to restru ctu re h er life. She began d ietin g an d established a strict exercise program for herself which included jo g g in g up to nine miles each day. O ver the next four m onths, she set up a rigid routine o f rising early to jo g before going to h er jo b . U pon re tu rn in g from work, she would jo g until d in n ertim e. H er evenings were taken u p with a regim ented exercise pro g ram she designed for herself. In the m onth prior to adm ission, h er by now rigid routine began to unravel. H er family reported that she becam e increasingly irritable an d she began to have difficulty sleeping at night. H er activity level, previously quite high, began to vary from day to day. She briefly visited a form er classm ate an d re tu rn e d from th e visit d esp o n d en t at the barrenness o f h er life w hen co m p ared to th at o f h e r friends. In the succeeding two weeks, periods o f calm ness an d ad eq u ate functioning becam e m ore frequently p u n c tu a ted with periods o f irritability, agitation, an d crying. H er m ood was becom ing m ore labile and h er sleep m ore erratic. She sto p p ed eatin g and was often restless, pacing abou t the house and u nable to sit still. Finally, in the week p rior to adm ission, she quit h er jo b . She claim ed th at she n eed ed the time to attend to several medical appointm ents, but never m ade any. Several days later she asked her father for help in contacting a female therapist. She had seen a male psychiatrist for several months following a previous psychiatric hospitalization, but had sto p p ed seeing him afte r an a rg u m e n t about con­ tin u in g on h er m edication. H er fath er d id not follow up on h er request. In the two days prio r to adm ission, she was involved in a physical alter­ cation with one o f h er sisters who refused to ru n an e rra n d for her. Ms. G described h er m ind as b ein g in turm oil from this p o in t on and h er rec­ ollection o f events was sketchy. As best she could recall, she ran next do o r to h er neighbors and called the police, claiming th at her parents had beaten her up. She was frightened o f w hat was h ap p en in g to her and late that night placed a call to h er form er psychiatrist. He was able to interced e with both the p atien t and h er family an d , after m uch discussion, the situation was resolved. T h e next evening, she left the house w ithout telling anyone w here she was going and her parents, after retu rn in g in the late evening from a social engagem ent, beg an to search for her. She d id n ot re tu rn hom e u ntil the next m orning, statin g th a t she had sp en t the night in a local p ark with friends. H er fath er contacted these youngsters who den ied know ing the patien t and said th a t she sat by h erself all n ig h t in the school yard talking to no one. Ms. G ’s p arents were able to p ersu ad e her to m ake an ap p o in tm en t with her form er psychiatrist. Shortly before the appointm ent, however, she again w andered away from the house an d spent the evening w alking th ro u g h the woods in a nature preserve near her home. She had been repeatedly w arned

216 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Plan ning not to venture into this are a alone at night as it was notoriously unsafe. W hile there, she m et a young m an with whom she was found kissing on a street co rn er by h er father. F inding h er e n g ag ed in such reckless behavior, her p aren ts were sufficiently concerned to b rin g h er to the hospital to have h er adm itted, fearing for her continued physical safety if allowed to rem ain at home. O n adm ission to th e hospital, she was described as a slim wom an who, for a variety o f reasons, was difficult to interview. She was preoccupied with h er physical ap p eara n c e an d was constantly re a rra n g in g h er clothes and her hair and staring intently at her hands and nails. W hen not preoccupied with her physical appearance, she gazed suspiciously aro u n d the room and seldom m ade eye contact with the interviewer. H er distractibility m ade it difficult for h er to concentrate an d she seem ed to have a great deal o f d if­ ficulty expressing herself, at times m aking motions as if to speak and being unable to do so. W hen directly questioned, she denied having any delusions o r hallucinations. She was alternately tearfu l an d anxious. She gave a d is­ jo in te d account o f h e r recent life an d gave as her reason for seeking hos­ pitalization th a t “I need help to come to term s with my sexuality an d get better.”

DSM -III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV: V':

A typical psychosis D eferred N one M ild— quit h e r jo b : a rg u m e n t with h er sister Fair— m oderate im pairm ent in both social and occupational functioning

Treatment and H ospital Course A year prior to the present adm ission, Ms. G h ad been a d m itted to the hospital with m uch the sam e symptomatology. She had responded well d u r­ ing h er previous hospitalization an d was disch arg ed as im proved. She had continued to see a psychiatrist until they d isag reed on the need for her to rem ain on m edication. W hen readm itted, an initial treatm ent plan was developed which focused on the reduction o f h er disorganization through individual, supportive psy­ chotherapy an d g ro u p psychotherapy. Family work was institu ted with the goal o f a rra n g in g alternative living a rran g em en ts following h e r hospital­

Major Affective Disorders I 217 ization. T h e provision o f a stru ctu red activity and d iet plan was felt to be im p o rtan t to help h er begin to reorganize h er daily routine. O ver the next several weeks, she was generally cooperative with h er hos­ pital treatm en t plan an d m an ag ed to m ake a m odest recovery. H er g ro o m ­ ing im proved an d re tu rn e d to its form er m eticulous level. W hen eng ag ed in stru ctu red activity, she was able to concentrate on the task at h an d and to work towards successful completion. However, her perfectionistic strivings occasionally interfered with this an d she continued to have difficulty in adapting to a more llexible approach. Left to her own devices w ithout clear plans or goals, she still evidenced a noticeable tendency to become som ewhat disorganized. H er most active treatm ent involvement was in her family th er­ apy. H er difficulties in living at hom e an d her need to separate from h er family were the focus o f h er family work an d led to disch arg e plans which involved h er in continued o u tp atien t treatm en t an d living in a halfway house. She was referred for day hospital treatm en t as a transitional phase betw een the hospital an d re tu rn in g to full-tim e em ploym ent.

P sychological A ssessm ent Psychological testing w'as b egun in the eighth week o f Ms. G ’s hospital­ ization, approxim ately h a lf way through h er hospital stay. She was given the WAIS, R orschach, B enton Visual Retention Test, an d the O bject S orting Test in an effort to resolve the rem aining u ncertainty re g a rd in g her d iag ­ nosis. A lthough given an ad m ittin g diagnosis o f atypical psychosis, the course o f h er illness, the n a tu re o f h e r sym ptom s, an d the d e g ree o f her disorganization did not help the treatm ent staff in form ulating a m ore pre­ cise diagnosis for Ms. G. In addition, the p rio r history o f hospitalizations without psychotic sym ptom s led several o f the treatm ent staff to raise issues concerning the possible diagnosis o f a personality disorder. Additionally, it was hoped th at the n a tu re an d d eg ree o f h e r continued disorganization in u n stru c tu re d situations could be clarified. Ms. G was cooperative with all testing procedures an d was m otivated to perform well. She arrived for each testing session meticulously dressed, each tim e in a different, well-tailored outfit. She gave m ore the ap p e a ra n c e o f a young businessw om an th an o f a p atien t in a psychiatric hospital. H er dress an d m a n n er gave the im pression o f som eone carefully a ttu n e d to external appearances and with an eye for detail. Ms. G ’s careful ex tern al prep aratio n for the psychological exam ination seem ed som ewhat at o d ds with the irritable, restless, and distracted person described in the initial referral. T h ere was some evidence o f her form er irri­ tability d u rin g her exam ination. For exam ple, on the WAIS C om prehension

2 1 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning subscale, th e item re q u irin g an ex p la n a tio n for how one w ould go about fin d in g one’s way o u t o f a forest p ro m p te d th e facetious resp o n se, “Ask a sq u irrel. No, even I w ouldn’t be th a t stu p id . You should ju s t keep w alking u n til you g et to a clea rin g . You may fin d a lake o r so m eth in g . All th e trees a re w hat m ake you lost. I have to find o p e n sp ac e .” An expansive a n d g ra n d io se a ir also seem ed p artly to ch arac te rize h e r m o od. In resp o n se to why p eo p le should pay taxes, she o ffered , “S ophia Loren d id n ’t , she th o u g h t th e rest in jail would do h er g o o d .” To the Vocab­ ulary su b test item calamity, she th in k s o f C alam ity Ja n e a n d th en rem ark s th a t, “ I can m ake u p so m e th in g b u t I don’t know. S om eone who has a lot o f sp irit, involved in trickery, w ho knows how to o u tw it so m eo n e.” H er ap p aren tly fluid associative style as seen in h er definition o f calamity correlates with the clinical findings o f h er clistractibility an d racing thoughts. Moreover, in several instances d u rin g th e psychological ex am in atio n , an d especially u n d e r tim e pressure o r in the context o f a m ore expansive m ood, she seem ed subject to u n ex p e cte d e rro rs o r a p erseverative fixation on details. For exam ple, u n d e r tim e p ressu re on th e A rith m etic su b test o f th e WAIS, she m akes a subtraction e rro r on an early item and resorts to w riting out a second, later item on th e palm o f h er h a n d an d so loses th e tim e bonus for h er correct answer. H er Picture C om pletion subscale score on th e WAIS is low ered by h e r fixation on irrelevant details. For som eone so clearly a ttu n e d to e x te rn a l a p p ea ra n ce s, she is su rp risin g ly u n a b le to identify th e m issing a rm in the reflection, th e m issing fin g er on the h an d , a n d the miss­ in g eyebrow as th e a b sen t d etails in th e sketches. W hile these dif ficulties m ake only a m in o r c o n trib u tio n to h e r cognitive inefficiency u n d e r th e stru c tu re d testin g situ atio n pro v id ed by th e WAIS, w here she functioned on an overall average level w ith full scale, verbal, an d p erfo rm a n c e IQs o f 108, 109 a n d 104, respectively, they becom e m ajo r lia­ bilities u n d e r th e less stru c tu re d conditions o f th e O b ject S o rt a n d R or­ schach testin g situations. In each o f th e first seven item s o f th e O b ject Sort test re q u irin g th e su b ject to choose all objects w hich “b elong w ith ” a stim ­ u lus object , h e r final assem blage o f item s is scored as loose. For ex am p le, she chooses th e larg e sp o o n a n d knife, th e toy sp o o n , knife, a n d fork, th e real a n d toy pliers, screw driver, cig arette a n d cigar, th e p ip e, th e toy h a m ­ mer, th e corks, bell, m atches, ru b b e r sto p p er, w hite c a rd , a n d piece o f p aper, th e su g a r cubes a n d th e e ra s e r as all “b elo n g in g to g e th e r” w ith the stim ulus object o f the large fork. She gives as h e r reason for all o f these items “b elo n g in g to g e th e r” as th e fork b ein g an e a tin g utensil, “so I picked the knife a n d th e spoon . T h e se a re tools for e a tin g so I picked th e o th e r tools. T h e ru b b e r th in g (sto p p e r) is w hat you’d use to o p en th in g s for d in n e r a n d th e index ca rd is for th e recipe. T h e p a p e r you’d use for th e sh o p p in g list a n d th e e ra se r is for if you m ad e a m istake. T h e bell rem in d s me o f th e

Major Affective Disorders I 219 d in n e r bell. T h e cigars, cigarettes, and m atches are for sm oking afte r d in ­ n er which I associate with eating. T h e corks a re for the wine after d in n e r an d the su g ar cubes are for the cof fee.’" T h e loose concept o f a meal, from the sh o pping to the cigarette an d coffee afterw ards, is highly u nusual in such a context where most subjects tend to choose much narrow er concepts for organizing the sort. H er overinclusiveness and h er tendency to move f reely f rom one association to the next while guided by a large, background idea is universally noted th ro u g h o u t the O bject S orting Test. As with the O bject S o rtin g Test, the Rorschach is in terp reted by Ms. G as an o p p o rtu n ity to give free rein to w hatever th o u g h ts e n te r h er m ind as she is confronted with th e percep tu al am biguity o f th e inkblots. She evi­ denced a high level o f verbal productivity w hen she was given the Ror­ schach. In contrast to an average of 2 0 -3 0 responses given by most individuals, she p rod u ced a total o f 74 responses, usually initiating h er responses rapidly, within 5—15 seconds o f being presented the card. She ten d ed to focus on details o f the blots at the expense o f organized whole responses, a n d m any o f h er detail responses m ade use o f u nusual areas o f the blots or o f the white space. H er approach to the Rorschach was generally characterized by an altern atio n betw een an unreflective, overinclusive a tti­ tu d e an d p eriods o f preoccupation with endless details. T h e personal idiosyncrasy o f her response style is also noted in the absolute paucity o f p o p u la r responses (3). However, anim als, com m on­ place objects and plants com prised nearly tw o-thirds o f h er responses. W hen color and shading, which tap affective reactivity and anxiety com ­ ponents, respectively, form ed p a rt o f the d ete rm in an ts o f the response, th ere was a distinct preference for em phasizing these features as p ri­ mary, with form characteristics secondary. T h u s, 70 p ercen t o f these com plex responses were scored with eith er color o r sh ad in g as th e pri­ m ary d e term in an t, at tim es with form reflecting reality appreciation which was som ew hat uncertain. W hen this latter observation is taken in com bination with the content o f m any o f h er responses, the initial im pression o f a som ew hat idiosyncratic but generally bland and unrem arkable protocol requires some modification. M any o f the responses are seen as decorative o r occu r in festive settings. A bell and a m ask are seen on card /; w hite doves a n d a flower are seen on card 111-, card IV produces a rosebud an d people with long, flowing veils; card VI contains a starb u rst and card VII a n o th er bell; cards VIII and IX both have flowers, with card IX having a parasol an d a chiffon blouse with high collar an d puffy sleeves as well; cardX provides both fireworks an d stream ­ ers. T hese responses typically occur in isolation ra th e r th a n as p a rt o f a larger, m ore organized festive scene. T hey are rem iniscent o f h er focus on external appearances and h er fascination with detail, while at the sam e time

2 20 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning d em o n stratin g h er considerable difficulty in p roperly ap p reciatin g these elem ents as parts o f a larger, com plex scene. H er organizational dif ficulties m ight also be viewed from the vantage point o f a pronounced em otional sensitivity an d responsivity. She is easily th reaten ed by an environm ent she often perceived as d an g ero u s an d destructive as reflected in h e r response o f “a cat who’s been electro cu ted ” on card VI o f the Rorschach. In the face o f such th rea t she som etim es retreats into an avoidant passivity. N ondescript leaf percepts p resented on several of the inkblots represent this trend. She feels especially insecure and vulnerable w ith reg ard to establishing h er psychosexual identification beyond surface appearances. O n card III o f the Rorschach, she could not d eterm in e the sex o f the p o p u la r h u m a n figures, ultim ately d ecid in g th at they were “h alf male and h alf fem ale.” O ften feeling inundated by her expe­ rienced problem s, she sometimes feels that she is in the “bottomless pit” she perceived on card IV, from which th ere is little hope o f escape.

Treatment P lanning and O utcom e U pon review o f h er test m aterials, the ex am in in g psychologist e m p h a ­ sized Ms. G ’s “magical and unrealistic thinking, peculiar, overprecise speech, suspiciousness, paranoid ideation, and hypersensitivity to criticism” as psy­ chological test findings which com prom ised her capacity to function effec­ tively in u n stru c tu re d settings. H er awareness o f these difficulties was perhap s behind her prehospitalization attem pts to regim ent and o rd e r her daily routine. H er em phasis on “superficial an d external criteria” was seen as related to narcissistic elements o f her personality functioning and m ight be seen as attem p ts to establish h e r identity by proclam ation ra th e r th an by identification and integration. Ms. G ’s treatm ent team was able to m ake use o f these findings to e m p h a ­ size with b oth h er an d h er family th e n eed for a stru c tu re d aftercare p ro ­ gram . They therefore focused the bulk o f their energies on helping h er and h er family work th ro u g h the need for h er to move o ut o f the house into a stru c tu re d residential settin g and atten d a day hospital as interm ed iate steps to help h er ultimately retu rn to work an d p u rsu e a more independent living situation. H er attention to external appearances was an asset in help­ in g h er to gain acceptance at a halfway house an d h e r reality testing and acceptance o f h er illness im proved to a significant d eg ree so th a t she was able to recognize the need for these aftercare plans. Additionally, she agreed to re tu rn to o u tp atien t treatm en t with h er form er psychiatrist, who would also continue to work with the family. T h e com bination o f the psychological test results an d the brevity o f Ms.

Major Affective Disorders I 221 G ’s sym ptom atology p rio r to adm ission led to a single d ischarge diagnosis o f schizotypal personality disorder. However, m any elements o f her psycho­ logical test results and her clinical sym ptom atology (ignoring its brevity due to rap id hospitalization) are characteristic o f a bipolar disorder. A lthough she presented few clear-cut, classical features o f b ipolar patients d u rin g a m anic phase o f th e ir illness, o u r review o f h e r psychological test findings seem ed m ost consistent w ith a diagnosis o f b ipolar disorder. Following h er d isch arg e from the hospital, Ms. G d id well for a tim e b u t was read m itted . At th a t tim e, th e clinical p icture h ad resolved an d it was possible to m ake the b ipolar diagnosis. She has since done well o u t o f the hospital, rem aining u n d e r psychiatric care with continuing pharmacological treatm ent b u t m anag in g to re tu rn to full-tim e em ploym ent and moving from the halfway house to a supportive g ro u p a p a rtm e n t w here her daily functioning can be m onitored an d fu rth e r am eliorated.

2 2 2 / Psychological Assessment, Psychiatric. Diagnosis, a n d Treatment P la n n in g

EXHIBIT

I.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Sym ptom s/D iagnosis Bipolar, manic, without psychosis Fights with sister Irritab le m ood C rying spells U nable to sit still Restless Racing thoughts Distractibility

Involvement in activ­ ities with p o ten ­ tially painful consequences

Describes h er m ind as “in tu rm o il” Gaze w anders; poor con­ centration; overcon­ cern with m inor m atters Goes to secluded area with stran g er despite past w arnings

Irritab le an d expansive m ood Acts w ithout deliberation u n d e r tim e constraint Uncritically overinclusive and perseverative Alternately, focuses on m inor details at the expense o f a larger, more integ rated view Im pulsive, swayed by her feelings o f the m om ent

II. Personality Factors

U npredictable and impulsive

Actions are inap p ro p riate to larg er social context

III. Cognitive Abilities

Average intelligence

Average intelligence

Self-preoccupation and sensitive to rejection

Feels vulnerable and readily becomes absorbed in internal world

Ability to profit from stru ctu re

Perform s best with a high level o f external stru ctu re Lack o f a cohesive id en ­ tity ham p ers independence

IV. Psychodynam ics

V.

T herap eu tic E nabling Factors

Desire to separate from h er family VI. Environm ental D em and and Social A djustm ent

Few friends and difficulty sustaining relation­ ships with others Feels overprotected by p arents b ut frequently relies on their assist­ ance and ju d g m e n t

Potentially affectively responsive b ut readily th reaten ed and quick to w ithdraw Feels ra th e r powerless in the face o f ex ternal dem ands

Major Affective Disorders / 223

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests

Scaled Score

In fo rm atio n C o m p reh en sio n A rith m etic Sim ilarities Digit S pan V ocabulary

9 13 8 12 14 13

Performance Subtests Digit Sym bol P icture C om pletion Block D esign Pictu re A rra n g e m e n t O bject A ssem bly Verbal IQ Perform ance IQ Full Scale IQ

14 9 12 10 10 109 104 108

MMPI Sum m ary FLK /

2 '4 3 7 0 8 6 -1/9:5 R orschach Sum m ary

N u m b e r o f R esponses Rejections P o p u lars O rig in als Average R /T ch ro m atic Average R /T achrom atic F% F+ % A% H% W :M M :S um C

74 0 7 3 (- l) 6" 12" 55 53 34 16 11:5 5:4

224 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o rschach Sum m ary

m:c VIII-X% FK + F + Fc% (H + A):(Hd + Ad) Apperception W D d Dd + S

10:14 27 64 22:15 17% 53% 3% 27%

M ajor A ffective Disorders / 225

EXHIBIT

3

R orschach Sum m ary

Response

Inquiry

Scoring

I . 5"

WFAP

1. Looks to me like a bat. 2. O r a leaf. Has p art o f it missing.

2. T he way the edges were formed. (Any particular leaf?) Maple leaf.

WFPI

3. U p on top I see two chickens.

3. (?) Sections o f ink blot that looked like two chick­ ens. Feathers. (?) No, didn't say that. Yes, I did. T he way it was designed.

DFA

4. T his p a rt in here looks like a bell.

DFObj.

5. T his especially looks like a little creature with claws com ing out o f it.

5. You could see a little tiny face with beady eyes . . . a bat-type face. Little parts com ing out, looked like claws. (Was it a bat's face?) Looked like a little anim al in bat/squirrel family.

DFA

6 . T his p a rt in here is sort o f like an abstract design with negative and positive space contrasting it.

6 . W ithin the design there were open spaces. 1 always pay attention to contrasting sections. (?) Four white spaces helped to form shapes out o f negative spaces.

D C 'F Art Pec.

7. If you tu rn it upside down, it's alm ost like a mask. 8. Very interesting. Five points, pointy lines and soft aro u n d edges. 1 think it would have m ore conti­ nuity if lines cam e to a point. T hese are too sharp.

WF Obj.

8 . (Soft?) Part had pointy lines diverging from cen­ ter and an o th er looked softer. (Soft?) Wasn’t a solid black. D ifferent g ra ­ dients in the tone.

WcF Abs. Confab

2 2 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatvient P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

II. 4" 1. Looks like a p air o f lungs.

1. They had . . . it was really an x-ray. H ad x-ray, smoky look. I think x-ray shows up as white, not black. It’s reversed.

2. Two faces looking at each other.

DFkAt

DM Hd

3. A n x-ray o f a chest.

DFk X-ray At

4. A lam p shade.

SF Obj. O

5. Two eagles. Eagle heads.

5. Two eagle heads. T he outline, the form. They weren’t distinct. I m ade them out to be.

DFAd

6 . A torch.

6 . (?) Way it was shaped. Actually, if you don't m ind, I think it looks like a penis. (?) T h e way it was shaped.

DF Obj DF Sex

7. A sea crab.

7. It had spidery things com ing o ut o f it. Pointy aro u n d the edges.

DFA

8 . A zipper.

8. It had those lines in it. Looked like a zipper opening. (Opening?) Like it was halfway pulled dow'n. It’s broken. Way it cam e apart.

diF Obj.

9. A hole. (Puls it at a distance and stares at it.) You’re draw n into this w hite spot in the center, like a parasol. 10. Reminds me o f cotton dolls, straw dolls.

SF Obj.

10. Dress and body, no head. (Straw dolls?) No, more th an outline.

SF(H d)

M ajor A ffective Disorders ! 2 2 7

R orsch a ch S um mary

Response Lizard or snake.

/ nquiry 11. Same p a rt th a t I called the penis. (What about blot made it look like snake}) Shape. May I see inkblot again? Rough edges on it.

Scoring DFA

III. 3" 1. Two figures. They're reaching arm s into . . . I can’t d eterm ine w hat sex they are. Like h alf male, h alf female.

1. ( What did you mean}) A p p eared th at they had busts on top, on bottom alm ost phallic symbols and shoes here high heels.

DM H P

T hese look like fish, almost.

2. (Fish}) Way they were shaped. H ad hands stuck in som ething, looked like the top o f a fish.

DFA

Butterfly.

3. (Butterfly?) Wings. Could have been a bow tie. Actu­ ally, it looked like an upside down butterfly. (Anything besides wings}) No. Body was missing.

DFAP

Looks like someone lay­ ing on their back, kicking their leg up in the air.

4. (?) Also looked like a sea horse. (?) Way leg or tail went.

DMH DFA

B irds, w hite doves.

5. (White doves}) Negative space. (What do you mean}) T he space aro u n d the inkblot itself.

SFC'A

Looks like a medical sign down there.

6 . H ad twisting lines.

drF-Syr

Looks like a flower. Looks like A frican heads.

drF P l (African heads}) Way it was shaped. (Anything besides shape}) More o f a prehis­ toric m an.

D FHd

2 2 8 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orsch a ch Sum m ary

Response

Inquiry

Scoring

IV. 24" 1. It also looks like a leaf to me.

T he outline. Looked like th e leaf had been d ip p ed in ink an d pressed onto card.

WFP1

2. Looks like a rosebud.

It seem ed th a t there were petals th at were opening. Have to change top. Doesn’t open till later on.

DF.FtnPl

DF A rch SF-Ldsc.

3. Castle in a valley. 4. People with long, flowing veils.

Women. W ind blowing th ro u g h them .

DF.mFH.Cl

5. A bottom less pit.

(?) It was d a rk an d center drew your eyes into it and downward.

d iC 'F Ldsc

6 . Dogs on their hind legs. 7. Looks like someone’s feet being tap p ed . You know, feet is u p in the air.

drFM -A 7. (Tapped?) Heel was u p in the air, like when it’s being flexed.

DM Hd Peculiar verbalization

8 . T hese are all like horns com ing out in the air. (Okay)

ddFAd

9. Kind o f like a dragon. Skull here.

DF(Ad)

Second sitting (next day) V. 2" 1. Looks like a bat. (Giggles) 2. Pair o f tweezers.

WFA 2. It was an opening. T he way they were opened, though I wouldn’t use those tweezers, because they’re obviously broken because they o p en th a t wide.

DF Obj.

M ajor A ffective Disorders / 2 2 9

R orschach S um m ary

Response

Inquiry

Scoring

3. A crow.

Has m outh o p en and face. Not too accurate.

DFMAd

4. A crocodile with his m outh open.

(?) Rem inded me o f those cartoons when I was younger o f a crocodile waiting in moats.

DFMAd

(Puts hand over various por­ tions of card.) WFMA

5. A bird in flight. (?) Shape. No indication o f foot o r thigh. Looked good and muscular.

dFH d

1. Looks like a cat who’s been electrocuted.

H ead, m outh, fat body, no tail. (?) W hiskers and paws, (What . . . electro­ cuted?) Way it was flat­ tened out and had all kinds o f ja g g ed lines and edges. (Flattened out?) Legs were straig h t out, not tucked under. Very round body. (Anything else?) Mainly face area. All those edges. (Anything else?) Stretched.

WFA

2. A leaf.

(Leap) Shape.

DFP1

3. O pen claws.

(W hal. . . open claws}) Just looked th at way.

diFM Ad

6 . Calves o f legs. (Okay)

VI. 8"

dFAt

4. Little heart. 5. A tunnel.

5. (Tunnel}) A d ark line going th rough the center, like an u n d erg ro u n d tu n ­ nel o f a worm.

D C 'F T unnel

2 3 0 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch S um m ary

Response 6 . A starburst. (Okay.)

V II. 21" 1. Dancers. 2. I get the im pression o f a leaf. 3. A bell. 4. Pig faces.

5. Razor blades.

I tufuiry 6 . (Wliat . . . slarhurst?) T h e gradients in tone. H ad like a sunflower-type appearance.

drC 'F P I

1. (?) Leg being kicked in air. 2. (Leaf ?) Just shape.

DM Hd

Snout-like, scrunched-up faces. (Scrunched up}) H ad w rinkled. (Wrin­ kled}) Darker lines going th rough it. (Razor}) Flat an d thin. (Anything else}) Square. (Thin}) Lightness o f the ink. (Say more}) Just seem ed very sm ooth. Dif­ ferent gradients o f ink m ade it look like one brush stroke.

6 . E lephant head. V III. 10 Pretty colors (smiles). 1. A fish.

2. B ird’s face.

Scoring

SFP1 SF-Obj. drFcA d

DFc Obj.

DFAd

1. (Fish}) T h e colors and the scales. (Scales}) T he d if­ ferent shades. 2. (Face}) T h e leathery effect and beak and shape. (Feathery}) Almost fu rry effect. Chicken’s type texture, baby chicken. (Texture}) Way ink was stroked on paper. (Anything else}) Wasn’t sm ooth outline. It was unfinished.

WFC.FcA

drFcA d

M ajor Affective Disorders ! 231

R o rschach S um m ary

Response 3. Racoon.

4. Flower.

Inquiry 3. Pair o f them . Seem ed perched on som ething, the way they were holding th eir heads down. A nd legs. (Anything else?) No. 4. (Flower?) It ju st kind o f b u rst open. Colors and shape o f petals.

Scoring DFMA

DCF.mFPl

5. T he skeletal system.

5. Seemed like bones. We used to draw bones in draw ing class.

DFAt

6 . Brushes. (Okay)

6 . (Brushes?) Strokes and the lines. (What do you mean?) Lines going th rough the d ark area th at m ade the outline.

d iC 'F Obj.

1. Flower.

1. (Flower?) Kind o f exotic flower. D ifferent colors and way it was o pening up. (Opening up?) 'I bp portion. It was spreading apart.

WCF.mFPI

2. Vase.

2. (?) I’d prefer it as reverse side. Makes b etter piece o f a rt work. Shape. (Any­ thing else?) No.

D(S)F Obj. Peculiar verbalization

IX. 12"

2 3 2 I Psychological Assessment, Psychiatric Diagnosis, an d Treatment P la n n in g

R o rschach Sum m ary

Response

Inquiry

Scoring

3. Parasol.

3. R uffled edges. (Ruffled?) Lines went in an d out, and up an d down. T he edge o f w hat looked like bottom o f a parasol.

d rF Obj.

4. Pool o f water, puddle. W ater drops, like form ed on a formica table.

4. (Water drops?) T he ink itself was m ixed with w ater and had a tra n sp a r­ ent effect. C luster o f w ater th a t fell o u t on table ju s t before it spreads out. (Transparent effect?) It wasn’t a solid tone. H ad clear, light look to it.

d rcF Water

5. Blouse.

5. H igh collared and puffy sleeves. (?) H ad chiffon look to it. (Chiffon look?) T he way the ink is used so lightly.

DFcCl

6 . O utfit. (Okay.)

6 . D ifferent colors.

W FCCloth

1. Fireworks.

1. T he bursts here. (Bursts?) Ink was spread out. (Anything else?) D ifferent colors.

DWCF Fireworks

2. Stream ers.

2. T hose pink. Seem ed to be moving like stream ers through the air. Whole card h ad party effect. C hild’s party.

DWmF.CF Obj, Party

X. 0"

3. M ustache. 4. Pair o f eyes.

D FH d 4. (Eyes?) First I saw a mus­ tache and those two dots were to com plete the face.

D FHd

M ajor Affective Disorders / 233

R orsch a ch Sum mary

Response

Iru/uiry

Scoring

5. Pair o f crabs.

DFA

6 . Little bat in center.

DFA

7. Insect. 8. Lobsters. (Okay.)

DFA (Lobsters?) Just those two areas. Had shell-like qual­ ity. Spindly claws. (What . . . shell quality?) Smooth­ ness o f the ink. (Anything else?) Shape.

DFcA

234 ! Psychological Assessment, Psychiatric Diagnosis, ami Treatment Planning

BIPOLAR DISORDER, MANIC, W ITH PSYCHOTIC FEATURES Mr. M was ad m itted to the hospital for the second tim e in the last year two days after C hristm as. T h e Day H ospital sta ff h ad tried for most o f the clay to persuade him to adm it him self voluntarily to the inpatient service. They had not been able to contact him for th re e days an d he h a d not been seen at the halfway house where he was living. Both staffs were concerned about his d eterio ratin g level o f functioning over the last two weeks. For the last few days, he had been celebrating the holiday in the bars o f a n eighboring city an d celebrating his decision to em b ark on a new career. At 29 years o f age, he felt th a t it was tim e he chose a career and the day before C h rist­ mas he had decided on a care e r as a political lobbyist ra th e r th a n e n terin g his fath er’s very successful re stau ra n t supply business. H aving m ade the decision, he felt th a t “the world was lifted from my shoulders.” He had re tu rn e d to his room to collect his personal belongings an d th en had coine to the Day H ospital to be disch arg ed from th eir care. He would not accept the Day H ospital sta ffs recom m endation o f hospitalization an d instead, th reaten ed them with legal action. He was finally hospitalized against his wishes on the recom m endation of two physicians who h ad worked with him in the Day H ospital. T h e previous C hristm as, Mr. M h ad also been preoccupied with his career plans. At that time, he was living with his father and stepm other hav­ ing given u p his own ap a rtm e n t one year before th a t following a suicide attem pt and brief hospitalization. He m ade two m inor suicide attem pts that previous C hristm as season in the context o f despair over his f u tu re and feel­ ing guilty about his sexual attraction to his stepsister. He was ad m itted to the hospital, w here he was given a diagnosis o f m ajor depression and responded well to a series o f 10 ECT treatm ents. He had been d ischarged to the Day H ospital in Ju n e . His a rro g a n t and d isd ain fu l a ttitu d e h a d kept him from m ak in g friends with the o th e r patients in the Day H ospital. He felt he h ad license to treat the sta ff an d th e ir recom m endations with con­ tem pt as his father h ad prom ised to employ him in his own com pany fol­ lowing his treatm en t in Day H ospital. Mr. M’s stepm other and th e Day H ospital staff finally h ad p e rsu ad ed his fath er o f the need to w ithdraw this o ffe r in o rd e r to help Mr. M develop m ore realistic career plans. W ith the o ffer w ithdraw n, the sta ff h ad grown m ore insistent th a t he ad h ere to the rules o f the p ro g ram . He becam e increasingly d efian t an d as the anniversary o f his suicide attem p ts ap p ro ach ed with the C h ristm as season, his behavior becam e m ore erratic and disorganized. W hen his car broke dow n an d he could no longer come an d go as he pleased, his atten d an ce at the Day H ospital becam e sporadic.

Major Affective Disorders ! 235 S uspecting the onset o f a manic episode, th e Day H ospital sta ff began a m edical w orkup to clear the patient for treatm en t with lithium and requested a psychological evaluation to help assess his present condition. A lthough the psychological evaluation was com pleted shortly before his inpatient admission, he procrastinated in gaining medical clearance for the lithium . In the face o f his escalating clinical state, he was involuntarily ad m itted to the in p atie n t service. At the tim e o f his adm ission to the in p atien t service, Mr. M was found to be quite cfistractible an d overactive. His speech was pressu red an d his th in k in g was described as tangential. His af fect was mildly expansive and elevated. He described his m ood as “h ap p y ” as he was looking forw ard to his planned career as a political lobbyist and was unshakable in his convic­ tion o f boundless success. H e said th at in the last few days he had had a great deal o f energy and h ad n ’t n eeded any sleep. He ap p aren tly recog­ nized his need for treatm en t, however, an d requested th at his legal status be ch an g ed to voluntary so th a t he could begin his lithium treatm en t. He was allowed, in fact, to convert his legal status th ree weeks a fter adm ission, at which time he wrote th at he was requesting the change in o rd e r to pursue a “m edication adjustm en t du e to a series o f hypom anic episodes.”

DSM -III-R D iagnosis Axis Axis Axis Axis

I: B ipolar disorder, manic, with psychotic features II: None IV': M ild— broke up with his girlfriend V:Poor— m o d erate im p airm en t in both social relations and occupational functioning

Treatment and H ospital Course Mr. M was initially treated with antipsychotic medication pending medical clearance for initiating treatm ent with lithium. W ithin a week and one-half, clearance was obtained, lithium was initiated, and ad eq u ate plasm a levels were achieved. His antipsychotic m edication was tap ered an d m aintained at a lower level th ro u g h o u t his hospitalization. His initial response to the antipsychotic m edication included d im inishm ent o f his pressured speech an d grandiosity and some im provem ent in his concentration. His th in k in g rem ained tangential, however, and he was prone to irritable outb u rsts, and rem ained overactive. At the end o f his second week on the lithium , his manic sym ptom s had completely rem itted and he was discharged to resume

236 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning his treatm en t at the Day H ospital and his living situation at the halfway house.

Psychological Assessm ent Mr. M was assessed by the psychologist in the Day H ospital two weeks p rior to his adm ission to the in p atien t service. His re ferrin g th erap ist reported that he had shown a recent increase in “erratic behavior,” had been talking to h im self in public places, and was m ore irritab le and u n co o p er­ ative with his treatm ent. T h e psychologist was asked to assess the possibility o f an em erging psychosis and the presence o f an affective disorder. He was given the WAIS-R, the MM PI, Rorschach, TAT, and SCT d u rin g the course o f the exam ination. His behavior d u rin g testing was noteworthy. He was described as arriving prom ptly for his th re e evaluation sessions an d generally was cooperative with the exam ination. However, he began m uttering o r h u m m in g to him self on several occasions and when questioned abo u t these behaviors, would attrib u te them to fatigue o r his interest in the flute, respectively. D u rin g a b rie f interview at the close o f the testing, he suddenly becam e an g ry an d refused to answ er any fu rth e r questions and would give no reason for his su d d en anger. His cognitive functioning as assessed with the WAIS-R was extremely var­ iable. He achieved full-scale, verbal, an d p erfo rm an ce IQs o f 102, 118 an d 85, respectively. His subscale scores ran g ed from the b o rd erlin e to very superior levels. His best p erfo rm an ce was achieved in those areas w here he could rely on the recall o f overlearned m aterial (Information and Vocabulary). T h ere was no evidence o f any acute d isru p tio n o f eith e r his attentional o r concentration abilities. His lowest score on the verbal subtests indicated a relative im p airm ent in his u n d e rsta n d in g o f conventional social norm s (iComprehension), although his absolute p erfo rm an ce was w ithin th e norm al range. O n the perform ance subtests, Mr. M dem onstrated both absolute and relative deficits in discrim inating essential from unessential details in pic­ torial representations (Picture Completion), a deficiency consistent with some difficulty in m aintaining adequate reality testing ability. His relative deficits on the perform ance subtests were generated prim arily by a com ­ bination of psychom otor slowing and ineffective trial and erro r strategies w hen he was unable to provide an im m ediate response. T hese d ifficul­ ties ap p eared to be more functional th an organic. Overall, his pattern o f relative strengths and weaknesses suggested that he was likely to be seen by others as having m ore th an an average intellectual endow m ent

Major Affective Disorders I 237 despite a history o f little b ette r th a n average educational perform ance an d his present test p erform ance. Mr. M s p erfo rm an ce on the less stru c tu red tests o f the battery, the Ror­ schach and TAT, also indicated difficulties w ith reality testing. O n the R or­ schach, he gave a total o f 44 responses an d although he relied alm ost exclusively on the form o f the inkblots to justify his percepts, his use o f form was idiosyncratic o r unusual in almost h alf of these responses (F + % = 53). His TAT stories suffered because o f his fluid thinking as well. He often had trouble com pleting the story because he was unable to determ ine the details o f the pictures. He would begin a story an d then, as his attention becam e distracted by some detail o f the p icture, he would eith er revise his original story or suggest several alternative stories, d epending on the interpretation o f the detail. For exam ple, his First story was told to a picture o f a seated boy w hose head rests on his hands. Before him is a violin an d a bow resting on some papers. Mr. M began his story in a conventional way by stating that it “looks like a child w ho’s looking over his music before he prepares to play the violin.” He could not d eterm in e if the boy was p re p a rin g to play the violin o r h ad in te rru p te d his playing to study the music an d so he tu rn e d his attention to the details o f the picture, hop in g to get some clue to the boy’s behavior. H e in te rp re te d a shadow on the boy’s face as “he has a wad o f chew ing tobacco in his m o u th ” an d as he went on to in spect the face, he stated th at the boy was “cross-eyed, actually. He’s looking inw ard, b o th eyes are in the inside p a rt.” T h ese details did not help him to decide betw een his original proposals; instead, he went on to w onder if the boy was sleeping. Finally, with no fu rth e r clues to the boy’s em otional state, he was unable to com plete the story satisfactorily. T h e distractibility an d overattention to m inor details found in this story were pervasive features o f his Rorschach an d TAT protocols an d consistent with his p o o r discrim inative ju d g m e n t on the Picture Completion subscale o f the WAIS-R. His R orschach responses were very p redom inantly detail responses (39 o f the 44 responses), indicating a breakdow n in his o rg an i­ zational abilities (as noted above, also reflected in his TAT stories). For exam ­ ple, on card III, he First rep o rted the two h u m a n figures which are frequently seen, but spoiled the response because he could neither integrate the central nor the lower details into the p ercep t and becam e distracted by the ostensibly incongruous “erections” o f w hat first seem ed to him to be fem ale figures. Mr. M was inordinately preoccupied with sexuality. O n the R orschach, he gave seven responses with “a woman’s genital a re a ” as the con tent o f the response. A lthough th re e o f these were ju d g e d to be o f ad e ­ q u ate form quality, the rem a in d er were n o t an d were rep o rted because for Mr. M, a “line down the m iddle and two equal areas” were all th a t were required to form the genitalia.

238 / Psychological Assessment, Psychiatric Diagnosis, arul Treatment Planning T h e intellectualized, censored quality o f his test protocol was fu rth e r em phasized by the almost complete absence o f eith er color or shading d eter­ m inants in the Rorschach, evidence o f his pronounced effort to contain his emotions and limit his impulsivity. T he disruptive potential o f allowing him ­ self to be aroused by stro n g feeling ne%ertheless cam e th ro u g h in the areas o f the blots selected and their content. O n card II o f the Rorschach, the first and th ird responses were “womans genitals” given to the central white space and the lower red detail, respectively. His second response, a p o p u la r one bu t som ew hat idiosyncratically presented, involved the large black details which were described as “two dancing bears sm ooching.” His final response to the card , given in w hat is by now a highly ch a rg e d , sexual context, was o f red C hristm as stockings located in the u p p e r red details. L ater in the Rorschach, he saw the large pink details on card X as resem bling Italy, b ut “a d ifferen t kind o f boot, m ore a work boot, to give som ebody a kick.” T h e fusion o f sexual and aggressive them es u n d e r the im pact o f em o ­ tional stim ulation was evident on th e TAT as well. His stories often h ad a protean quality an d after b eg in n in g fairly innocuously, evolved into grim tales o f sex and m urder. For exam ple, on card I3MF, Mr. M first noted the nude woman “with breasts exposed” and offered a story o f a professor who “slept with h er and got up very early, show ered” an d p rep a re d to study, a story o f a doctor who’s been tre a tin g h er an d is ru b b in g his eyes after “a long vigil,” or a m u rd e re r who “can’t b ear to look at w hat he’s d o n e.” Such d isruptions as those noted on the less stru c tu re d tests were also found in Mr. M’s m ore conscious presentation o f him self on the MMPI an d SCT. On the MMPI, his peak elevation was on scale 8, a scale involving social and em otional alienation, lack o f ego mastery, a n d f rankly bizarre sensory experiences. He endorsed items from this scale indicating th at he had “very peculiar and strange experiences” and “strange an d peculiar thoughts” and agreed th at there was som ething w rong with his m ind an d th a t he was afraid o f losing his m ind. O n the S C L he served notice o f th e dram atic behavior th a t can eru p t when he is emotionally stim ulated. For example, he notes th a t it looked impos­ sible, so he “dove out the window” an d when she refused him, he “was devestated (sic).” H e acknow ledged having difficulty controlling his im pulses (i.e. my sexual desires “sometimes get the better o f m e,” his conscience bothered him most when “stole (sic)” and when I think back, I am ashamed that “I acted so selfishly at tim es”), b u t is nevertheless given to acting in ways th a t attract attention. H e expressed wishes to be “a professional m usician” o r “a professional a th ­ lete,” both being positions that would keep him in the public eye, an d points out th a t his greatest fear as a child was “being ignored and o\'erlooked by my m other”; he now fears “being ab andoned.” While he has difficulty with establishing adequate levels o f self-control, he at the same time rails against

Major Affective Disorders / 239 the limits on his behavior im posed by others. O n the SCT he resents “taking orders” o r “conform ing to rules” and regards him self as “having been held back” by his parents.

Treatment P lanning and Outcom e T h e exam ining psychologist felt that Mr. M was susceptible to tran sien t losses o f reality testing, particularly when he was a tte m p tin g to m odulate either sexual o r aggressive feelings. His present efforts to m aintain an ade­ q u ate level o f self-esteem seem ed lim ited to the developm ent o f som ewhat grandiose ideas (he had worked in the political cam p aig n s o f several local politicians an d did have some musical talent). However, in his present state, it seem ed unlikely th at he could m arshall his resources sufficiently to actu­ ally carry out the work involved in forw arding his ideas. T h e psychologist felt th a t w ithout swift intervention, he was likely to escalate into a florid m anic state an d was concerned th a t when he m et with difficulty in p u ttin g his ideas into practice, his frustration and disappointm ent would again pro­ voke suicidal ideas and attem pts. T h e psychologist’s rep o rt was useful in h elping Mr. M’s treatm en t team in the Day H ospital adam antly p u rsu e the need for his rehospitalization 011 the in p atien t service an d , as noted above, he responded quite well and rapidly to a p p ro p ria te pharm acological intervention. Following his dis­ charg e from the in p atien t service, he was read m itted to the Day H ospital. At his readm ission interview, he ag reed to abide by the general rules for Day H ospital patients an d to im prove his ability to socialize with them . He m ade som e progress in explo rin g his career choices and was m uch more realistic in considering w hat would be req u ired o f him . He im proved his attendance and his socialization an d a referral was m ade to a less structured Day H ospital program w here he would have m ore flexibility in p u rsu in g his career goals. In the interim between program s, he decided to visit a for­ m er room m ate in a n earby city and although he becam e mildly depressed and reported a retu rn o f some suicidal ideation d u rin g the visit, he was able to cut the visit short on the advice o f his psychiatrist and successfully nego­ tiated the transition to the new p rogram .

2 4 0 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

E

X

H

I B

I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

I. Symptoms/Diagnosis Bipolar, manic, with psychotic features Elevated and expan­ sive mood

Has had world lifted from his shoulders

Strained efforts to control affect and impulses; underlying depression

Increased activity

Spent last three days in bars “making friends”

Pressured flow o f associa­ tions without adequate controls

Pressured speech

Pressured speech

Speaks rapidly

Flight o f ideas

None

At times has more ideas than he is able to con­ vey. Sexually preoccupied

Delusional grandiosity

Complete confidence in becoming a political lobbyist

Expresses wishes for p u b ­ lic adulation; im paired reality testing

Decreased need for sleep

Hasn’t slept in 3 -4 days but feels fine

None

Distractibility

Very distractible

Easily distracted and derailed by m inor details

Overinvolvement in activities with potentially pain­ ful consequences

C annot recognize three day absence caused problems at residence and Day Hospital

None

None

Inability to persist in achievement o f long­ term goals

II. Personality Factors

Easily feels rejected and “overlooked”

M ajor A ffective Disorders / 2 4 1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

111. Cognitive Abilities

None

Probably average intelli­ gence although ap p ears brig h ter lead­ ing to expectations in excess o f ability. Uses intellectualization extensively.

IV. Psychodynam ics

None

G randiose ideas used to shore u p im paired self-esteem Evidence o f psychosexual confusion and defenses against experienced psychosexual inadequacy

V.

T herapeutic E nabling Factors

VI. Environm ental D em and and Social A djustm ent

Prior response to somatic treatm ent

None

Vocational goals some­ what consistent with past accom plishments

Still functioning on an overall average intellec­ tual level

C ontem ptuous of efforts to set helpful limits

Feels d om inated when expected to conform to external dem ands

Able to make friends but unable to keep them

Lim ited em pathic ability; self-centered

2 42 / Psychological Assessmen t, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

WAIS-R S u m m a r y Verbal Sublests

Scaled Score

Inform ation Digit Span Vocabulary A rithm etic C om prehension Sim ilarities

13 15 14 14 10 12

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ Performance IQ Full Scale IQ

6 10 7 8 8 118 85 102

MMPI S u m m a r y F'K L : 8"597'46-230/1: R orschach Sum mary

N u m b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% Sex%

45 0

8 3 26" 13"(2RT’s missing) 84 53 29 11 17

Major Affective Disorders / 243

R o rsch a ch Sum mary

G eog% W:M M :Sum C in:c V III-X % FK + F + Fc% (H + A ):(H d + Ad) ception W I) d Dd + S

27 5:5 5:0.5 2.0 29 84 15:3 11% 60% 13% 16%

2 4 4 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

3

Ro rschach Summary

Inquiry

Response

Scoring

I . 1"

All these images are com­ ing to my mind. It kind o f looks like a head o f a wolf, here and here. 2 . The whole thing looks

1. The way it stuck out, the long snout that the coyote has.

DFA

2.

The way it’s formed, shaped. (What in particu­ lar}) T he line down the m iddle and two equal halves.

WF-Scx

3.

The shape.

dFSexO

like a woman’s genital area, anyway.

3. This looks like a woman’s breast.

(Separate response}) It’s the snout, Part o f the one I said before.

This looks like a coyote’s nose, from Road Runner. 4. These look like hands or claws, here. 5. If these two things were tilted, they’d look like the M atterhorn in Switzer­ land which I ’ve been to.

4. 5.

(Hands or claws}) Hands. I guess. (?) Shape.

dFH d

It’s formed that way. T h a t’s the shape. Here’s the peak.

dF'Geo.

I don’t know, down the bottom, the long straight line looks like a spine, and the thing sticking out at the bottom.

dF-At

T h a t’s about it. 6 . This sort o f looks like the bottom o f a spine, like somebody’s coccyx.

II. 18" 1. Again, it looks like a woman’s genital area, here’s openings.

1. Same. Up and down slit. Just the openings.

SF-Sex

M ajor A ffective Disorders / 2 4 5

R o rschach Sum m ary

Response

Inquiry

2. It looks like two dancing bears, sm ooching here in the m iddle, touching noses.

2.

3. T his also looks like a womans genital area down here.

3. Just sh ap ed like it. A nother slit down the middle.

DFSex

4.

DFCCloth

I don’t know w hat these two red things are su p ­ posed to be. Almost looks like C hristm as stockings.

5. Actually, this side sort o f looks like a m ap o f New E ngland (names stales), no not New E ngland, it’s like when you see a m ap o f C onnecticut and N o rth ­ ern Westchester (names places). Also, you can h alf see New E ngland, the top p art, New H am pshire and Vermont. III. 25" H m m , this, boy th a t’s a strange picture.

Right here. See. (Bears smooching?) T h a t’s how 1 see it. T hey’re shaped th at way and they’re touching.

Scoring

W hatever. I'hey look like stockings, curve to the left or right, except they were backw ards or upside down (shifts uncomfortably). Stock­ ings could look like red stocking o f Boston Red Sox.

5. T hat's ju s t how it's sh ap ed — like a m ap o f those places.

WMAP

DF-Geo

2 4 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum m ary

Inquiry

Response

Scoring

1. T his looks like two women with high heels are balancing some kind o f wide, long, large wide cushion in front o f them , this looks like some kind o f globe. But it doesn’t m ake any sense that it’s women because they both have penises. They look like women with heels but it’s very strange because they both have erections.

1. T hey were leaning on some kind o f large foot cushion, o r looks like a globe, stationery thing, revolves around. (?) You know how in a house or library there’s a globe sit­ ting in a framework. You spin the globe aro u n d . (?) Yeah. T h e only th ing I can think is th at some men are fooling around from behind, an d their erections are sticking out between the women’s legs. I don’t know how to make sense o f th at one.

W M .Fm H , Obj,Sex P

2. T his p a rt looks like butterfly.

2 . I don’t know, looks like a butterfly, wing spread, I don't know.

DFAP

3. T hese two things look like a m ap o f Cyprus, each o f them .

3.

It’s sh ap ed like a map. Looks to me like G reece or C yprus— a country in the M editerranean. T h a t’s all.

DF-Geo

4. T hey also kind o f look like electric guitars, crazy electric guitars.

4.

I don’t know. T h a t’s what it looks like to me. T he neck, the body. See it.

DF-ObjO

5. Also, if I’m looking at it upside down it looks like two horses, like the old D enver Broncos helm et, way back . . . with one leg kicking back. 6 . Did I say this looks like som ebody’s pelvic area?

5.

It has the same kind o f shape. T he leg sticking back here.

DFM(A)

T his looks like Greece, I can’t really tell.

6 . (Pelvic area?) Kind o f side (gestures) sweeping, kind o f looks like a pelvis.

DFAt Peculiar verbalization

M ajor A ffective Disorders / 2 4 7

R o rschach Sum m ary

Inquiry

Response

Scoring

7. See the strips o f land. It looks like they’re ju ttin g out into the w ater or som ething, the way it is in Long Island with the bay.

DF-Geo

1. Well, this again looks like a woman’s genital area.

1. It’s shaped th a t way. T he whole thing sort o f looks like a woman’s private area.

drF'-Sex

2 . I don’t know, this looks like a, som ething, I don’t know w hat the hell it is, some kind o f a, if you take the whole thing, it looks like the head o f a turkey down there.

2.

It’s strange, like the head o f a turkey. It’s got that shape.

DFA

1.

It also could be some kind o f long branch h an g in g down. T h e same shape. (Hanging down}) T h e position o f it. T he direction it’s p ointing in.

Add: DFPI

2.

You know, this up here sort o f looks like an anus. (Anus}) Same shape. C ould be a hole here.

Add: dF-AtO

I looked at it and thought o f the locations o f all those places.

DF-Geo

7. T h e pelvic area also looks like a Long Island area, with strips o f land stick­ ing into the bay. IV. 14"

3. T his looks like the M etro­ politan area, Long Island, Bronx, Brooklyn, Q ueens, Westchester, C onnecticut, R hode Island, Massachusetts

3.

V. 13" 1. T his entire thin g looks like a butterfly. E ither a butterfly or, yeah, butterfly.

1.

T h e shape.

WFAP

2 4 8 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch Sum m ary

Inquiry

Response

Scoring

2. T his area here looks like the Eastern end o f Long Island. T his is north, south fork. H am ptons, Montauk.

2. Like the others. It’s shaped th a t way.

DF-Geo

3. T his kind o f looks like a w ishbone down here.

3. Just the shape.

DFAto

4. T his again looks like a woman’s genital area, the lips here, maybe the clito­ ris here.

4. It’s the shape. T he two lips.

DF-Sex

1.

The shape. T h a t’s all.

WFAdP

2. T his whole left area looks like a m ap o f France (names parts), if it d id n ’t stick out so m uch it would look like a m ap o f France.

2.

T h e s a m e a s th e o th e rs .lt has the form o f country.

DF-Geo

3. T his kind o f looks like a m outh and some kind o f tra p p in g device o f a bee­ tle o r insect. H ere, except this part.

3.

T he shape.

dF-Ad

4. T his kind o f looks like the Eastern seaboard, Florida.

4. A nother one where I looked at it and th a t’s w hat it rem inded me of, the East coast down to Florida.

VI. 13" H m m (Looks at me). 1. T h e entire thin g looks like a bear skin rug. H m m (Sighs, looks at me).

drF-G eo

M a jo r A ffective Disorders / 2 4 9

R o rschach Sum m ary

Response

Inquiry

Scoring

V II. II" (Shifts, hums) 1. T his p a rt really looks like a woman’s genital area. T his is sort of the crack o f h er back side.

1. I don’t know. Just did. W ith the crack o f her back side down there.

dFSex

2. W hat else is there? O h, hm m . T hese look like two young people, here, chil­ d ren , yeah. Looks like two young children, look­ ing at each other. W ear­ ing Indian feathers, and they’re eith er carrying children in some back pack, o r som ething else. Maybe these are back packs an d these are the looking at each other, to get a b etter look.

2. Shape o f children’s faces. They are looking at each other.

D M H.O bjP

3. T his looks like a m ap o f Q ueens and Brooklyn (names parts).

3. 1 ju s t see it as a m ap and the shape is like Q ueens and Brooklyn.

DF-Geo.

1. O h, um , these two things look like two, I don’t know, wolverines o r b ad g ­ ers, they look like a lion, not beaver, legs are too long, same th in g on either side.

1. ■Hie shape.

DFAP

2. H m m , it looks like there’s two outlines o f bats over here. T hese two look like bats.

2. T h a t’s w hat they look like. Cause they had the wings. (Shrug).

DF-A

V III. 8"

2 5 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch S um m ary

Response 3. T his whole th in g kind o f looks like a m ountain.

Inquiry

Scoring

3. T he shape. T hat's all. T he peak is here.

DFGeo

4. It ju s t does. I ju s t see it as a m ap o f those countries.

drF-G eo

1. T hey kind o f look like dogs over here, a little dog with short tail, legs here, sticking out there, and paws.

1. Just the shape.

DF-A

2. T his kind o f looks like a therm om eter, up the m iddle, the head is kind o f round.

2. Shape.

drFO bj

3. T his also kind o f looks like the Howard Johnson’s symbol, the baker leaning forw ard to give the little boy som ething, this is the back o f the apron, maybe, doesn't quite m ake sense this is the cook’s hat, baker’s hat.

3. T he form o f the whole thing. It looks like he’s leaning forward.

DM(H)

1. T his very small area here looks like heads o f horses.

1. I don’t know. 1ju s t looked and that's what I saw, the shape o f a horse’s head.

ddF-Ad

2. T h e entire blue th in g kind o f looks like a crab.

2. T h e shape.

DFAP

(Anything else?) M m m m . 4. T his looks like France a little bit. T h is is probably N etherlands, then Germany.

IX. 45"

X. 33" (Mutters, hums, whistles)

M ajor A ffective Disorders / 2 5 /

Ro rschach S um m ary

Inquiry

Response

Scoring

3. T he spine an d , then, the pelvic bone. T h e picture ju s t has th at form. T h a t’s all.

DF-At

4. Yeah, this kind o f looks like Italy, but it’s a d iffer­ ent kind o f boot, m ore a work boot, to give some­ body a kick. T h a t’s why there’s no heel, unlike Italy, with sh arp point. To give som ebody a kick.

4.

It was kind o f sw ung back, and swings for­ w ard, to give som ebody a boot.

drM H d ,C lo th

5. T hese kind o f look like crabs, also. T hese look more like crabs, actually.

5.

Same shape.

DFA

6 . T his one yellow area kind o f looks like Alaska.

6 . Shape o f Alaska.

T his looks like the pelvic area o f som ebody again, down here.

DF-Geo.

252 / Psychological Assessment, Psychiatric Diagnosis, and, Treatment Planning E X H I B I T

4

T h e m a t ic A p p e r c e p t i o n T e s t

CARD 1 (Takes o ff glasses, inspects) Looks like a child who’s, um , looking over his music before he prepares to play the violin. (Pause) Either he’s p re­ p arin g or he’s played a little and he’s kind o f dum bfounded by the music and he’s looking over the music before he plays again. Kind o f a strange looking kid. He looks like he has a wad o f chewing tobacco in his m outh and this eye looks kind o f . . . (?) Looks kind o f drowsy. (Eye}) Kind o f cross­ eyed, actually, looking inward. Both eyes are in the inside part. (Done}) Well, perhaps he’s played the beginning, now he’s looking over the rest, first page, or could be second page. He actually could be sleeping, b u t I don’t think he is. (Ruminates a bit further) CARD 5 H m m . This looks like a woman who’s looking into a room and is d isturbed by what she sees. O r surprised. It looks like she’s surprised. Anyway, she’s looking into the room, not at the table, it looks like there’s a couch. (Wait) Past the table, like she’s looking in on somebody. Actually, it doesn’t look like she’s surprised or shocked, she’s ju st looking in on some­ body, like a child or an old person . . . (more description of room) (What led up and how turn out}) Doesn’t look like it’s anything really eventful. It looks like she’s going to look in, close door, and go back to where she was. CARD 6BM T his looks like a m other and h er son. It’s probably d u rin g the winter because he has a top coat on. She’s looking out the window, seems like watching for something. (What}) Like a taxi, or maybe somebody’s com­ ing to pick him up. He’s going somewhere. (Pause) Now it could be the police that are coming, and he’s going to jail. (For what}) I don’t know, it looks like he’s well-m annered, so maybe a white collar crime, embezzlement. Looks like a young guy. Maybe he’s a bank teller who’s stolen money or a ju n io r accountant who’s ju g g led the books. (Let’s stop) CARD 10 H m m m . Well. T his looks like a priest consoling one o f his parishioners. This is definitely an adult. I'his doesn’t look like a child because the nose is too long. Maybe it’s an adolescent. He’s kind o f consoling this person. H e looks very tearful and unhappy. (More}) No. I think it d ef­ initely looks like a priest. Consoling person. It m ight be an old woman, m ourning the death o f someone. Looks like somebody’s grandm other. This one’s definitely a priest. My first thought was th at it was two homosexual men. But it really doesn’t look like that. CARD 12M

This looks like someone has either ju s t died o r is very sick.

Major Affective Disorders / 253

T h e m a t ic A p p e r c e p t io n T e s t

Probably very sick. T his person looks like they’re trying to heal them . (Pause) E ither th a t o r they’re bein g given th eir Last Rites. (OK). CARD 13MF H m m (Takes o ff glasses, inspects). T his can be one o f two things. O bviously there’s a woman lying on the bed, nude, with breasts exposed. T h is m an eith e r slept w ith h er an d g ot u p very early, showered, or at least got dressed very early. (Wait) Either to leave early, o r there’s books here, so maybe he’s a professor, o r else he’s going to study here, but probably not, because he has his tie on. T h ere’s a few o th e r things it could be. He could be a doctor, he’s been tre a tin g her, it’s been a long vigil, he’s ru b b in g his eyes, m aybe he’s never been to bed with her. He’s probably n ot a doctor, though. (Wait) T h e o th e r alternative is th a t she’s ju s t died, an d he has his h and over his face because he can’t b e a r to look anym ore. H e m ight be a doctor but I do u b t it, because she’s unclothed. (Wait) A nd the last th in g it could be is th at he’s ju s t m u rd e re d her, and he can’t b ear to look at w hat he’s done, an d he’s looking away and h id in g his eyes. CARD 14 H m m . O h. It looks like a m an looking out a window. Like at the m oon. E ither the m oon o r the sun has ju s t come up. N ot a young m an, 3 5 -4 5 , a nice head o f hair. L ooking o u t window. Maybe he’s star gazing at night. B ut it looks like the sun has ju s t come up, because it’s d a rk in here and b rig h t out there. (Thinking and feeling) I th in k he’s th in k in g a b o u t the day to come, and he’s ju s t th in k in g about th e day to come. Maybe thin k in g o f a wom an, I don’t know, he m ig h t be an alcoholic, he’s ju s t woken up, he’s trying to clear his head, o r m aybe a d ru g addict, o r m aybe a musician. I don’t know. Because you can’t see an y th in g o f the room . CARD 15 (Looking at me often, staring when I look up.) H m m ! T h is looks like som eone who’s stan d in g in the m id d le o f a graveyard, with crosses, headstone. Looks like he’s looking at this cross, in very deep thought, think­ ing o f the person who’s buried here, (p) Looks like a woman, because it looks like a woman’s hands. H er h a ir is pushed up on one side. Plus it looks like a woman’s coat. (Wait) (Huge yaum) Like I say, kind o f looks like in d eep th o u g h t or m ourning . Looks like th e woman’s lost a good deal o f weight, draw n in cheekbones. (Mutters) (Didyou say something?) I’m tired today . . . I got u p at 5:30 to com e here! (Lost weight?) Yes. (Describes picture) (Why}) Cause she’s in m ourning. T h is is h e r husb an d who d ied. O r h e r child.

254 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

2.

He often wished he could be a professional musician.

3.

It looked impossible, so he dove o ut the window.

5.

When she refused him, he was devastated.

6.

/ used to feel I was being held back by actions taken by my parents.

8.

As a child my greatest fear was bein g ignored a n d overlooked by my mother.

17. 19.

Sometimes he wished he was a professional athlete. I could hate a person who forced his will upo n others.

23.

When I met my boss, I was wary o f him .

24.

When I think back, I am ashamed th a t I acted so selfishly at times.

36.

Taking orders is a necessary evil.

37.

I dislike to conform to stupid rules.

53.

M y sexual desires som etim es get the b ette r o f me.

54.

His conscience bothered him most when he stole.

68.

When they put me in charge, I feel good.

72. 77.

When he was punished by his mother, he felt resentful. When they told him what to do, he felt angry.

83. 87.

More than anything else, he n eed ed stru ctu re. I am afraid o f bein g abandoned.

Major Affective Disorders / 255

DISCUSSION Mr. M. a 29-year-old, single male was tested d u rin g an escalating manic epi­ sode for which he was hospitalized. T h u s, his test results provide a picture o f classic manic behavior in the testing situation. He had sym ptom s o f pres­ sured speech, expansive and elevated affect, boundless energy, exaggerated self-confidence, and grandiose career plans. In un stru ctu red situations, his thinking was idiosyncratic and unusual. He was quite distractible, and often energetically em bellished his responses to sm all an d insignificant stim ulus details. T h e content o f m any o f these responses is evidence o f his sexual preoccupations. The testing confirm ed the clinical im pression th a t he was beginning to escalate into a full-blown manic episode. T h e m anic sym ptom s were b ro u g h t u n d e r control with the stu ctu re o f the hospitalization and m edication. At th at point, the issue o f life goal expectations surfaced, as th e wealthy fath er expected his son to take over the fam ily business and h ad dif ficulty recognizing his son’s illness an d dis­ ability. f am ily sessions with psychoeducational m aterial were used to assist the family in read ju stin g th e ir expectat ions o f the son. W ith the assistance of some freedom from the family expectations an d o f the m edication th at d am p en e d his own grandiosity, Mr. M was able to recognize his need for a day hospital which could help him develop som e c areer goals o f his own and related work skills. He was d ischarged to a relatively u n stru ctu red day hospital w here these goals were successfully p u rsu ed . T h e case o f Ms. G, a 23-year-old, single fem ale, was m uch less prototypic in regard to manic sym ptom s and behavior. Prior to her first hospitalization, she was gaining weight an d becom ing lethargic, b u t began to function in a jo b with the encouragem ent o f her family. D uring her eighth week o f hos­ pitalization, she was refe rre d for testing due to continued uncertainty re g ard in g h e r diagnosis. T h e brevity o f h e r acute sym ptom s an d the aty p ­ ical n ature o f her presentation m ade it difficult for the hospital staff to settle on a confirm ed diagnosis. She was given a d ischarge diagnosis o f schizotypal personality disorder. W hile she presented few typical sym ptom s o f m ania prior to the hospi­ talization, h er next adm ission shortly a fte r h er disch arg e clearly seem ed to be p recipitated by a m anic episode. T h u s, the test results from h er first hospitalization are those o f a young woman in a very d istu rb ed , b u t nonpsychotic, episode th a t p red ated by several m onths a clear-cut manic epi­ sode. Irritability was m anifest in h e r flip, hostile com m ents, som e o f which she im m ediately retracted. H er cognitive organization an d controls broke dow n in the u n stru c tu re d parts o f the testing. H er expansive and overinclusive th in k in g was dram atically d em o n strated in the object sorting task.

256 I Psychological Assessment, Psychiatric Diagnosis, ami Treatment Planning Likewise, h er 74 responses on th e Rorschach evidenced verbal expansive­ ness and idiosyncratic use o f small details, color, and shading com bined into non-popular responses. W hile she doesn’t present with clear affective polar­ ities, h er th in k in g was expansive an d flighty ra th e r th a n u nusual o r w eird. Also, she engaged people ra th e r th an p u ttin g them off. Like the previous case o f Mr. M, the hospitalization was successful in red ucing m anic sym ptom s an d p rep a rin g the p atien t for discharge. T h e family had high aspirations an d was relatively successful, an d th e ir ex p ec­ tations o f the patient had to be lowered th tough psychoeducational means. T his patient h ad m ore th in k in g distu rb an ces outside o f m anic episodes th a n d id Mr. M (note h e r diagnosis o f Schizotypal at first adm ission), and th u s she was disch arg ed to a m ore stru c tu re d day hospital. H ere she received very direct an d stru ctu re d help in the developm ent o f vocational skills. It is a com m on clinical m yth th at bipolar patients need lithium treatm ent an d little else. T his is often not the actual situation, an d these two cases are illustrative o f the multiple vocational and family/social issues bipolar patients face between illness episodes. T hus, treatm ent planning for bipolar patients m ust always include, b u t not be lim ited to, m edication treatm en t.

CHAPTER 5

Anxiety Disorders

A. OBSESSIVE COMPULSIVE DISORDER W ITH A N D W ITHOUT PERSONALITY DISORDER Obsessive com pulsive d iso rd er is classified as one o f a n u m b e r o f anxiety disorders on Axis I. T h e essential features are recurrent obsessions o r com­ pulsions o f such severity as to involve m arked distress, consum e great am ounts o f tim e, an d /o r significantly interfere with norm al routine. T h e most com m on obsessions, th a t is, persistent ideas, thoughts, im pulses or im ages, experienced as intrusive, are repetitive thou g h ts o f violence, con­ tam ination and doubt. Compulsions such as handw ashing, counting, check­ ing, and touching are th e repetitive intentional behaviors th a t are the stereotypic responses to obsessional thoughts. T his d iso rd e r is often asso­ ciated with depression, anxiety, and phobic avoidance. H ie Axis I disorder is distinct from, b ut may be related to, Axis II Obses­ sive Compulsive Disorder, one o f the Cluster C (including avoidant, d ep en d ­ ent, and passive/aggressive) personality disorders characterized by anxiety an d fearfulness. T h e essential feature o f obsessive com pulsive personality d iso rd er is a pervasive an d longstanding p a tte rn o f perfectionism and inflexibility.

OBSESSIVE COMPULSIVE DISORDER Ms. H arrived at the hospital at th e exact time she h ad been given for an intake evaluation. She presented as a petite, meticulously groom ed young w om an o f 25 years o f age who sm iled shyly w hen first in tro d u ced to the interviewer. She stated th at “my present condition is o f a compulsive nature an d it is m aking it uncom fortable to lead a norm al life.” As the interview contin ued, it becam e a p p a re n t th a t she h ad led a progressively more

257

2 58 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning restricted life, with m uch o f h er tim e and energy being devoted recently to rituals o f cleanliness an d unrelenting preoccupations with the possibility o f contam ination by “grease.” She feared contam ination of her person, her clothes, an d h er hom e. H er concerns had grown to the point that her cleaning rituals, which she herself recognized as out o f prop o rtio n to the realistic possibilities o f con­ tam ination, req u ired m any hours o f her tim e each day. T h e tim e she devoted to these rituals h ad e x p an d ed as m ore an d m ore personal items required h er attention. H er routines had becom e m ore and m ore rigid so th a t if in te rru p te d in h e r endeavors, she would have to begin all over again to insure the cleanliness o f h er articles o f clothing, %'arious personal effects, an d h er own body. O ne m onth p rior to h er adm ission, she h ad left h er jo b in o rd e r to be able to devote sufficient tim e to m ain tain in g the im m acu­ lateness o f h er perso n and her w ardrobe. Ms. H was a devoutly religious Catholic an d h er obsessions and co m p u l­ sions had first developed five years previously after term inating a pregnancy by abortion. No one in her family knew o f eith er h er sexual indiscretion o r h er abortion; in fact, until her present admission and despite th ree brief attem p ts at o u tp atien t treatm en t an d one brief psychiatric hospitalization, she h ad kept the events concealed from everyone. H er social and sexual life revolved around her boyfriend. She had broken o ff h er relationship w ith him a year an d o n e-h alf ago while he was on an extended business trip. Shortly after, she had noticed “sm all bugs” in her bedroom . She had thoroughly cleaned the room, h er clothing, an d her p e r­ sonal effects, but rem ained preoccupied with the possible reinvasion of her room an d h ad finally called the exterm inator. Feeling that the a p a rtm e n t was indelibly contam in ated , she h a d moved into an o th e r a p artm en t. More recently, fearing th at these quarters had also become contam inated, she had re tu rn e d hom e to live with h er paren ts in h er child h o o d bedroom . H er m o th er becam e involved in h elping the p atien t clean an d d id several loads o f wash for her each day, often washing the same articles several times a day. H er wash had to lx- done separately f rom the rest o f the family’s wash, particularly h er fath e r’s soiled clothes, as his work often b ro u g h t him into contact w ith greasy an d oily m achinery a n d she feared th at h e r clothing and, ultimately, h er perso n also would becom e co ntam inated. A p a rt from h er preoccupations with contam ination, there were no o th e r d isturbances in her cognitive functioning n oted on m ental status ex am in a­ tion. She d id describe h er m ood as “sad ,” but was otherw ise u n ab le to clearly describe her em otional state an d , clinically, her affect was ju d g e d to be constricted and dysphoric. She also rep o rted a decrease in a p p e tite and difficulties in sleeping o f two to four weeks d uration. She recognized that h er fears regard in g contam ination were unrealistic and th at her clean­

Anxiety Disorders I 259 liness was overdone. She felt th at h er overconcern p e rh a p s was related in some way to the hum iliation she h ad experienced at eight o r nine years o f age when she h ad been sent hom e by the school nurse because o f head lice which she and several o th e r child ren h ad contracted. She stated th a t she h ad profited som ew hat from h er previous b rie f hospitalization. H er tre a t­ m ent at th a t tim e h ad included pharm acotherapy, which she h ad discon­ tinued after b eing d isch arg ed . She ag reed to be ad m itted for evaluation and treatm en t o f h e r obsessive and com pulsive difficulties.

DSM -III-R D iagnosis Axis I: Axis II: Axis III: Axis IV: Axis V:

Obsessive com pulsive disorder, rule out m ajor depressive d iso rd er D eferred None M oderate— recent d eath o f her g ra n d fa th e r to whom she h ad felt close Fair— m oderate im pairm ent in both social and occupational functioning

Treatment and H ospital Course Ms. H ’s initial evaluation focused principally on the severity o f her depressive sym ptom atology an d , shortly after adm ission, a diagnosis o f m ajor depressive d iso rd e r was confirm ed. She was b eg u n on an antidepressant an d afte r she h ad achieved and m ain tain ed adequate serum concentrations for one m onth, there were noticeable improvements in h er sleep, ap p etite, an d m ood. T h e trea tm e n t sta ff wished to begin to address h er cleaning rituals, but were u n certain how to proceed. Strict lim its were placed 011 the am ount o f time she was allowed to eng age in these activities an d the am o u n t o f tim e was gradually decreased over the weeks following adm ission. In the face o f significant sym ptom atic im provem ent, Ms. H was offered the opportunity for a long-term hospitalization in o rd e r to resolve her long­ stan d in g difficulties with dependency on her family an d h er inability to express herself emotionally. A ttention was also to be directed at helping her to increase h er capacities for vocational functioning th ro u g h a stru c tu re d vocational plan. A lthough she seem ed willing to go along with the treatm ent sta ffs recom m endation, she was actually quite am bivalent abo u t staying in the hospital.

260 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

P sychological A ssessm ent Ms. H was referred for psychological testing at the start o f h e r second m onth o f hospitalization. At th a t tim e, although there h a d been some im provem ent in her depressive symptomatology, her psychiatrist had begun to feel th a t she would need continued treatm en t with antidepressants to realize fu rth e r gains. Q uestions re g a rd in g the extent an d severity o f h e r depressive sym ptom s an d , in light o f h e r p rim ary diagnosis o f obsessive com pulsive disorder, a recom m endation as to w hether a su pportive o r exploratory psychotherapy would be m ore a p p ro p riate at the present time was requested. Finally, in light o f h e r possible willingness to work on o th e r in terp erso n al issues while rem ain in g in the hospital, the refe rrin g psychi­ atrist also wished help in considering how to approach these issues with her. Ms. H was given a WAIS-R, R orschach, TAT, an d DAP by th e exam in ing psychologist. She coo p erated with the evaluation but, th ro u g h o u t, seem ed disconnected from th e exam ination an d ap p ro ach ed the tests with a d etached air o f intellectual curiosity. H er m a n n e r was ponderously delib­ erate an d , at times, w hen u n su re o f h er response, she would flatly reject any a tte m p t by the ex am in er to en gage h er in an exploration o f her uncertainty. Ms. H ’s WAIS-R results revealed a full-scale IQ o f 83, a verbal IQ o f 92, an d a perform ance IQ o f 76. T hese scores were seen as inconsistent with h er prem orbid level o f fu nctioning and were found to be lowered in p art by h er overly cautious response style which d enied h e r the benefit o f a d d i­ tional points for p ro m p t com pletion o f the task. For those subtests w ithout tim e constraint, occasionally successful efforts at e n co u rag in g h e r to guess when she was unsure o f the correct response revealed both adequate knowl­ ed g e an d startlin g gaps in h er general fu n d o f inform ation. For exam ple, after she replied “I don’t know” w hen asked to identify Louis A rm strong, the ex am in er requested th a t she guess. She th en revealed th a t she had thought he h ad “som ething to do with music” and was “a saxophone player.” W hen the ex am iner asked h er to identify the continent on which Brazil is located, she First claim ed she d id not know an d , when encouraged, she refused to guess. In response to a second request at the end o f the ex am ­ ination, she answ ered correctly. Alternatively, she th o u g h t Labor Day was in May and th at Robert E. Lee had once been President o f the U nited States. H er relative streng th s were in th e areas o f rote m em orization o f digits, u n d e rsta n d in g o f social norm s, an d capacity for abstract tho u g h t. G rap h ­ ically reflective o f her indecisive and d eliberate m anner, she n o ted on the Picture A rran g em en t subtest, “ I can’t figure this one out. It doesn’t m ake sense to me. It would take m e too long, b u t if I h ad enough tim e, I would

Anxiety Disorders ! 261 come to some sort o f decision.” In short, the WAIS-R gave a b u n d an t evi­ dence o f the procrastination, rum inativeness, and ambivalence character­ istic o f obsessive compulsive disorders. O n the projective tests, particularly the TAT, there was considerable evi­ dence o f depression. D eath and separation, fear o f intimacy and ultimate rejection were perseverative themes and typically occurred in the context o f longing for sustained emotional contact, which somehow did not occur d u rin g life. For exam ple, card 15 prom pted h er to tell a story concerning “a very old man standing in a cemetery late on a winter n ig h t. . . depressed about being alone since his wife died.” He has come to the cem etery to talk to his wife “to get as close to h er as he could” and talking to her, he feels “com forted.” In the same vein, she told a story to card 12M involving a grandfather taking his leave from his grandson, who feigns sleep in ord er to avoid saying goodbye. A few days afterw ards, the grandson calls the grandfather “and lets him know he was awake but felt too sad to actually say goodbye and the g ran dfath er un d ersto o d .” These them es o f sadness and longing typically arise because life’s events move too swiftly and she is perennially surprised at what happens next. It would be “w onderful” if she “could do the same thing every day” (card 14), but is frequently left trying to “understand what she hadjust seen as beinga normal part o f life” (card 3GF). However, even the total routinization o f life fails to pre­ vent emotional upheaval, as she recognized i n her story to card 13MF. H er story revolved arou nd a m an who goes into the den at the same time every evening to consult his law manuals and, on this occasion, finds his wife dead. She had “slit her wrists because she felt that she was losing control o f her life and he wouldn’t acknowledge that. He wouldn’t acknowledge she was ill in any way and refused her to see a doctor.” Such stories help to forge a link between her obsessive con­ cerns with isolating the contam ination, the “disease” o f emotions, by a d h e r­ ence to orderliness. Unfortunately, an in n er em ptiness and im poverishment are her chief rewards. Her Rorschach provided additional examples o f her impoverishment and despair. Card V produced “a dead chicken” because the legs look “lifeless . . . like if a person relaxed th eir legs and they were ju s t hanging there.” Card VI led her to tentatively suggest “possibly the inside o f a pit, like from the inside o f a piece o f fruit.” Inquiring into the reason for its resemblance to a pit, she was able to say th a t “you can ju st tell that you’re down to rock bottom . . . if you were to tear a pit open, you’d see its deep center, its core.” Finally, card X revealed “a baby without arm s” because o f the “head and legs and they were sm all.” H er figure drawings were o f tiny persons with asym metric, shrunken bodies and enlarged heads. T he house was repre­ sented only by a roof out o f which a chim ney extended and above which was a large, unconnected billow o f smoke. Leading from the front door was

262 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning a p ath which broadens out as it extends upw ards above the peak of the ro o f and term inates in th e air.

Treatment P lanning and Outcom e The psychological report was useful to Ms. H ’s treatm ent team in helping them to confirm th e ir suspicions o f a co n cu rren t depressive d iso rd er for which she continued to receive pharmacological treatm ent and to which she responded. H er indecisiveness, h e r attem pts to keep h erself unm oved by em otion, an d h er ped an tic tone all were seen as consistent with h er adm is­ sion diagnosis o f an obsessive compulsive disorder. H er general lack o f inter­ est in w hat m otivated eith er h e r own o r others’ behavior, h er lim ited psychological resources, and h er need for a high d eg ree o f stru c tu re and task focus argued against a reliance on an interpersonal therapy as the treat­ m ent o f choice. A recom m endation o f a behavior m odification approach to her compulsive cleaning difficulties was accepted and im plem ented with some success. Also described in the exam ining psychologist’s report was a suspicion th at Ms. H ’s com pulsivity was in p a rt an effort on h e r p a rt to stave o ff a m ore pervasive regression and decom pensation. T here were concerns that unless her treatm en t were to continue in a stru c tu re d setting, such as a n in p atien t unit, attem pts to address her fears o f intimacy and her long-standing an g er at h er family would prove too much for her to m anage. H er treatm ent team therefore moved quickly to help h e r accept th eir recom m endation o f con­ tinued in p atien t treatm en t an d were able to enlist her parents’ su p p o rt for co n tin u in g the hospitalization. A lthough some headway was m ade in h elping Ms. H to becom e m ore em otionally expressive and m ore em otionally involved with o th ers, she was not felt to be ready to re tu rn to work and to an independent living situation at the conclusion o f h er hospital stay. She was referred to a day hospital w here she could continue to receive help with these issues and to a halfway house. H er individual psychotherapy was ca rrie d out by the psychiatrist who h ad referred h er for in p atien t treatm ent. She disliked the halfway house and attem pted on several occasions to p e r­ su ad e h er p arents to let her re tu rn to live with them , b u t they refu sed to give perm ission. She was ultim ately u nable to utilize the day hospital p ro ­ g ram an d after rep eated attem p ts to engage h er in w orking tow ards increased socialization an d im proved vocational functioning, she was dis­ c h arg ed after four m onths. She continued in h er individual psychotherapy and at the tim e o f h er disch arg e from the day hospital, was p re p a rin g to re tu rn to work.

A nxiety Disorders / 2 6 3

E X H I B I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

I. Sym ptom s and Diagnosis Obsessive compulsive disorder Obsessions

C ontam ination by dirt, especially grease

Perseverative thinking

C om pulsions

Ritualized groom ing and cleaning in excess o f hygenic requirem ents

Compulsively deliberate

Distress and in ter­ ference with role functioning

Q u it jo b to devote time to cleaning

Aware o f inefficiencies in functioning due to present distress

II. Personality Factors

Procrastination and indecisiveness

Becomes indecisive in the face o f uncertainty to avoid confrontation

III. Cognitive Abilities

Average intelligence

Below average intelli­ gence with cognitive inefficiencies due to rigidity and o th e r p e r­ sonality factors

D ependency gives rise to hostility to w ard o ff the expected rejection

Avoids intim acy for fear o f becom ing too d ep en d en t and being rejected

Aware th a t her fears and h er response to them are out o f proportion to realistic circum stances

Reality appreciation is largely intact.

Prior treatm en t response to medication

None

Excellent prem orbid functioning in highly stru ctu red and routinized work setting

Functions best in stru c­ tu red situations

Extrem ely limited social life; no e n d u rin g close relationships

Difficulties in establish­ ing and allowing close relationships

IV. Psychodynamics

V.

T herepeutic E nabling Factors

VI. Environm ental D em and and Social Adjustm ent

264 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning E X H I B I T

2

W A IS -R S u m m a r y

Verbal Subtests Inform ation Digit Span Vocabulary A rithm etic C om prehension Similarities

Scaled Score 5 11 9 6 10 10

Performance Sublests Picture Completion Picture A rrangem ent Block Design O bject Assembly Digit Symbol Verbal IQ Performance IQ Full Scale IQ

7 7 6 5 8 91 76 83

R orscha ch Summary

N um ber o f Responses Rejections Populars O riginals Average R/T chrom atic Average R/T achrom atic F% F+ % A% H% W:M M:Sum C m:c V III-X % FK + F + Fc% (H + A ):(Hd + Ad)

17 0 6 0 58" 95" 53 65 41 12 3:1 1:0 3:4 29 71 7:2

Anxiety Disorders / 2 6 5

R orschach Summary

A p p e rc e p tio n

W 18% D 59% d 0% D d + S 23%

2 6 6 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

EXHIBIT

3

R o rschach Sum m ary

Response

Inquiry

Scoring

I. 3" 1. Looks like a butterfly to me. C an 1 change that? It looks like a bat to me.

In here rem inds me o f a bat’s head or som ething. (Bat}) T he whole shape o f the ink on the card. (Any­ thing else}) Not really. Just looked m ore like a b u tte r­ fly. I guess it was the pointy sides. A butterfly has wider, floppier sides, and butterflies are pretty. To me, it looked a little more scary to me. Just th at it really looked like a bat to me and I’m really scared by bats. T h e little head b o th ­ ered me. It looked leathery like a bat. It seem ed creepy to me. (Creepy}) Just was.

WFcAP

2. Looks kind o f like a leaf.

T h e p arts th at ju tte d o u t and cam e to a point and the fact th at it was irre g u ­ lar. Leaves are like that. Sometimes they’re missing th eir tops and sides. (Any­ thing else}) No. It's like a crusty old leaf. No, now th at I say th a t I’m e m b ar­ rassed because it doesn’t look that much like a leaf.

drFc-Pl

Looks like a womans body w ithout a head. T h a t’s it.

3. T h is looks like her hands reaching upw ard. It doesn’t m ake sense th at it doesn’t have a head but I could really clearly see a woman’s outline.

DM Hd

A n xiety Disorders I 2 6 7

R orschach S um m ary

Response

Inquiry

Scaring

II. 32" 1. Ju st the sh ap e a n d those pointy th in g s th a t cam e o u t, like a n ten n a s from the fro n t o f it. {Anything else?) No.

DFA

2. A nd it looks like a h eart. I don’t m ean, m aybe I do m ean b oth. T h e actual h e a rt o rg an . A nd th a t’s it.

2 . I guess ju s t th e sh ap e o f it. (Anything else?) No.

drFA t

3. T h is p a rt in here looks like so m eth in g b ut I ’m not su re if I’m su p p o sed to respond to this p a rt. {Whatever you like). T h is p a rt looks like a h u rric a n e lam p to me.

Ju st th e sh ap e o f th e to p o f it re m in d ed m e o f a h u r r i­ cane lam p, a n d also h ad the stem -like bottom . (Any­ thing else}) No.

1. It looks like a . crab.

uh

SF Obj

III. 15" 1. Looks like a bowtie. P art o f it looks like a bowtie. T h a t’s it. T h a t’s all I see.

1. Shape

D FC lothP

2 . I guess the sam e p a rt resem bles a butterfly.

2. A gain th e shape.

DFAP

1. T h e p a rt o f the blot so rt o f went o u t like th at (motions) and th e ra b b it’s feet look big a n d fluffy, a n d they go out like th at. (Fluffy}) It looks soft an d furry.

DFcAd

IV. 72" I don’t know. D oesn’t look like an y th in g to me. 1. Maybe dow n h ere this and this rem in d m e m aybe o f rab b it’s feet. T h a t’s it.

2 6 8 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum mary

Response

Inquiry

1. (Drops card). It rem inds me o f a dead chicken. T h a t’s it.

1. All things th at ju t o ut are like a d ead chicken. It’s so lifeless. Like the rest o f the body’s han g in g up here and the legs down here look lifeless. Doesn’t look so m uch like chicken legs up here. (Else?) No. Just those things th at I call legs. (Other parts of body ?) No. (Dead rather than alive?) Yeah. Lifeless legs. They weren’t straight lines, like if a person relaxed th eir legs. It’s like a chicken th a t’s ju s t h a n g in g down dead.

W Fm-(A) Confab

1. Especially in here w here it gets darker. (Anything else?) I guess it must have looked like . . . you can ju s t tell th at you’re down to rock bottom . I don't know, it’s h a rd to explain. (Rock bot­ tom?) If you were to saw a tree in half, you’d see the grain. It’s ju s t like if you were to tear a pit open you’d see its deep d ark cen­ ter, its core. (Certain piece of fru it in mind?) No.

d iF C ’-PI Confab

Scoring

V. 45"

VI. 115" It doesn’t really look like anything to me. 1. Possibly the inside o f a pit, like from the inside o f a piece o f fruit.

A nxiety Disorders ! 2 6 9

R orschach Sum m ary

Response

Inquiry

Scoring

VII. 2'45" A re you only supposed to look at these one way, the way you hand them to me? (Whatever you like). I really don’t see anything at all. I . T h e way th a t a d o g sits and the little th in g th a t I called the paw. (Anything else?) No.

DFMA

1. 1 see a frog.

1. Just the shape o f it, and it ju s t looked like frog’s legs, the way they were spread a p a rt like that. (Else?) No.

DFM-A

2. Two animals. I don’t know w hat they’re called . . . pos­ sum s . . . you know, they even look a little like rats to me. It would really su r­ prise m e if som eone else would look at this inkblot and not see the rats or pos­ sums. It’s alm ost like they were painted on there. It’s so clear. T h a t’s it. T h a t’s all I see.

2. T he m ore I looked at it they looked like rats to me. They really did! (Rats?) Just the shape. (Else?) I could ju s t very clearly see the o u t­ line o f rats! (Reaction?) I don’t know why. Don’t know if I’ve ever seen a rat. (Feel affected by these?) I ju s t keep thinking th a t if I ever saw one o f those in a room with me alone, I don’t know w hat I’d do. I rem em ber h earin g th a t there was a rat who lived in the wall o f an ap artm en t I used to live in.

DFAP Confab

1. O ne side o f it looks like a little dog with its one paw up. T h a t’s it. VIII. 50"

2 7 0 / Psychological Assessment, Psychiatric Diagnosis, an d Treatment P la n n in g

Ro rschach Sum m ary

Response

I nquiry

Scoring

IX. 1 '40" N othing. I don’t see anything. 1. I think all o f them kind o f rem ind me o f bugs. Like if you were to take a bug and look at it u n d e r a micro­ scope, this is w hat you’d see. T hey all seem to have little feelers o r arm s to them . T h a t’s really it. Feel­ ers o r arm s to them .

1. I’m th in k in g o f one bug, probably ju s t from looking th ro u g h books and seeing a picture o f a bug and then seeing it u p close and, oh! (Holds head). It looks much scarier when it gets m agni­ fied. (Many or one?) 1 think all o f the cards I’ve seen so far have rem inded me o f bugs. (Bugs?) Guess I saw little feelers on them all. (Feelers?) Like w here 1 traced on the last card, antennae-like things. They ju s t rem ind me o f little arm s or feelers or antennae.

WF-A Confab

1. T he p a rt th at looked like the baby’s legs to me, that m ade it look like needlenose pliers, the way they come to g eth er at the top.

DF Obj.

X. 2 1 5 " 1. T he only th in g 1 see is needle-nose pliers.

(Holds card up to face, back down, back up, back down). 2 . 1 suppose 1 see a baby w ith­ out arm s. T h a t’s it.

It ju s t looked like a baby to me. I could see a head and legs and they were small. (Baby rather than person?) I guess ju s t the size o f it. (Without arms?) I couldn’t see any arm s on it. I proba­ bly shouldn’t have said it unless I saw the whole thing.

DF-Hd

Anxiety Disorders I 271

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

C A R D 1 1'5" T h e re ’s a little boy s ittin g at th e table w ith a violin in fro n t of h im . I fo rg o t th e q u estio n s. H e, th e little boy, is sad b ec a u se he w a n te d his fa th e r to play th e violin w ith h im , his fa th e r also h a s a violin. H is fa th e r said they, h e d id n ’t have th e tim e, he was w o rk in g on a sales p re s e n tatio n . A n d th e little boy is fe e lin g very sad a n d sh u t o u t b ec a u se he h a d ask ed his fa th e r several tim es to play w ith him b u t he was always too busy, it seem s. (End?) L itter on th a t ev ening th e little boy was re a d in g a n d his fa th e r walked in p lay in g h is violin a n d su g g e ste d th a t they play to g e th e r fo r a w hile. A n d th e little boy ra n o u t o f th e ro o m to get h is violin. C A R D 2 I '25" In th e p ictu re is a m a n a n d a w om an a n d th e ir niece w ho was v isitin g fro m New' York. A n d she h a d co m e o u t to th e field to see w hat h e r a u n t a n d u n cle w'ere d o in g b efo re she w'ent o f f to th e library. (Thinking or feeling?) Well, th e niece is, feels a m a z e d a t how h a r d h e r un cle is w o rk in g a n d she feels sad . . . th a t h e h a s to w ork so h a r d to m a in ta in w hat he has. A n d th e sto ry e n d s . . . u h m . . . I d o n’t know' . . . A n d th e sto ry e n d s by th e niece p ro m isin g th a t she will visit every su m m e r b ecause she knows th a t th a t w ould m e a n m o re to th e m th a n a n y th in g m oney c o u ld buy. C A R D 3G F 30" Okay. In th e p ictu re is a y o u n g girl a b o u t 24 who’s co m ­ in g o u t of h e r f a th e r’s ch ick en coop. She h a d g o n e dow n th e re to ask h e r fa th e r if h e w ould m in d g iv in g h e r a rid e to h e r g r a n d m o th e r ’s a n d she o p e n e d th e chicken c o o p d o o r an d she saw th a t he was ju s t killing a chicken a n d she tu r n e d away in d is g u s t. . . and she was feeling hate. (?) T ow ard h er fath er. (End?) It will e n d by th e girl d e c id in g . . . n o t even to ask fo r th e rid e a n d w alk in g in s te a d to try a n d u n d e rs ta n d w h a t she h a d ju s t seen as b e in g a n o rm a l p a r t o f life. C A R D 5 35" In th e p ic tu re th e re ’s a la d y w ho’s lo o k in g in to h e r living room from h e r b ed ro o m . She was loo k in g o u t th e d o o r because she th o u g h t she’d h e a rd a noise a n d she’s feelin g sc a re d a n d h e r h e a rt is b e a tin g very fast. A n d th e sto ry e n d s by th e lady h e a rin g th e m ilk m a n ’s tru c k p u llin g away fro m th e c u r b a n d she realizes th a t th e noise she h e a rd was h e r m ilk b e in g d r o p p e d in h e r m etal box a n d she feels very relieved. C A R D 10 35" In th e p ic tu re is a m a n a n d a w om an. T h e m a n is h o ldin g th e w om an a n d th e w o m an is u p se t b ecau se sh e c am e h o m e to fin d . . . th a t the delivery tru c k h a d left o f f h e r couch a n d c h a ir a n d they h a d b een recov­ e re d in th e w ro n g fabric. A n d th e w om an is feelin g very d is a p p o in te d a n d

2 72 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

a little angry. (What’s the man thinking or feeling}) He’s feeling u n d e rstan d in g and angry. (?) T h at the store could do such a stupid thing. (End}) T h e story will en d by the m an m aking a deal with Macy’s th a t they would n ot only fix w hat they h ad done b u t would also d o an additional love seat for the sam e price. CARD 12M 1'45" I see an old m an looking at his g ran d so n an d the g ra n d fa th e r had come really to say goodbye b u t found his g ran d so n sleep­ ing. At first he thought he’d wake him b ut decided ju st to look instead. And the g ra n d fa th e r was feeling a g reat deal o f p ride ju s t seeing how beautiful his g randson was. (Grandson feeling}) T h e g ran d so n was asleep. I take th a t back. T he way I was going to end it was the grandson was awake so he could have been feeling som ething. T h e g ran d so n sensed the g ra n d fa th e r’s pres­ ence in the room and felt up set because he knew he h ad come to say g o o d ­ bye and the way the story ends is th a t the g randson calls the g ra n d fa th e r several days later and lets him know he was awake b ut felt too sad to actually say goodbye an d the g ra n d fa th e r u n d ersto o d . CARD 13MF (Turns card over, then back.) 1'25" I would say a m an and a wom an . . . (2 '2 5 ") . . . and they’re in a d en . . . in a house, in th e ir house, and the m an h ad come into th e d en to consult some law m anuals as he did every evening at the sam e tim e an d found his wife . . . d ea d . . . A nd he felt . . . well, he was shocked. (How did she die}) She slit h e r wrists. (Why’d she do that}) Because she felt th at she was losing control o f h er life an d he wouldn’t acknow ledge that. (?) He w ouldn’t acknow ledge she was ill in any way and refu sed her to see a doctor. (End.}). . . T h e story will en d by the m an going back to work an d resu m in g his norm al . . . lifestyle. CARD 14 T hese are h a rd . (1 '45") In the picture, there’s a . . . young m an looking o u t o f a window on the to p o f a high tower overlooking the ocean. A nd he h ad come u p to the tower to sit and th in k as he o ften d id in the early m orning hours. (Thinking or feeling}) He was thinking how won­ d e rfu l it would be if he could d o th e sam e th in g every day. (?) Com e to this sam e spot everyday because a fte r only a few h ours th ere his m ind seem ed som ew hat clearer. A nd the story ends . . . by him h e arin g a fire whistle and he knew it was time to get back to the grind. (What was grind.}) Just like every­ day stuff. (Like}) Work, family, friends. CARD 15 1' 10" In the picture, there’s a very old m an standing in a cem ­ etery late on a w inter night. A nd he cam e to the cem etery because he couldn’t sleep. A nd he was feeling very gloomy and depressed about being

A nxiety D isorders / 2 7 3

T

h e m a t ic

A

p p e r c e p t io n

T

est

alone since his wile died. And when she was alive, they had some o f their best talks late at night, so he felt it appropriate to get as close to her as he could and the story ends by the man having had a conversation ju st as though his wife had been standing there, and he fe lt. . . com forted. (C ou ld he talk w ith his w ife}) No. She didn’t answer back.

274 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

OBSESSIVE COMPULSIVE DISORDER W ITH MIXED PERSONALITY DISORDER Mr. J is 22-years-old, presently unemployed, and living with his mother. He was first hospitalized at age 18 following his high school g rad u atio n an d in the context of his fa th e rs su d d en d e a th in an autom obile accident. He becam e overw helm ed with anxiety, leading to frequent, acute attacks of panic. He had failed to respond to two brief hospitalizations an d subse­ quently sp en t alm ost a year at a long-term , private psychiatric hospital w here his anxiety and panic attacks rem itted w ithout pharmacological treat­ ment. He was able to live alone and attend college with the help of individual psychotherapy and atten d an ce at a stru c tu red day hospital pro g ram , but his anxiety and panic retu rn ed . He was given trials of several anxiolytic and antidepressant medications without any ap p a re n t benefit. He moved in with his younger sister and finally with his mother, b u t for the last six m onths, his increasing fears of contam ination by o th e r people’s bodily substances and an en su in g host of hygienic rituals and rigid avoidance of contact with objects touched by o thers have m ade it extrem ely dif ficult for him to be m a n ag e d outside the hospital. Mr. J ag reed w ith his m o th e r’s recom m endation th a t he seek hospitali­ zation a n d he was read m itted to the private hospital w here he had been treated previously. His functioning d eterio rated fu rth e r an d , dissatisfied with his progress, he requested tran sfer to a dif ferent hospital. His m other supported the transfer, feeling that he needed a greater am ount of structure in his daily living which was not being provided by the hospital staff. He had been “very depressed ” for the last two m onths. He slept as m uch as 12 hours a day in o rd e r to avoid becom ing preoccupied with his fears of con­ tam ination. He lost weight since his fears o f contam ination req u ired him to limit his food intake. U nable to w ard off his intrusive thoughts, he had becom e suicidal. At the time of his transfer, he stated he was requesting admission because “I’ve had p aranoid episodes since I was 17. B eginning this February, I started to be afraid to touch a n y th in g .” He began the interview' by placing a handkerchief on the seat o f the chair, explain in g th a t he d id n o t want to becom e contam inated by the chair. He said this fear was irrational, yet he could not sit down until allowed to use the handkerchief. T h ro u g h o u t the exam ination he kept his h an d s in his pockets. He touched n o th in g for fear that he would contam inate any object with which he cam e into contact. He rep o rted he was very tense an d he looked anxious an d was restless. His speech was digressive, b u t th ere was no evidence o f a form al th o u g h t dis­ o rd e r noted d u rin g the exam ination. He rep o rted persistent, intrusive

Anxiety Disorders / 275 thoughts having to do with contam inating or being contam inated by bodily substances. He washed his hands frequently in order to protect him self from these contam inating substances.

DSM-III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV: V:

Obsessive Compulsive D isorder Mixed personality disorder None Severe— recent hospitalization; d ro p p ed out o f school Fair— m oderate im pairm ent in both occupational and social functioning

Treatment and Hospital Course Following his admission, the hospital staff developed a highly structured, milieu treatm ent plan th at included a daily diary o f his thoughts, feelings and activities. He was confronted by the staff around his compulsive rituals and was allowed to spend progressively less time engaged in them as treat­ ment progressed. He developed some insight into the relationship between his ang er and his intrusive thoughts and compulsions and, as he became better able to express and tolerate his anger, his intrusive thoughts and com­ pulsions dim inished. As he began to evidence some m oderate degree o f im provem ent, his depressive feelings and hypersom nia rem itted. He con­ tinued to have difficulties in his social relationships and spent little time with others.

Psychological Assessment Mr. J m ade a good adjustm ent to the stru ctu red treatm ent plan im ple­ m ented by the hospital staff. He was referred for testing d u rin g the first week o f hospitalization to help with his differential diagnosis, to determ ine the n atu re o f a previously reported learning disability, and to assess his potential for psychotherapy. T he prim ary issue in the diagnostic differential was his capacity to adequately test reality, given the dram atic effect o f his obsessions and compulsions on his behavior. He was given an MMPI, Ror­ schach, TAT, SCT, and DAP to help with the diagnostic differential and psy­ chotherapy assessment. He received a battery o f neuropsychological screening tasks, including the WAIS-R, Wide Range Achievement Test

2 7 6 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning (VVRAT), Ravens Progressive M atrices, an d S p reen -B en to n B attery to help assess his neuropsychological difficulties. His behavior d u rin g testing was largely u n rem ark ab le with the exception of a g re a t deal of restless m o to r activity such as jiggling his leg. H e h a d no dif f iculty follow ing th e e x a m in e r’s in stru ctio n s w hen they involved h a n ­ d lin g test m aterials, b u t otherw ise kept his h an d s in the pockets of his shorts. O n th e WAIS-R, he o b tain ed full-scale, verbal, a n d p e rfo rm a n c e IQs of 9(3, 97 an d 94, respectively. C o m p ared to the results rep o rted th re e and four years previously, th e re was som e low ering of his verbal IQ. T h e p a tte rn of his various subscale scores su g g ested relative w eaknesses in co n cen tratio n , a tte n tio n , a n d visual-m o to r c o o rd in a tio n a n d sp eed . His 1)AP also su g ­ gested difficulties w ith visual-spatial integ ratio n . H is visu al-m o to r deficits were p a rtly neuropsychological in orig in . He evid en ced a m o d e ra te g ra p h a esth esia in b oth th e rig h t a n d left h a n d s an d a m ild fin ger agnosia on the left side. Fine m otor co ordination was im paired to a m o d erate d e g re e . In a d d itio n to th ese se n so rim o to r deficits, he also gave evidence of som e m ild artic u la tio n p ro blem s an d in te rm itte n t w ordfin ding difficulty. His W'RAT p erfo rm an ce placed him at sixth g ra d e levels in bo th sp ellin g an d m ath a n d at only th e n in th g ra d e level in re a d in g . His accounts of his school dif ficulties, b o th behavioral a n d academ ic, a n d his strategies to circum vent his read in g dif ficulties in p a rticu lar were suggestive of long-standing neuropsychological im pairm ents. T h ese im p airm en ts may have been related to a specific le a rn in g disability for w hich he h a d le a rn ed to c o m p en sate partially o r p e rh a p s to a m o re d iffu se p a tte rn of atypical cognitive developm ent. In eith er case, these neuropsychological deficits h ad com prom ised his integrative cognitive abilities a n d continued to m ake it d if­ ficult for him to use th ese abilities, p articu la rly w hen psychologically d is­ tressed. H is distress was evident in his MMPI w here seven o f th e 10 clinical scales (scales 1 ,2 ,3 , 6, 7, 8 andO) a n d his F scale all h a d pathologically h igh T scores of 70 o r greater. T h e rem ainder, with the exception o f scale 9, were scored at 65 o r above. Mr. J’s relatively h ig h e r WAIS-R subscale scores showed a p referen ce for factual m aterial a n d a h e ig h te n e d sensitivity to en v iro n m e n ta l cues. Mr. J relied on his h y p era le rtn ess to preserve his reality testin g abilities w hich, on th e w hole, were fo und to be reasonably intact. O n th e R orschach, for ex am p le, he gave seven p o p u la r resp o n ses in an expansive re co rd w ith a total o f 42 responses, b u t m an a g e d only a b o rd e rlin e a d e q u a te co n sen su al a p p reciatio n o f th e fo rm of th e in kblots (F + = 79%). However, th e re was a strik in g total absence o f resp o n ses w hich in c o rp o ra te d color, reflectin g an extrem ely g u a rd e d em otional reactivity. Instead, he was overly ideational a n d ru m in a tiv e (M = 6) a n d was c a p tu re d by th e sh a d in g o f th e inkblots a n d th e black a n d w hite c o n trast, featu res of his R orschach re c o rd w hich

Anxiety Disorders / 277 in d icated th e presence of a g re a t deal of anx iety an d in tern al tension. His sense of this anxiety was th a t it was p o tentially explosive. For ex am p le, on card 1, this was clearly p ro jected in his re p o rt of two tiny d etails w hich re m in d e d him of “a n u c lea r bo m b clo u d .” T h e sense of total a n n ih ila tio n w hich developed from a single, sm all d etail was p e rh a p s clarif ied by his TAT stories. H e was obviously p reo ccu ­ pied w ith d e a th an d th e d isru p tio n a n d loneliness th a t re su lted for those w ho h a d survived th e d e a th . O n th e FAT, th e m ajority of th e stories involved very negative them es. T h e causes of d e a th in clu d ed a h e a rt attack (card 5), suicide (cards I I an d 1 5), acts of w ar (card 10), term inal cancer (card 13MF), m ad n ess (card 3BM), a n d a d ead ly ch ild h o o d disease (card 12M). In each case, th e survivors failed to m ake a successful a d ju stm e n t to the loss a n d , in each case, th e c a ta stro p h e resulted from som eone’s a tte m p t to establish a life o u tsid e th e p a re n ta l hom e. In these stories, he m ad e it clear th a t grow ing u p a n d estab lish in g a life th a t was in d e p e n d e n t of his ch ild h o o d hom e was to invite c ertain disaster. A ny such a tte m p t w ould be p u n ish ed by d e a th . It is little w onder th a t such a pervasive fear would give rise to an intolerab le a m o u n t of anx iety an d episo d es of acu te p anic in th e co n tex t of ef forts d ire c te d at in d e p en d e n ce an d m a tu ra tio n . The solution to this d ilem m a a p p e a re d to lie in th e rigid m a in te n a n c e of a co m p lian t a n d subm issive p o stu re a n d a co m p lem en tary avoidance of situatio n s a n d p eo p le w ho m ig h t stim u late fo rb id d en a g g res­ sive o r sexual wishes. In a d d itio n , protective devices such as th e “b o xing gloves” a n d “goalie m ask ” re p o rte d on card IX of th e R orschach m u st be em ployed to effectively survive. Mr. | s T A T an d SC T responses m ad e it c lear th a t h e felt u n a b le to n eg o ­ tiate th e ad u lt w orld o f work a n d relationships. O n th e SCT, h e re p o rte d th a t he felt h a p p ie st w hen “ I d a y d re a m ” a n d th a t w hen w ith his m other, he felt “p ro te c te d .” Since ch ild h o o d , his g re ate st fear was th a t “m y p are n ts w ould d ie ” a n d he felt to blam e w hen “his fa th e r d ie d .” His fa th e r was described as the ideal m an an d always “was nice to m e.” His lost relationship with his fa th e r was clearly q u ite im p o rta n t to him . O n th e FAT. th e only story with a positive outcom e (card 7BM) concerned a father an d a son. Hie fath e r en co u rag es th e son to accept a sch o larsh ip to college ra th e r th a n a high paying job a n d , follow ing th e fa th e r’s advice w hich “tu r n e d o u t even­ tually to be a g o o d decision in th e long r u n ,” th e son “tu r n e d o u t to be a successful b u sin essm an .” H e continued the them e on th e next card (6BM) wher e a m o th er an d son w ere s e p a ra te d by th e son’s decision to take a b e tte r pay in g job o u t o f town. T h e m o th e r a n d son were d escrib ed as “really, really close, especially since h er h u sb an d died, his father, a n d he lives right n e a r h er now th at he’s grown up an d takes care of her.” A lthough th e son moved away; leaving the m other

2 7 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning “shocked an d depressed an d conf u sed ,” he “doesn’t like bein g away from his hom e a n d he really misses his m o th er” and he eventually “quits his jo b and moves back hom e” w here he is “a lot h ap p ier.” Mr. J a p p e a re d to yearn for a restoration of his earlier family situation an d seem ed willing to renounce in d ep en d en t strivings. However, such a renunciation would require him to accept a view of himself as a resourceless an d hopelessly ill child. T his view was graphically portrayed in his male fig­ u re draw ing. He drew a tiny, empty, sm iling figure on b en d ed knee with o utstretched arm s w hom he described as 24 years old o r so a n d “happy . . . reaching out to grab som ething.” Surprisingly, his female figure was draw n in exactly the sam e p o stu re b u t was d escribed as “con fid en t, happy, strong an d aggressive.” T hese two desexualized figures were in terchangeable except for th eir hairstyles and a small halo which was draw n over the head o f the m ale. T h e g re a t sim ilarity of the figures, but certainly not of th eir descriptions, suggests the conflict he feels in adopting a helpless, dependent, child-like role. T h is conflict an d the tra p it posed for him also surface in the Rorschach. In one response to card II, he used the intern al red details to identify “a m an scream ing, he’s tra p p e d in so m eth in g .” O n inquiry, the eyes are “eyes in a f row ning face enclosed in here, in the black, like a cell.”

Treatment P lanning and Outcome Mr. J had m ade substantial progress in red u cin g the am o u n t of time he spent engaged in washing rituals and in allowing himself to physically con­ tact his environm ent u n d e r the stru c tu re of his n u rsin g supervised, behav­ ioral care plan. However, his success was itself a source o f anxiety for him for he felt it im plied a rap id disch arg e from the hospital an d an en su in g loss of su p p o rt. T his them e of ab an d o n m e n t in the face of success, which was consciously recognized by him in the context of his hospital treatm en t, provided the psychologist and his treatm en t team with a focus for th eir treatm en t recom m endations. His neuropsychological deficits were acknow ledged by the treatm en t team and were explained to him as settin g real limits on w hat he could accomplish. His need for consistent su pport to develop com pensatory strat­ egies was accepted as valid and he was able to work productively with the th erap eu tic activities d e p artm en t to develop com pensatory skills. He was also helped to see th a t o u tside of these real deficits and his realistic fears for his own ability to m aintain an in d ep en d en t existence th ere were irra ­ tional elem ents to his fear which were a source o f conflict for him . He was of fered an o p p o rtu n ity to explore these fears in g rea ter d ep th in his individual psychotherapy. He g radually cam e to u n d e rsta n d th at his

Anxiety Disorders I 279 obsessional thoughts and com pulsive behaviors served prim arily to defend him against his feelings of anger, guilt, an d f ru stratio n which had crystal­ lized aro u n d his fa th e rs d eath an d were p e rp e tu a te d by his real concerns over his m o th er’s health an d his fear of losing her as well. In his g roup psy­ chotherapy, he was able to recognize th a t a n g e r and tension held less destructive potential th an he had im agined and he became increasingly able to express his own feelings in this context. Equally im portant to his f u rth e r progress was his family therapy. T h e psy­ chological assessm ent was first utilized to help Mr. J ’s m o th er u n d erstan d his real neuropsychological problem s. She h ad worked in m edical settings an d found these results easy to accept. Initially, she felt they confirm ed the need for Mr. J to rem ain d ep e n d e n t on her. She later becam e aware of an d able to express h er own lim itations and conflicts with reg ard to how much she could d o for him . O ver the next several m onths, he learned th a t his m o th er d id not need for him to be d ep en d en t an d his m o th er learned that he was able to lead a happy life away from her. Mr. J’s hospitalization lasted alm ost a year. At the end of th a t time, the hospital staff recom m ended to him that he live in a halfway house, attend a day hospital, and continue with his individual an d family psychotherapy. T hese plans were accepted by him and he m ade a good ad ju stm en t after leaving the hospital.

2 8 0 / Psychological Assessment, Psychiatric Diagnosis, a nd Treatment P la n n in g

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Obsessions

Will contam inate o r be contam inated by others

Obsessive preoccupation with catastrophe and death

C om pulsions

Excessive hand-w ashing, keeps hands in pockets

None

Mixed personality disor­ d e r with d ependent and schizotypal features

Marked im m aturity and very limited insight, but reality testing not grossly disturl>ed

I. Sym ptoms/Diagnosis Obsessive compulsive disorder

II. Personality Factors

O d d speech; paranoid ideation; m arked social anxiety and isolation III. Cognitive Abilities

IV Psychodynam ics

Possible history o f learn ­ ing disabilities

Sensorim otor and spatial orientation im p air­ ment; academ ic p e r­ form ance m uch below college g rad e level

D ependent on m other

U nw arranted guilt over fath er’s d eath ; fears his independence will be difficult for his m other Infantile yearnings for a protective environm ent

V.

T herapeutic E nabling Factors

Functioning improves in a stru ctu red environm ent

Adept at using external cues and direction to organize his behavior Is capable o f com pliance when safety is g u aran teed

VI. Environm ental D em and and Social A djustm ent

Unable to m aintain inde­ pendent living

Poor p lanning and o rg a­ nization without external structure; expects to fail

Anxiety Disorders I 281

A r e a ok

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

No close friends; no lei­ sure pursuits

Limited em pathie skills and uncertain psycho­ sexual identification

282 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT WAIS-R

2

S u m m a ry

Verbal Subtests

Scaled Score

Inform ation Digit Span Vocabulary A rithm etic Com prehension Similarities

11 8 10 8 9 11

Performance Sublests Picture Completion Picture A rrangem ent Block Design Object Assembly Digit Symbol

14 11 7 8 8

Verbal IQ Performance IQ Full-scale IQ

97 94 96

MMPI

S u m m a ry

F*LK: 8!2**7"610'345-9/ R orschach Sum m ary

N um ber o f Responses Rejections Populars O riginals Average R/T Chromatic: Average R/T Achromatic: F% F+ % A% H% W:M M:Sum C m:c V III-X %

43 0 8 I 7” 12” 56 79 44 16 6:7 7:0 6:6 21

Anxiety Disorders / 283

R

orschach

S

um m ary

FK + F + Fc% (H + A ) :( lld + Ad) A p p erce p tio n VV 14% D 63% d 9% Del + S 14%

63 21:5

2 8 4 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

3

R o rschach Sum m ary

Response

Inquiry

1. It’s a wolf. Do I describe the picture or som ething? (Just tell me urhat it looks like. Some people see more than one thing.)

Whole thing. (Wolp) T he ears and the triangulartype face.

Scoring

I. 4" WFA

2. A nd I see two birds-like statues o f two birds.

2. H ere. T h e top part. (Birdlike?) Like the e a r p a rt o f the wolf looked like it had a feathery tail and beak. Just the general shape. (Feath­ ery?) T h e shape and the way the ink is light and d ark in places. Reminds me o f som ething light and feathery. (Statues?) It looks still.

DFcA

3. A nd I see, um , I see like lit­ tle paws o f a d a m — no not a d a m — a, a lobster. Little legs (gestures).

3. T h e shape.

dFAd

4. Looks like two— two m ush­ room s o f a nuclear bom b cloud. A m ushroom cloud.

4. They were, like, foam ing on top, an d they shot up like a m ushroom . (Foamy?) Um , they ju st, uh, the top o f them looked like, like gaseous-like.

dKF.cF Expl

5. A nd it looks like little— like, like . . . like am oebas, or small anim als, floating around.

5. They seem ed to be very small and sw im m ing very fast and erratically. (Seems that way?) T h e way they seem ed to be b u m p in g into one another, an d the way the ink w ent— like they were in motion.

ddFM A

A nxiety Disorders / 2 8 5

R orschach Sum m ary

Response

Inquiry

6. A nd it looks like a top o f a teap o t— a percolator, you know, th at type o f thing. T h a t’s about all.

6. T h is here. (Percolator?) Just the shape sort o f rem inded m e o f one.

drF-O bj

1. T he pelvis . . . area. Like an x-ray o f the hip. Pelvis.

1. H ere— it’s everything b u t the red. Here’s the sacrum — w hat do you call it-the Xray bottom o f the backbone. (X-ray?) T h a t’s the only way you could see the different parts. I guess— the color. (Color?) Just the black versus white.

W Fk.FC '-A t

2. T here’s, u h . . . two . . . dogs th a t are rubbing noses.

2. T h is h a lf here and this half here. (Including this}) No, none o f the red; ju st the black split in half. (Dogs rubbing noses}) Shaped that way. T he way they’re touching.

WFMAP

3. T h ere are fighting m unchkins-like, little, Fighting . . .

3. Heres, these two red things. (Fighting?) T he way the red dots came o ff them . (How um that}) It seem ed—ju s t seem ed to make ’em seem to be more in turm oil. (Munchkins?) I don’t know— they ju st seem ed like small people.

DM(H)

4. A nd there’s like, I think it’d be like a type o f a crab o r a shellfish with sort o f antennas.

4. H ere. (Shellfish?) T he over­ all shape. A ntennas.

DFA

5. T here’s u h , like a lam p you see in the park, to light the walkway.

5. I'he white. (Lamp?) Just the shape.

SF Obj

Scoring

II. 14"

2 8 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

Rorschach Sum m ary

Response

Inquiry

Scoring

6. T h ere seem s to be a m an scream ing— he’s trap p ed in som ething— tra p p e d in a cell o r som ething. (Cell?) Yeah, a room o f some type.

6. Ju st— well it’s not as good on both sides, b ut you can see in this red in here, like eyes on a frowning face. Like enclosed in here, in the black, like a cell. (Cell}) H e ju s t seem ed trap p ed in it. (Trapped,}) His face— th at he was sad and stuff.

D M -H d, A rch.

7. I see an outline o f a dog's head. T h a t’s all I can see.

7. Here. Ju st the shape.

dFA

1. T here’s a bowtie.

1. T he red th in g in the m id­ dle. (Bowtie}) Just the shape.

DFCIothP

2. A nother picture o f the hip.

2. R ight in here. (Picture of a hip}) Ju st looked like it . . . in this one, well, it’s mostly in both o f them -the p art th at looks like the coccyx. T h e p a rt o f the spine th at sticks down there in the m iddle. (Show me) Yeah, there, it’s th at line there. Not so m uch in this one, but you can see it here. And also, the shape o f the sides.

DFkAt

3. Two women fighting over som ething.

3. T his here and here. A nd they seem to be in a tug-ofwar type thing. Pulling this here.

WMHP

III.

6"

Anxiety Disorders I 2 8 7

R o rschach Sum m ary

Scoring

Response

In q u iry

4. Two, like, uh, I don’t know w hat you’d call th em — like cartoon characters, som e­ th in g you’d see in a ca r­ toon. A nd they seem, like, scream ing back and forth to each other.

4. Yeah, here and here. And w hat makes them look like they’re arg u in g is the way the ink comes o ff them there. A rg u in g verbally. (Show me) T here. (The dob?) Yeah. (Cartoon characters?) Yes, the head, the arm s, tail. Has to be a tail.

DM(H)

5. A nd, like, two m ushroom clouds again.

5. Here and here. (Clouds?) T he shape. (Anything else?) No.

drF C loud

6. A nd then, uh, two m en with, with, who are very stern and have big noses. (Hurns to self, puis foot on chair and jiggles it.)

6. Right here, this is the neck, th eir head, the eyes, the lips, the nose. (Stern}) T he, the, the way th eir lips were, and th eir chin. (Mean?) D rooped, like. T he chin d rooped.

DM Hd

7. A nd uh, two guns. T h a t’s all 1 can see.

7. Right here, here’s the trig ­ g er and the barrel. T he same over here. (Gun?) Just the shape.

DF-Obj

I. U h, the, the spinal colum n.

1. U h, here. A nd th at looked like the lx>ttom. (Spirnl col­ umn?) Um, the shape. A nd like, on each o f the bones, they have a spine o r some­ thing that comes o ff them , like condiles. (?) Yeah, p ro ­ tuberances, and those looked like that.

DF-At

2. T here’s two, there’s a boot.

2. T he shape. T h e points here.

DFCIothP

IV. 45"

2 8 8 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

Ro rsch a ch Sum m ary

Response

T here’s a shadow o f a bird — like the ones you m ake with your fingers, th at you shine in front o f a light (gestures with hand).

Inquiry

Scoring

H ere and here. (Shadow}) U h, just like the beak and Stuff. (Show me}) Uh, here. Doesn’t look like a real birds’ head. It could be like the shadow. (So not looking real made il seem like a shadow'}) Yeah, not looking real. (Anything else}) No. I don’t think so.

DF(Ad)

4. Looks like a bear rug.

T he whole thing. T his is the head, these are the arm s, an d that's the tail. (Bear rug}) T he shape. The head was there, an d the tail.

WFAdP

5. It’s, looks like kind o f like w here they light the flame for the Olympics, or a torch, like in a tem ple. Like in a B uddhist tem ple.

I m eant like a torch stand. T his p art here, and this p art going up. T h e flame would go in there. (Torch stand}) T he shape.

DFObj

V. 5" 1. A butterfly.

1. Uh, this way. (Butterfly}) Wings. S haped like one.

WFAP

2. Ah, a dolphin.

2. Here, this, this is its body, this is its head and m outh. A nd it looked like it’s in motion. (Dolphin in motion}) I don’t know—-just looked that way.

DFM-A

3. A back view o f a rabbit. Uh . . . (long pause) T h a t’s all 1 can see.

3. Here, here’s its ears and its tail. A back view.

dFA

1. Here. (Wolf's head}) Shape.

DFAd

VI. 4" I. Um, it looked like a wolf’s head.

A nxiety Disorders I 2 8 9

R orsch a ch Sum m ary

Response

Inquiry

Scoring

2. Well here's w here the strings go and then here— you notice how the color changes?— it goes o ut and down here and then back.

d rF C '-O bj

1. Two girls, Indian girls, staring at each other.

1. Outlines. (Indian girls}) They had a feather, kind of, on their heads.

D M H.ObjP

2. Two elephants. A nd then (Hold on) . . .

2. Well, well, the elephants go kind o f the way you’re look­ ing at it. Here’s the eyes, and the head and the trunk.

3. Two pigs.

3. Just upside down. Here's the eyes an d the nose. T his is a little th in g o ff the head.

4. A nd then, uh, a dom ed arena. T h a t’s all I can see.

4. T his th in g here, this whole thing. (Domed arena}) Just the shape. (Sltoxv me parts of it}) Here’s like, the roof. A nd these are the sides. 1 sort o f filled in here so it would be like level.

DF-Arch

1. Here. (Rats}) T he shape.

DFAP

2. A. a guitar. (Sighs, puffs)

T h a t’s about all I ta n see. VII. 4”

DFA

DFA

V III. 3" 1. Looks like two water rats.

2 9 0 ! Psychological Assessment, Psychiatric. Diagnosis, a n d Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

Scoring

2. Here are its eyes, these are its arm s. T his is the rest. It looks all swervy-like, th a t’s why I saw that. (Swert>y?) It looked like, uh , ju s t like there were creases. Like he was very inanim ate . . . just creases. (How did creases make it seem inanimate?) It m ade it seem like light and spooky . . .

DFc(H) Peculiar verbalization

1. Two witches facing each other.

1. Just the shape. (Whole figures?) Yeah, whole figures.

DM(H)

2. A rabbit’s face.

2. H ere are the eyes. OK, it ends about here, and it goes up here into the brig h t— here are the ears— and down around here. (Rabbit’s face}) T he eyes and the ears, the shape. (What about eyes}) 1 don’t know, ju s t rem inded me o f a rabbit.

D(S)F-Ad

3. Two boxing gloves.

3. Looking this way at them , you can see it. T his is like the th u m b in here. It’s ju s t the shape.

DF-Obj

4. Um, a goalie’s mask, like in hockey.

4. OK, here’s the eyes. It goes down here and up, up here. For some reason, it looks very thick. I guess it’s the shading. So anyhow, it goes down to here an d aro u n d here.

dr(S)FcObj

2. Looks like a ghost.

I can’t see n o thin g else.

IX.8"

T h a t’s all I see.

A nxiety Disorders I 2 9 1

R orschach Sum mary

Response

Inquiry

Scoring

X. 6" I . Bugs crawling up a pole.

1. Here’s the bugs here and these are the antennas. And this is the pole.

DFMA,Obj

2. Two seahorses (Inspects card carefully, taps card).

2. R ight here. T h e shape of seahorses.

DFA

3. Two wolves looking at each o th er nose to nose.

3. R ight here-here’s the heads and here’s the nose. {Wolves?) Ju st rem inded me o f wolves. T h a t kind o f shape.

DFMA

T h a t’s all 1 can see.

292 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t i o n T e s t

CARD 1 U h . . . hm m . . . um . T h e kid got in trouble in school for getting bad m arks. A nd he was sen t— his parents sent him to his room to study, and he’s uninterested and he’s m oaning about it. {Hold on) A nd u h , he— he decides to try and, a n d learn the work he has to learn. A nd he goes into school and he fails anyway. A nd it seem s that no m atter how h a rd he tries, nobody believes he tries, and he still seem s to fail anyway. A n d — th a t’s it. (He doing}) S tudying for a test— o r stu d y ing for school in general. CARD 3BM A lady becomes, uh , really depressed, an d uh, because she becom es so depressed an d everything, she starts to lose h er family an d her jo b and everything. So— one day she eventually loses everything— h er fam ­ ily, h er friends and h er jo b — and she can’t function and she becomes hys­ terical. She starts crying and becomes so hysterical, she loses it. (?) Like she’s gone crazy. She eventually ju s t dies from n ot eatin g an d the elem ents— she ju s t walks aro u n d in the city and nobody knows her. She just dies because o f her, you know, h er life situation. (How does she lose everything from being depressed}) She ju st becomes so hysterical that she doesn’t care anym ore— she doesn’t care a bout anybody o r an y th in g — she ju s t pushes them away. (What led up to depression}) T h e pressures o f hom e, an d uh, h er jo b , an d ju s t— th e— pressures o f those things. (Dies from not eating and the elements}) Yeah— she ju s t w anders in the streets. CARD 4 U h, a m an and wife go on vacation an d uh, the, the, an d they go into a hotel and the guy at the desk is— extremely ru d e to the guy’s wife. A nd he’s really an g ry an d wants to hit ’im, an d his wife is scared and is holdin’ him back an d tryin’ to calm him down. A nd w hat h a p p en s is, uh , they— they— the guy at the desk and the woman’s hu sb an d — they ju st argue an d no violence breaks o u t and they ju st go on an d have th e ir vacation an d nobody says a n y th in g about it and it’s forgotten. (How does guy keep from hit­ ting him}) His w'ife talks him out o f it. (How was guy rude:) He was verbally abusive— ru d e and snide— and used foul language. (Any reason}) Just had a bad day. CARD 5 Ok. T his, this lady is sitting on th e — sitting in the first floor o f a house, an d , uh, all o f a su d d en she hears a large b an g o r a loud noise in a bedroom . So, uh, she ru n s up-upstairs an d , uh, opens the door, and she looks really a h — she looks very shocked an d petrified . W hat she sees is th at, um , h er husb an d h ad , u h , had a h e a rt attack an d h ad fallen to the g ro u n d . (Hold on) W'hile he was p ain tin g the ceiling o f the room . A nd, uh ,

Anxiety Disorders / 293 T h e m a t ic A p p e r c e p t io n T e s t

she, u h — w hatcham acallit— she, uh , it tu rn s out th at her hu sb an d died. A nd she’s — she survives— but it tu rn s o u t that h er life is depressing and h e r— h er ch ildren aren’t aro u n d anym ore, an d she’s just really alone. T h a t’s— th a t’s it. CARD 6BM A, a m o th er an d son are really, really close, especially since h er h usband died. His father. A nd he lives rig h t n e a r h er now th at he’s grow n up, an d takes care o f her. A nd one day he finds o u t th at because o f his jo b he has to move away. He decides— an d w hen he tells h er here, he’s really saddened, and she’s shocked and depressed and confused, and doesn’t know w hat she’s gonn a do. H e finally moves away an d she seem s to adjust, but he doesn’t like being away from his hom e and he really misses his m other. So eventually he moves back to— hom e— quits his jo b , and moves back home. A nd even tho’ he can’t m ake as m uch money and things like th at, he’s a lot h a p p ie r being hom e. (What does he miss?) Family an d friends. CARD 7BM OK, uh, a kid aro u n d 20 years old gets, uh, an o ffer for a good-paying jo b , and at the same time he gets a scholarship to college. Now he doesn’t know exactly w hat to do. In the picture here he’s talking it over with his father. He’s confused and scared, because this decision will affect him for the rest o f his life, so (hold on) so he decides, uh , to — his— him and his fa th e r— with the help o f his father he decides to go to school. At first the decision d id n ’t seem to be a good one, because he h ad to give u p a jo b , b u t it tu rn e d o u t eventually to be a good decision in the long ru n . He tu rn ed out to be a successful businessman. (Father thinking and feeling}) He’s feeling sym pathetic towards the son, th at he has to m ake a difficult decision. (Why decide school}) He feels it would b e— him and his fath er th in k it would be b etter for him in the long r u n — he’ll have b ette r opportunity. CARD 10 U h, a couple in th e ir early 60s hav eju st found out th at th e ir— th eir youngest son had died. He was, u h — he was, um , in— at w ar and he got shot and killed. A nd they’re very sad and depressed an d they, they try to com fort each other. But they decide to stay and u h , stay alive and try to get over th a t because they have two o th e r children an d they have g ra n d ­ children. But in — in tim e, they really don’t — miss this— miss the son that m uch. A nd they— they live with their oldest child and their grandchildren, they live very happily, co n sid erin g w hat h a p p e n e d to th eir youngest son. T h a t’s ab o u t w hat h a p p e n e d . (They think o f not staying alive at first}) No. CARD 12M A young o rp h a n contracts, u h , a deadly child h o o d disease, he— he suffers for a while an d eventually dies. T h e priest who ran the

294 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

orphanage that he was staying at adm inisters the Last Rites. T he child con­ tracted w hat he had because he d idn’t have the right food or medicine. A nd the priest was m ore upset an d m ore d esp o n d en t about th at, because the d e a th was needless. So— after the child dies, the father works and works and works to try to improve the conditions for the children. But no m atter— even th ough he works h a rd , no m atter how h a rd he works, ch ild ren still die an d he feels very an g ry and up set th a t c hildren die. But no m a tte r how h a rd he tries, he can’t help everybody. (When did child get sick?) At the orp h an ag e. (Why can't priest improve things?) Because prices go up and he has to take care o f m ore c hildren and m ore children each day an d su p p o rt for him goes down. CARD 13MF U h, u h , a guy’s, um , wife, she’s, uh , d o I have to start at the beginning? (How do you mean?) Do I start at the beginning, or should I think it all th ro u g h First like I d id last tim e. (Do it the way that’s most comfortable for you.) A young couple get m arrie d an d uh , soon afte r they get m arrie d , uh, th e — the wife becomes very ill. A n d — u h — u h , th e — the couple goes to a doctor, they go to a doctor, and they find out that the wife’s g onna die— she’s got term inal cancer. (Hold on) So they decide to sp e n d — she has about two or th ree m onths to live— so they decide to spend all their time together. A nd w hat h ap p en s— this is when she dies. She’s dead, she don’t know w hat’s going on. But he’s really upset and bereaved an d confused. A nd, u h , so he— he eventually leaves where they’re living an d moves away and gets a new jo b . H e never rem arries o r anything, b u t he does okay, I guess. (She died at home?) Yeah. CARD 14 A young— a guy about 24 is, uh, is, is m arrie d an d uh, he’s— he’s cut ’em — he cut him self o ff from everybody— his family, his bro th ers an d sisters, his cousins and everything. (Hold on) A nd w hat h a p p en s is, is his wife leaves him . She— she goes— she went crazy an d she— she killed h er­ self. A nd, uh, this— this guy is ju s t sitting on a windowsill w ondering w hat to do with his life now. H e wouldn’t — he doesn’t kill h im self o r anything, but w hat he decides to do (hold on) is to go back an d try to be close to his family again. He tries an d tries, b u t he keeps th in k in g abo u t his wife. A nd even though the family gets close again, he’s never as close as it was before he m et his wife. (Why cut self off?) C ause all he cared abo u t was his wife. A n d — and nothin’ else. (Why she leave him?) Cause she went crazy— she d id n ’t know w hat she was doin’. (How he feeling?) D epressed. CARD 15

A n old m an is— is— is all alone an d his friends have all died,

A nxiety Disorders I 295 T h e m a t ic A p p e r c e p t io n T e s t

so w hat he decides is to go to the cemetary and visit ’em. A nd— and he goes early in the m orn in g to visit ’em , and, uh , he stays th ere all day— u h , look­ ing an d going th ro u g h the tom bstones of each of his friends. H e— he stays there until about m idnight— and, he puts his hands together an d starts cry­ ing because he’s so alone. A nd w hat h ap p en s is, u h (hold on) so w hat h a p ­ pens is, at a bout 12 m id n ig h t he decides to leave, and he feels so alone th a t he doesn’t think life is w orth living. So he killed himself, an d nobody knew about it, or cared, or m issed him .

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EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

4. He felt to blame when “his fa th e r d ie d .” 8.

As a child my greatest fear was “m y p a re n ts would d ie .”

9.

My father always “was nice to m e.”

10. The ideal man “is m y d a d .” 13. M y first reason to him was “fear.” 16. Most fathers “a re c a rin g .” 35. When he thought o f hismother, he “w ished he could be n e a r her.” 41. / / / can’t get what I want, I “p re te n d I d o not c a re .” 42. When I am criticized, I “p re te n d not to c a re .” 46. When they didn’t invite me, I “p re te n d e d not to c a re .” 47. He felt very tense when “he has to c o m p ete .” 70. When my father came home, I “always g o t so m e th in g .” 74. I feel happiest when

“I

d a y d re a m .”

87. / am afraid o f “e v e ry th in g .” 94. When he was with his mother, he fell “p ro te c te d .”

Anxiety Disorders / 297

DISCUSSION Obsessive com pulsive d iso rd e r is equally prevalent in males an d females. O u r m ale case, Mr. J, rep o rted compulsive sym ptom atology which arose in a two-year context o f anxiety and panic following the d eath o f his father. By the tim e o f hospitalization, the core conflictual them e was an intense fear o f contam ination, leading to m ultiple restrictive rituals and behaviors. T h is notion, in fact, may have had som ething to do with the referral for psychological testing. T h e central questions in this referral concerned the extent to which his reality testing was intact, a referral question which is quite com m on w ith obsessive compulsive individuals who require hospital­ ization. T h e issue o f his ability to test reality is also related to the refer­ rin g th erap ist’s question about the ability o f the patient to p rofit from psychotherapy. T h e test results seem ed quite congruent w ith the clinical picture and were quite helpful in ad d ressin g the referral questions an d fu rth e rin g the treatm en t plan. He was extrem ely rum inative an d overideational, with a lack o f em otional reactivity. His projective test findings revealed the d ep th o f his preoccupation with loneliness an d catastrophic death . O n the other hand, there was some evidence that he could reach o ut to parental figures for help and guidance. In addition, while reality testing was at times borderlin e, he was able to produce a n u m b er o f p o p u la r responses and the plan o f a supportive but gradually m ore exploratory therapy seem ed feasible. T h e case o f Ms. H , a 23-year-old w om an with rituals o f cleanliness and fear o f contam ination, provides some sim ilarities and contrasts. Like Mr. J, her obsessive compulsive behavior seems related to a significant life event. W hile Mr. J ’s preoccupations with d eath are related to the su d d en d eath o f his father, Ms. H , a devout Catholic, first developed h er sym ptom s after term in atin g a pregnancy by abortion, a fact which she hid from her family and a behavior which conflicted with her deeply held religious beliefs. Prior to the onset o f Axis I obsessive com pulsive sym ptom s, she possessed m any traits o f the obsessive com pulsive personality disorder, traits th a t seem ed less prom inent in Mr. J. T h e testing referral cam e after some progress in treatm e n t involving sym ptom atic relief w ith antidepressant m edication, b u t fu tu re therapeutic efforts h inged on th e d e p th o f depression an d w hether o r not the patient could respond to an expressive or a supportive psychotherapy. H er full-scale IQ o f 83 and h er cognitive style em phasizing rote m em ory an d the u n d e r­ stan d in g and adheren ce to social norm s suggested th a t a m ore supportive approach to treatm ent might be more congruent with h er cognitive and p e r­

2 9 8 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning sonality styles. H er Rorschach responses revealed a pro fo u n d sense o f desp air and em otional im poverishm ent an d suggested th at expressive psy­ chotherapy would be too am bitious an u n d ertak in g . T h e psychological test m aterial also suggests th a t h er depression is o f an anaclitic type, with a profound sense o f inner im poverishment and a h u n g er for contacts w ith others. She a p p e a rs to have m ixed personality d iso rd er traits, including d ep en d en t, obsessive com pulsive, an d passive aggressive characteristics. She seem s chronically dysthym ic, with little energy, and chronically at the bo rd ers o f despair. H er self-concept o f a sm all child seen in h er figure draw ings m ight suggest th a t she would ap p ro ach a therap ist as a distant authority figure an d proceed to en gage in passive/aggressive m aneuvers. It is interesting to note how th e Axis I obsessive com pulsive behaviors resolved in these two individuals. Mr. J, th ro u g h treatm en t, ex perienced relief in the exploration o f his fa th e r’s d e a th an d w hat it m eant to h im . His obsessive com pulsive sym ptom s d isap p eared an d he re tu rn e d to his prior level o f functioning. He was discharged to a day hospital and halfway house because he h ad been un ab le to function independently since his adoles­ cence. In some contrast, Ms. H found little sym ptom relief in h er explora­ tion o f h er dynam ics in therapy and retu rn ed to an anxious an d dependent m ode o f operation. She seem ed the m ore likely o f the two to reexperience Axis I obsessive com pulsive features in the fu tu re.

B. POST-TRAUMATIC STRESS DISORDERS CHRONIC A N D DELAYED T his is an Axis I d iso rd e r in which sym ptom s follow a seriously stressful event which is typically beyond th e realm o f usual h u m a n stressors. T h e traum atic stressors u n d e r consideration are typically those o f m ilitary com­ bat o r civilian experiences such as earth q u ak es, floods, rap e, assault, a ir­ plane crashes, large fires, etc. T h e sym ptom s that follow the traum atic event include disorder-specific sym ptom s such as recurrent an d intrusive images o f the traum atic event, an experience o r feeling th at the event is reoccurring an d /o r intense distress at ex p o su re to stim uli th a t symbolize o r resem ble th e traum atic event, an d efforts to avoid tho u g h ts o r feelings associated w ith this trau m a. They also include nondisorder-specific sym ptom s such as difficulty falling asleep, irritability, difficulty concentrating, an d hypervigilance. Since military com bat and its deleterious effects are the most obvious and o ccur to so m any individuals, especially after an occasion such as the Viet­ n am conflict, the diagnosis is probably mostly utilized in these situations

Anxiety Disorders / 299 an d u n d eru tilized in th e civilian population. It is also am ong com bat vet­ erans th at the disorder has been most often investigated. Psychological test­ ing o f com bat veterans with and w ithout PTSD has revealed th at the form er are m ore seriously d istu rb ed , with hig h er scores on sym ptom scales m ea­ suring depression, fatigue, confusion, anger, and anxiety (Fairbank, Keane & Malloy, 1983; Hyer, O ’Leary, Saucer, Blount, H arriso n 8c Boudewyns, 1986). We have chosen two quite differen t cases of PTSD, one involving a m ale com bat veteran an d the o th e r a fem ale who was a victim o f domestic com bat involving sexual an d physical abuse.

POST-TRAUMATIC STRESS DISORDER, CHRONIC Ms. B is a 39-year-old teacher w ho has been u n ab le to work for the last few m onths because of back problems. She has been su pporting herself on social security disability. In the last few weeks, she has becom e increasingly depressed and preoccupied with events o f her early childhood. She was ad m itted to a psychiatric evaluation unit on the advice o f her physician for a p eriod o f observation an d evaluation. T his was h er first psychiatric hospitalization, although she was seen as an o u tp atien t on several occasions since age 19. She h ad been bulim ic in the past, b u t h ad recovered in treatm en t several years ago. However, she had continual difficulty functioning on her jo b and in h er social life because o f h er problem s in early life which constantly preoccupied her. At age seven, she had been blam ed by h er family for an injury sustained by h er younger brother. Since that time, she rem em bered being repeatedly beaten by her m o th er an d m ade to stay in th e d ark in an u pstairs linen closet for hours at a tim e by h er older brothers, who repeatedly abused h er sexually from the age o f 10 until h er late adolescence. O ver the years, she had not been able to keep herself from thinking about these events. W hen co nfronted with ex tern al cues such as television shows o r o th e r women with sim ilar histories she en co u n tered d u rin g h er work, she would vividly recall these events an d su ffer nightm ares. T hese n ig h t­ m ares would continue for m any nights and she would then be afraid to sleep and becom e severely depressed. At these times especially, she becam e w rap p ed u p in h er guilty feelings an d once again she would a ttem p t to unravel the circum stances o f h er younger b ro th e r’s injury an d h e r own m otivations at the tim e o f his injury. A lthough she could vividly recall the im m ediate circum stances o f her b ro th er’s injury, she could never see beyond the brief m om ent o f his having been in ju red . She d id not know if h er guilt was b ro ught on by having su r­ vived the accident unscathed or because in some way, as h er family believed,

300 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning she h ad been responsible for its occurrence. She w ondered if she were in some way responsible for h e r bro th ers sexual abuse o f h e r as well. In any event, she no longer trusted her memory an d com plained o f having trouble concentrating. A t the tim e o f the adm ission, Ms. B was dressed casually an d presented as a th in , m iddle-aged woman whose physical ap p e ara n ce was consistent with h e r chronological age. She cried in term ittently th ro u g h o u t the eval­ uation, especially w hen reco u n tin g the events o f h e r early life. She was clearly preoccupied with these events an d th e guilty feelings she had about them . At times, she becam e so physically tense th a t she would shake. She described her m ood as “sa d ” an d h er affect was depressed an d som ew hat constricted. O n gross clinical exam ination, no abnorm alities o f conscious­ ness o r h ig h er intellectual functioning were found.

DSM -III-R D iagnosis Axis I: Axis Axis Axis Axis

II: III: IV: V:

Post-traum atic stress disorder, chronic. M ajor depression, recu rre n t, w ithout psychotic features None Idiopathic lu m b a r pain Severe— serious illness leading to disability Fair— m o derate im p airm en t in social relations and mild im p airm en t in occupational functioning

Treatment and H ospital Course Ms. B was treated with an antidepressant which began to alleviate her depressive sym ptom s. However, she still continued to be preoccupied with the events o f h er early life. H er psychiatrist atte m p te d to ad d ress these in an exploratory psychotherapy; however, she experienced no relief from this b rie f course o f treatm en t.

P sychological A ssessm ent Ms. B was referred for psychological testing two weeks after h er ad m is­ sion. H er psychiatrist was chiefly interested in an assessment o f her person­ ality functioning to help place h er present difficulties in a b ro a d e r context an d to rule o ut the possibility o f a psychotic disorder. She was evaluated

Anxiety Disorders / 301 over three testing sessions and her exam ination included the WAIS-R, Ror­ schach, TAT, M M PI, SCT, B en d er Gestalt, and DAP. H er full-scale and verbal IQs were 119 an d 114, respectively, placing her in the high average range o f intellectual functioning. H er p erfo rm an ce IQ was som ew hat lower (105) an d in the average range. T h ere was relatively little intertest scatter in h er subtest perform ance. H er relative strengths were in the areas o f abstract reasoning, general range o f inform ation, and knowl­ edge o f words; in all o f these her intellectual functioning was superior. Her relative weakness was in the area o f psychomotor speed where her perform ­ ance was most likely com prom ised by h e r depressive disturbance. T h e rem ain d er o f h er p erfo rm an ce gave some evidence o f m ild im p a ir­ m ents in concentration and attention (Arithmetic and Digit Span) and reflected the degree to which anxiety was able to encroach on her otherwise quite adequate perform ance as, for exam ple, on the B ender Gestalt. These test results also lent some psychom etric credence to h e r com plaint o f d if­ ficulties in concentration. A m ong the p erfo rm an ce subtests, her relatively high score on the Picture Completion subscale indicated a tendency for hyperalertness and vigilance. H er MMPI profile also contained evidence o f h e r vigilance com bined with h er m istrust o f o th ers (scale 6) o ccu rrin g in the context o f significant depressive d isturbance (scale 2 > 80), including m ultiple som atic concerns. She also rep o rted a history o f episodes o f depersonalization and d ereali­ zation, b u t denied any o th er psychotic sym ptom atology. T h e re was no evi­ dence from the R orschach o f m ore serious difficulties in reality appraisal. However, o f the 25 responses given to the Rorschach, the occurrence o f five h ard anatom y responses (e.g. “pelvic bone”) and the use o f black/white con­ trast o r shading as d e term in a n ts for eight o f the responses were consistent with a depressive d iso rd e r and h er preoccupation with unexplained back pain. T h e interplay o f these various factors revealed significant inform ation about h er personal style o f dealing with emotionally evocative m aterial. For exam ple, on card VII] o f the Rorschach, th e first fully chrom atic card in the series o f 10 cards, she initiated her first response quickly. She described the whole card as looking like “th e insides o f the shell o f a d ead horseshoe crab, the skeletal structure with a lot o f gaps. T his would Ik - the bony p a rt.” H er second response continued with the sam e sense o f h a rd and d u rab le substances which are preserved from insult. She rep o rte d the whole card as giving the im pression o f th e “inside o f a skull with the sinuses. An X-ray o f the inside o f the skull and sinuses. Bone stru c tu re and sockets for eye orbits an d spaces for the sinuses.” In describing the outer, protective su r­ faces she saw, she is careful to note that they a p p e a r in contrast to the “gaps” an d “spaces.”

302 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning C om fortable now with the colorful aspects o f the c ard , she rep o rte d her last response. A gain, using the whole card , she saw “w ater with rocks o r grass and a lion . . . lu rch in g from one side to the o th e r [and] his reflection in the water.” Now the d u rab le substances (rocks an d grass) are step p in g stones for a pow erful anim al (lion) who is none too surefo o ted in his tra ­ verse. T h e sequence, content, an d d ete rm in a n ts o f h er responses readily evidenced the in n er em otional tu m u lt an d vulnerability she experiences. T his gives rise to h er need to m aintain a protective o u te r shell against fu r­ th e r h u rt, which she experiences as a highly precarious an d effo rtfu l endeavor. In the interp erso n al aren a, th e sam e tension a p p e a re d in the context o f “frustration” and “confusion,” as well as in conflict over goals and outcomes. O n card I o f the TAT, the young boy “stays fru strated an d co n fu sed ” because “he’s torn between trying to please his parents and playing with his friends.” H er story to card 6GF involved a young woman who is “su rp rised ” an d “sta rtle d ” at “a dirty old m an propositioning h e r” and in the end, “she ju s t moves away from him an d keeps it to herself.” A lthough avoidance ap p eared to be her prim ary response to conflicting feelings, in one instance she was able to propose a m ore h o p efu l solution. Card 4 depicts a m an in silhouette against an o pen window with an arm an d a leg raised above the lower sill. Ms. B described the card as “this guy is in a d ark room and there’s a window th at’s the only source o f light. 1 don’t know if he wants to be there. Maybe he’s lonely an d he’s isolated himself. He looks like he’s reach in g o u t o f the window try in g to jo in in with the rest o f life an d people, b u t he’s afraid to .” She went on to describe him as “cu rio u s” an d felt “he wants to give up the way he feels . . . he looks eager.” W hen asked to com plete the story, she concludes th a t “I guess he goes o ut an d gets over his feelings.” H er h ope th at feelings could be co nfronted an d worked th ro u g h was a positive fin d in g in h er protocol. She rep o rted a restricted social life (scale 0 from the MMPI > 75) but, while avoidant, was not disinterested in people; nor was she w ithout some understan d in g o f positively supportive and altru­ istic motives in others. For her, these motives were best c a p tu re d in those with scientific o r academ ic interests. H er first figure draw ing was o f a m an w earing the tradition al w hite coat o f a scientist. He was draw n with glasses and was described as som eone who “dislikes suffering” and who wished that “he could m ake everybody healthy an d m ake the world a h a p p ie r place.” H er second draw ing was o f a woman, her sister-in-law. She again expressed a positive sense o f th e figure, no tin g th a t she “dislikes my m o th er” and wishes th a t “1 would be happy; th at people w ouldn’t get sick; th a t my b ro th er would be m ore o p en with her.” A lthough presum ably sm iling and w ishing to be helpful, the fig u re was nevertheless draw n with h er hands behind h er back and ap p ears more frightening than warm. T h e eyes o f the

Anxiety Disorders / 303 fig u re are w ide o pen an d slightly malevolent; h er smile paradoxically reveals a m outh filled with sharp, pointed teeth.

Treatment P lanning and Outcom e T h e exam ining psychologist rep o rted th a t the test findings gave a b u n ­ d an t evidence of a m ajor depressive disorder and th at there was no evidence o f significant difficulties in reality appraisal th at would suggest a psychotic disorder. Additionally, the psychologist felt th a t h er rep o rted intrusive rec­ ollections o f and recurrent dream s about past traum atic events, the test find­ ings su p p o rtin g h e r estran g em en t from others, difficulty concentrating, m ild hyperalertness an d vigilance, and som ewhat constricted affect were all supportive o f a diagnosis o f a chronic post-traum atic stress disorder. Ms. B ’s psychiatrist recom m ended th a t she continue h er in p atien t tre a t­ m ent at a hospital specializing in the treatm en t o f post-traum atic stress disorders. She accepted the recom m endation an d m ade arran g em en ts for an adm ission in two weeks w hen they h ad an o p en in g available. She was subsequently ad m itte d an d treated with n arcotherapy an d psychotherapy, with some minim al sym ptom relief. Following this course o f inpatient treat­ m ent, she was able to re tu rn to work an d continued in an o u tp atien t psychotherapy.

3 0 4 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

EXHIBIT

I.

I

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

Sym ptom s/D iagnosis Post-trauvuitic stress disorder, chronic

A. Recognizable stressor

C hronic, severe physical and sexual abuse

Perseverative thinking em phasizing h er own vulnerability

B. Evidence o f re ­ experience o f traum a — recurrent and intrusive recollections

R epeatedly plagued by recollections for m any years

O ffers reports o f child­ hood trau m a and recu rrin g dream s w ith­ out solicitation

— recu rren t d ream s

R ecurrent dream s

N um bing or reduced involvement -m ark ed ly d im in ­ ished interest

Socially w ithdrawn

Social withdrawal

-feeling o f d etac h ­ m ent or estrangem ent

None

R eports transient feelings o f depersonalization and derealization

-constricted affect

Affect depressed and constricted

Depressed and con­ stricted affect

— hyperalert

None

H yperalert and vigilant

I). Two sym ptom s

— sleep disturbance

C hronic difficulty

None

— survivor guilt

Related to b ro th ers accident

None

— trouble concentrating

None

Mildly im paired concentration

— exposure intensi­ fies sym ptom s

Television shows and clin­ ical histories o f others exacerbate intrusive recollections

Anxiety Disorders / 3 0 5

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

II. Personality Factors

Possible psychosis in flu­ encing personality fuctioning

Intact reality appraisal; no evidence o f psy­ chotic sym ptom atology

Possible histrionic p e r­ sonality disorder

No significant hysterical features b ut may over­ react to m inor events sym bolizing earlier traum atic events

None

Average to superior intel­ lectual abilities with present functioning com prom ised by depression and anxiety

Perform ance anxiety and strong wish to please lead to avoidance and im pairm ent o f p e r­ sonal relationships

Strong wish to please but m istrustful o f others; unresolved passived ependent feelings

Successfully resolved past history o f bulimia

Reports past success in resolving bulimia

III. Cognitive Abilities

IV. Psychodynam ics

V.

T herapeutic E nabling Factors

E ager for g reater involve­ m ent with others and hopeful about success­ ful resolution o f pres­ en t difficulties A dequate range o f internal coping abilities b ut these are presently underutilized VI. Environm ental D em and and Social A djustm ent

Lim ited history o f inti­ m ate personal relationships

Self-protectively avoids close personal relation­ ships for fear o f h u rt

306 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

W A IS -R S u m m a r y

Verbal Subtests

Scaled Score

Info rm ation Digit S pan Vocabulary A rithm etic C om prehension Sim ilarities

14 12 14 11 13 15

Performance Subtests Picture C om pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ Performance IQ Full Scale IQ MMPI

12 11 11 11 9 119 105 114

S u m m a ry

F'LVK: 8 2 W 3 4 9 1-7/5# R orsch a ch Sum m ary

N um b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% A t% W:M

25 0 9 0 9" 11" 56 92 48 20 16 10:3

Anxiety Disorders I 307

R

orschach

Sum

M :S um C m :c V II1-X % FK + F + Fc% (H + A ):(H d + A d ) A p p e rce p tio n W D d Dd + S

m ary

3:0 3:3 32 68 13:4 40% 48% 8% 4%

3 0 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

EXHIBIT

3

R orschach Sum m ary

Inquiry

Scoring

1. Looks like a pelvic bone.

1. The shape o f it and the spaces in between. Possibly an X-ray o f bones— black and w hite . . . d a rk greyish color.

W (s)Fk.FC 'A t

2. Looks like a bat with the wings.

2. W ings here. Body here. Basically looks like a bat. Eyes here and little h ands here.

WFAP

3. T his p a rt looks like a crab with little pincers or claws.

3. T he sh ap e— the bulgy eyes and the little claws.

DFA

1. Looks like wings o f a b u t­ terfly with the long tail and the antenna on top.

1. W ings here. Long tail here. A nten n a here. T h e shape. Swallow tail.

DFAP

2. Looks like two dogs with their noses touching. Looks like ears.

2. Ear . . . snout . . . profile.

DFMAP

3. Pelvic bone, hollow m iddle.

3. T he shape o f it and the holes.

W(s)FAt

1. Looks like a butterfly.

1. Hie w ing shape and the lit­ tle body in the m iddle. T he shape.

DFAP

2. Looks like the head o f a fly with those huge bulging eyes.

2. Like a National G eo­ graphic. A close-up photo o f enorm ous com pound eyes.

DFAt

3. T h ere could be two women carrying ju g s o r two d an c­ ers and they’re dancing around this thing in the m iddle.

3. H ead, neck, back. Looks like a woman because o f the bust.

W MHP

Response I. 18

II. 2"

III. 10"

Anxiety Disorders / 30 9

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

IV. 26" 1. T hese look like wings to me, o f some kind o f m anta ray or som ething.

1. Big flat— alm ost like a flounder. T h e shape basically.

WFA

2. Back o f the head o f a dog. These would be the ears. Look furry.

2. (Top half) T h e ears and the fur. (?) T h e shading looks like it’s furry.

drFcA d

1. T h e wings and the rest.

WFAP

V. 1" 1 Looks like a bat or a b u tter­ fly. Feet, wings, antenna, little head. G reat big w'ing spread.

VI. 6" 1. Looks like som ething from m arine bioogy.

Like in Jacques Cousteau. A n o d d creatu re at the b ot­ tom o f the ocean. T h e odd shape. H ead here— flippers or appendages here. Lying.

WFMA

2. T his looks like the snout o f a lion. T his looks like the m ark th a t often comes dow'n the face. T his the eyes, and this the nose.

Not a live lion— but a picture. The coloration. T hese would be the eyes (?) T h e d ark , the light and the shape.

dFcAd

Not real definite sh ap e— like cherubs. With fluffy nondescript outline, looks like a profile o f a face— neck, hair, nose, top o f head.

DM HP

VII. 4" L Looks like two cupids or angels. Looks like they’re facing each o th e r and this is the profile o f the face. Could be women with this the ponytail o r Indians with this the feather. 2. Clouds.

2 . (Bottom half) Looks like light and dark. (?) T h e shading. A nd no sharp outlines.

D(S)KF Clouds

3 1 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum mary

Response

Iru/uiry

Scoring

3. T h e shape.

SF O bj.

1. Looks like th e shell o f a horseshoe crab . . . cavities.

1. Looks like inside o f the shell o f a d ead horseshoe crab. Skeletal stru c tu re with a lot o f gaps. T h is would be th e bony p art.

D(S)FAt

2. In sid e o f skull with the sinuses.

2. X-ray o f inside o f skull and sinuses. Bone s tru c tu re and sockets for eye orbits and spaces and sinuses.

W Flk-A t

3. W ater w ith rocks o r grass an d a lion o r a 4-footed a n i­ m al a n d he’s lu rc h in g over from one side to the other. A nd this would be the reflection in the water.

3. T h is would be the w ater here. T h is the sh ap e o f a c o u g ar o r p a n th e r o r som e­ th in g . Looks like he’s try in g to get from h ere to here.

W FM .FK A P

1. R em inds m e o f th e shape o f it. S h ap e o f the fu n d u s o f th e uterus.

WF-At

3. Looks like a p ic tu re o f a lam p sh ad e. T h is th e m id ­ dle o f th e lam p a n d this the base. V III. 2"

IX . 20' 1. Looks like a pelvis. H ip bones (green) acetab u lu m here. T h is is th e illiac crest. T h is w ould be th e b la d d e r (white) ovaries an d fallo­ pian tubes. U teru s here. X. 12" 1. Two crabs. F idd ler crabs w ith one claw b ig g er th an th e other. 2. P art o f a face— eyes (yel­ low), nose, an d this would be a m oustache— th e g reen thing.

T h e shape.

2. H ere an d h ere a n d here. T h e shape.

DFAP

D (S)FH d

A nxiety Disorders / 311 R o rsch a ch S um mary

Response

3. Eyes (yellow) and furrows in the forehead (green ) and chin here (gray). 4. Someone parachuting.

Inquiry

3. The shape. Like a caricatu te o f a face. 4. Here. T he shape. Man and the parachute here.

Scoring

D(S)F(Hd)

DMH

312 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CA R D 1 This is a little kid and he’s looking at his violin and he’s supposed to be practicing. But he doesn’t feel like it. He’s torn between trying to please his p arents and playing with his friends. He’s fru stra te d and doesn’t know’ w hat to do. W ishing the violin would go away I guess. (?) T h e end he stays fru stra te d an d confused. C A R D 4 A m an and a w om an and she’s very m uch in love w'ith him but he seem s unable to comm it him self to one woman. He doesn’t seem capable o f a lasting relationship because there’s a picture o f a wom an in th e back­ ground. H e ju s t has casual affairs with a lot o f women. She loves him a lot. She’s try in g to hold onto him and reach him , b ut she really can’t. (?) She cares for him b u t p a rt o f h er is h u rtin g . She wants him b u t she’s fru strated . (?) I don’t think it’ll work out. C A R D 6G F A m an an d a lady in a living room in a p arty o r alone. I don’t know. He’s either suggesting som ething to her o r telling her som ething that she finds u n pleasant o r distu rb in g . She has a su rp rised look on her face. Maybe he’s a dirty old m an propositioning h er an d she’s su rp rised . She doesn’t know w hat to respond to him . . . o r to tell som eone w hat he was telling her. She’s ju s t kind o f startled. (?) She doesn’t say anything about w hat h a p p en ed . She ju s t moves away from him an d keeps it to herself. C A R D 7G F 1 can’t m ake it up. A m o th er an d a d a u g h te r a n d the m o th er seem s to be interested in the d a u g h te r an d the d a u g h te r is not interested. She seems distracted and looks like she wishes she were somew here else. She seem s like she feels m ore grow n up th an the way she’s treated . She’d rath e r be out do in g m ore adult things th an playing like a kid. She doesn’t seem very happy. C A R D 12 Two m en. I guess one is the father o r the g ra n d fa th e r an d the one lying dow n is th e son o r the grandson. He’s sleeping o r ju s t lo unging aro u n d . He doesn’t look like it’s bed time. He’s just sloppy and u nkem pt. He has kind o f a fu n n y look on his face like . . . I don’t know. T h e old m an is ap p ro ach in g him an d try in g to wake him u p — but he’s afraid o f w hat reaction the guy will have. He seem s intim idated by the younger guy— like maybe he’s snotty o r abusive. I don’t think he (younger) treats him very well. In the en d I think he probably backs o ff and walks away. C A R D 13M F A m an an d a woman an d the woman is in bed partly exposed. I don’t know if she’s dead o r alive. I th in k maybe she’s d e a d o r

Anxiety Disorders / 313 T

h e m a t ic

A

p p e r c e p t io n

T

est

som ething. He feels . . . a p p aren tly he’s done som ething to her. He ra p e d an d then m u rd e re d h e r an d th en he feels guilty o r asham ed. Like he’s done som ething and not realized w hat he did. 'H ie reality hits him and he doesn’t know w hat to do. I th in k he ru n s away o u t o f fear. C A R D 14 T his guy is in a d a rk room an d there’s a window th a t’s th e only source o f light. I don’t know if he wants to be there. Maybe he’s lonely and he’s isolated him self. H e looks like he’s reaching o ut o f the window trying to jo in in w ith the rest o f life an d people— b u t he’s afraid to. O nly h a lf o f him wants to be o u t in th e sunshine. (?) He’s afraid an d confused. Kind o f curious though. He wants to give up the way he feels. But he’s afraid to make th a t step. He looks eag er th o u g h . (?) I guess he goes o ut an d gets over his feelings.

314 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

3. I want to know i f my family “really loves m e o r n o t.” 6.

A t bedtime sometimes I ’m “a fra id to go to sleep because o f bad

7.

M en are “attractiv e to m e b u t I’m a fra id o f th em som etim es.”

d re a m s.” 12.

I feel “m ixed u p a lot o f tim es.”

23.

M y m ind is “p retty g o o d , b u t som etim es it gets m ix ed u p .”

28.

Sometimes I wish “ 1 could d isa p p e a r.”

Anxiety Disorders / 315

POST-TRAUMATIC STRESS DISORDER, DELAYED W ITH ALCOHOL ABUSE, EPISODIC Mr. W was a 34-year-old veteran who was m a rrie d , h ad five child ren , an d had worked for the last 14 years for th e city parks d e p artm en t as a g ro u n d s keeper. A fter g ra d u a tin g from high school, he was stationed in V ietnam in the m id-1960s and served as a riflem an in an in fan try platoon n e a r the dem ilitarized zone. Shortly a fte r he re tu rn e d from V ietnam , his uncle had helped him to get his jo b with the p ark s d ep artm e n t, w here he was known as a steady a n d reliable worker. O ver the last few years, he becam e interested in the history o f the war in V ietnam . H e began to w ithdraw from his family an d sp en t m ore and m ore o f his tim e in the b ed ro o m th in k in g an d read in g a b o u t V ietnam . As he becam e im m ersed in his studies o f the war, he becam e increasingly angry at the situation o f m any o f the V ietnam war veterans and also began to recall m ore vividly some o f his own w ar experiences w hich he h ad not rem em bered in years. H e rem em bered an d relived his disgust at the dead an d m utilated bodies o f A m erican soldiers he h a d seen. He also b eg an to realize th a t he an d his o u tfit m ust have killed m any civilians an d p e rh ap s A m erican servicem en in battles in the “free fire” zones where his platoon typically patrolled. His recollections alternately moved him to a n g e r an d sadness an d he began to d rin k m ore heavily to ease these feelings. As his d rin k in g becam e heavier, he began to reen act his w ar experiences. A few m onths before his adm ission, he h ad set a fire in th e woods late one night, claim ing th a t he was “b u rn in g o u t th e V ietcong.” His wife beg an to find him crawling th ro u g h th e yard at n ig h t with his g u n as if he were back in actual com bat. A few weeks before his admission, his reliving o f his w ar experiences began to encroach on him even w hen he was not intoxicated. W hile o u t h u n tin g with his friends, he h ad felt th a t an o th e r h u n te r was firin g a t him an d had started to fire back b u t was sto p p ed by a com panion. H e becam e increasingly frig h ten ed th a t he would do som ething to h u rt his fam ily and was particu larly concerned about h u rtin g his wife. D u rin g one o f his reliving experiences, he h a d p o in ted a g u n at h e r an d spoken to h er in a sexually d eg ra d in g m anner. Recently, he h a d taken to calling h er “m am a san” d u rin g sex and had begun to rem em ber his physical abuse o f V ietnam ese prostitutes. H e finally ag reed to e n ter the hospital afte r he had gotten d ru n k at his uncle’s house and in ju red him in a fight. He had fled in panic a n d w recked his car, finally ru n n in g o ut into a nearby field to escape the p u rs u in g Vietcong. A t the tim e o f adm ission, Mr. W was tense and anxious. H e spoke m ov­

316 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning ingly about his fear th a t he would “m aybe do som ething to h u rt my wife and kids” and realized th at his behavior had changed over the last few years as he h ad beg u n to study the war. He would give only vague accounts o f his w ar experiences, however, claim ing th a t he d id not rem em b er the sp e­ cific details, only how he h ad felt d u rin g th a t time. He described his m ood as “co ncerned” ; his af fect was anxious. T h e re was no evidence o f halluci­ n ations, delusions or o th e r alterations in his sense o f reality th a t could be elk ¡ted, with the exception o f those related to his reliving o f his traum atic w ar experiences. His concentration, attention, memory, ab stractin g ability, an d general fu n d o f in form ation were ju d g e d to be adeq u ate. He acknowl­ ed g ed that th ere were im p airm en ts in his ju d g m e n t aro u n d his reliving experiences, but otherw ise his ju d g m e n t seem ed intact.

D SM -III-R D iagnosis Axis I: Axis II: Axis IV Axis V:

Post-traum atic stress disorder, delayed. Alcohol abuse, episodic None Severe— m ultiple exposures to d ead an d m utilated service­ m en d u rin g his m ilitary service Fair— m o d erate im p airm en t in his social an d m arital relationships

Treatment and H ospital Course Mr. W m ade a good initial ad ju stm en t to the hospital unit. He presented no difficulties in his m anagem ent an d readily com plied with the psychia­ trist’s recom m endation th a t he begin Alcoholics A nonym ous m eetings for education about and trea tm en t o f his difficulties with alcohol. In his in d i­ vidual psychotherapy, he was able to recount his com bat experiences with a good deal o f affect. He was alternately, an d always appropriately, an g ry an d tearful, but continued to claim th at he rem em bered few details o f these experiences. Unless specifically asked about his war experiences, he avoided talking about them altogether. He acknow ledged th a t talking abo u t them caused him a g reat deal o f em otional upset which he p referred to avoid. A lthough his treatm e n t was progressing satisfactorily in som e respects, he continued to lie reluctant to fully ad d ress the relationship betw een his war experiences and his reliving experiences which h ad led him to seek hospitalization. Because o f the emotional turm oil induced by his discussing these experiences an d his obvious need to avoid discussing them in any

Anxiety Disorders / 317 detail, his psychiatrist asked for a full psychological evaluation to help d eter­ m ine if Mr. W could tolerate the affective arousal likely to be induced by a m ore exploratory stance on th e p a rt o f the psychiatrist.

Psychological A ssessm ent Mr. W was referre d for psychological testing in o rd e r to help d e te r­ m ine his capacity to utilize a m ore exploratory psychotherapy. C onse­ quently, his reality testing abilities, style o f affective m anagem ent, and capacity for establishing a working alliance in treatm ent were all in need o f assessment. He received a battery o f tests, including the WAIS-R, Ror­ schach, an d DAP. Mr. W ’s WAIS-R exam ination yielded scores which placed his full-scale, verbal and p erfo rm an ce IQs in the Average range. His scores were 99, 98 an d 100, respectively. T h e a p p a re n t evenness o f intellectual ability im plied by his IQs was belied by a closer exam ination o f his subscale scores. T hese ran g ed from the B orderline to Very S uperior levels. His m ost conspicuous weaknesses (Borderline level) were on the Comprehension, Object Assembly and Digit Span subscales; his relative strengths were found on the Arithmetic and Picture Arrangement subscales, the latter a test o f anticipatory planning (Very Superior and Suf>erior levels, respectively). This pattern o f strengths and weak­ nesses suggested th a t while he h ad inherently ad eq u ate powers o f concen­ tration an d showed b etter th a n average abilities to plan an d anticipate, his perfo rm an ce was susceptible to disrup tio n by anxiety an d he was prone to lapses in practical ju d g m e n t. O n the WAIS-R, there was no evidence o f serious defects in reality ap p re­ ciation. His R orschach protocol fu rth e r su bstantiated this fin d in g (F + % = 87). He was generally able to m aintain ad eq u ate reality testing, b u t did produce a significant n u m b er o f u nusual responses reflecting his preoccu­ pation with his com bat experiences even within a somewhat constricted rec­ o rd (19 responses). For exam ple, on the first card , his last response was “som ething a gook would p u t on its head, a helm et” which was offered with the card in its inverted position. D u rin g inquiry, the helm et is described as having horns, “like a Viking helm et.” Additional responses related to his m ilitary preoccupations, included a “flack vest” to card IV (again in the inverted position), “a good place to have an am b u sh ” to card VI, and ref­ erences to a 50-caliber m achine g u n an d “tops o f trees” seen from the van­ tage p oint o f a helicopter (card X). Mr. W ’s style o f affective reactivity was vividly portrayed in his Rorschach protocol. H e m ade relatively freq u en t use o f sh ad in g (reflecting anxiety) an d o f color (6 o f 19 responses); in four o f these instances, eith e r the sh ad ­

318 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning ing o r the color was the d o m in a n t d e te rm in an t. His color responses were alm ost invariably incendiary and dram atic and included “tire” (card II), “an explosion” (card IX), “a volcano” (card IX), an d “blood” (card X). O n balance, his R orschach protocol gave evidence o f difficulties in the m odulation an d adaptive expression o f affect. He generally experienced affect as disruptive and potentially explosive and was frightened that he had inadequate m eans o f containing and integrating his emotional life. However, his generally ade­ q u ate reality testing an d availability o f ad ap t ive cognitive controls held out the prom ise o f helping him to effectively integrate and reg u late his em o ­ tional turbulence. Mr. W gave several h u m a n p ercepts (two— cards III and VII) an d these m ade u p alm ost o n e-h alf o f his p o p u la r percepts. H e also p ro d u ced fairly adequate h u m an figure drawings. T h e latter were presented in a somewhat stiff an d rigid fashion, with frozen smiles and disproportionately short arm s, casual clothing, and a steady, straig h tfo rw ard gaze, b u t still acceptable in term s o f concept. T h ese features lent su p p o rt to the notion th a t he could be engaged in m eeting the challenges o f a m ore exploratory p sychother­ apeutic ap p ro ach in a straig h tfo rw ard fashion w ithout u n d u e d istortion o r regression. O n a negative note, he exhibited a p aran o id com ponent to his th in k in g and the use o f projection as a possible defense (e.g. th e “evil face” on Rorschach card I). Furtherm ore, he was currently uncertain over an d pre­ occupied with his sexual identification. T his was m irro re d in his response to R orschach card III o f Figures with b o th m ale and fem ale sexual ch arac­ teristics an d his draw ing o f a woman who a p p e a re d to be w earing both a skirt an d pants.

Treatment P lanning and Outcom e Based on the results o f his psychological evaluation, Mr. W ’s psychia­ trist was encouraged to proceed with his plans to assist him in integrat­ ing the em otional im pact an d intrusive n a tu re o f his war experiences and to encourage him to explore his feelings in more dep th th an he had h eretofore allowed. In anticipation o f this work, Mr. W was reassured th a t he h ad the resources to en gage in this exploration. A fter h earin g what he could be expected to experience d u rin g this phase o f his treat­ m ent, he agreed to proceed. He worked with the psychiatrist to develop a plan th a t w ould allow him sufficient o p p o rtu n ity to express and explore his feelings at a slow b u t steady pace. O ver the next few weeks, he was gradually able to discuss his com bat experiences in m ore detail and to analyze his reactions to them despite the an g er and anxiety they frequently aroused in him . He was able to see how virtually all o f his

Anxiety Disorders / 319 reliving ex p erien ces h a d b e en elab o ratio n s o f those aspects o f his com ­ bat ex p erien ces a b o u t w hich he was m o st tro u b led . O ver th e c o u rse o f his tre a tm e n t, he sto p p e d hav in g reliving exp erien ces an d he b eg an to in c o rp o ra te his V ietn am exp erien ces in to his life in a way th a t left him feeling he now h ad som e control over them .

3 2 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P lanning

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

I. Sym ptom s/D iagnosis Post-traumatic stress disorder, delayed Recognizable stressor

Vietnam war com bat experiences

None

Sets fire in woods “to b u rn out Vietcong”

Is preoccupied with his com bat experiences

Evidence o f reex ­ perience o f traum a — sudden acting as if the traum atic event were reoccurring

Shoots at h u n ters and o th e r im agined enemies Stalks enem ies in his own house

N um bing or reduced involvement — m arkedly dim in ­ ished interest

Spends most o f his time alone read in g about the war

None

— constricted affect

Avoids feelings related to his war experiences

A ttem pts to minim ize affective expression w ithout m uch success

— sleep disturbance

Difficulty sleeping

None

— exposure intensi­ fies sym ptom s

Sym ptom s activated by his study o f the war

None

Avoidance o f strong feelings

Strong feelings give rise to fears o f loss o f self-control

Two sym ptom s

II. Personality Factors

Some paran o id elem ents to his thinking

Anxiety Disorders / 3 2 1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

A dequate cognitive con­ trols given time for anticipation and planning III. Cognitive Abilities

IV. Psychodynamics

Average intelligence

Average intelligence b ut c u rren t perform ance im paired by anxiety

A ttem pts to repress and deny feelings associa­ ted with his combat experiences result in his “reliving" these experiences

Susceptible to explosive em otional reactions when confronted with aggressive or cata­ strophic feelings Uses projection as a defense Preoccupied with his masculinity

V. T herapeutic E nabling Factors

VI. Environm ental D em and and Social A djustm ent

G ood prem orbid adjust­ m ent and initial post­ com bat adjustm ent

In tern al resources are presently underutilized

Accepts the need for treatm ent

None

G ood work history

None

Has m aintained a social network and is con­ cerned about his family

Some capacity to identify with others

322 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT WAIS-R

2

S u m m a ry

Verbal Subtests Inform ation D igit Span V ocabulary A rithm etic C om prehension Sim ilarities

Scaled Score 11 7 9 15 6 10

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ Performance IQ Full Scale IQ

10 13 10 6 8 98 100 99

R orschach Summary N u m b er o f Responses Rejections P opulars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% Explosion% V V: M M :Sum C m :c V III-X %

19 0 5 0 12" 9" 47 87 13 32 11 11:3 3:4 3:2 37

Anxiety Disorders I 323

R

orschach

S

um m ary

FK + F + F c (H + A ):(H d + Ad) A p p erc e p tio n W% 58 n% 43 d% 0 I)d + S% 0

«8 5:2

3 2 4 / Psychological Assessment, Psychiatric Diagnosis, arul Treatment P la n n in g

EXHIBIT

3

R orschach Sum m ary

Response

Inquiry

Scoring

I. 3" i. Looks like a je t at first

1. Got wings on its front here. Big wings like an F I 04. Body o f plane is here. W ings here— fins for the back. Looks like a je t look­ ing down. Back g uns here.

WF-Obj

2. Looks like an evil face if you look in the m iddle o f it.

2. Big eyes, m outh, eyes like a jack -’o-lan tern , m outh across here. (Evil}) Looks like a B rothers H eidelberg album cover. A mythical picture o f a creature. I’ve associated it with th eir paintings.

W (S)FHd

3. C ould look like a bat.

3. M outh here. Little yicky teeth on its wings. Tail here.

WFAP

4. C ould be som ething a gook would p u t on its h ead — a helm et.

4. H ead would go here. Peak here. Protection over the ears. H orns look like a Viking helm et. (?) No.

WF Obj

II. 12 1. Looks like a space ship or rocket taking off.

Rocket inside it. H as the stu ff shooting out o f the rocket. (?) Dust rolling up arou n d it. (?) It’s dark. (?) It’s red . . . it’s fire.

D(S)Fm.CF Obj

III. 2" 1.

I’ve seen this already. Two women.

1. Boobs sticking out. T hey’re lifting som ething together. C arrying some old basket o f clothes o r som ething here. H igh heels on — how does th a t grab you.

WMHP

A n xiety Disorders I 3 2 5

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

2. Two m en with th e ir cocks sticking out.

2. Cocks sticking o u t here. C an call them fairies ’cause they have boobs sticking o u t (?) I d o n ’t know. I’d never see it.

VVMHP

1. Looks like a c re a tu re o u t o f the Trilogy.

1. Big feet here. Tail here. Big, big, big. H ere’s th e top. Here's the dinky head. Looks like he’s got hooks for arm s. (?) He’s ugly. (?) Look at the face (?) Small.

W F(A)P

2. Looks like som eone w ith a flack vest. Looks like the o utline o f a g uy ’s shoulders.

2. H ere. Here's the outline o f am m o pockets (all but Cen­ tral D). Z ip p er here. (?) T h e shape o f it. T h e d a rk spots look like w here th e pockets would be.

VVFcH

1. Looks like a kite in a movie. W ings here. Looks like a kite o f a flying d ra g o n (?) O n T V o r a movie. In Ja p a n they have all them d ra g o n kites. (?) M outh a n d tail like a d rag o n kite.

VVF O bj

IV. 10"

V. 12" 1. Looks like a kite.

3 2 6 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R o rsch a ch Sum m ary

Response

Inquiry

1. Looks like a good place to have ail am bush. Looks like two m ountains with a road th ro u g h the m iddle o f it. Looks like a river.

1. River is d a rk w here the vegetation m ight be. As it comes up along a hill, vege­ tation wouldn’t be so dark. T h e center could be a road, (m ountains?) the banks. C am e up on both sides (?) T h e shading. An am bush— wouldn’t go now’here if you got caught in there. Would be a cross fire dow'n there.

2. Here’s a delta o r som ething.

2. Comes down and washes out. Spreads out. Water and d irt all built u p here (?) Water is light and d irt is dark.

Scoring

VI. 10" W FK.FcLdsc

V II. 2 0 ' 1. Looks like two people look­ ing at each other, b u t I don’t know w hat’s on top o f th eir heads. Looks like ju st h a lf o f them up there.

1. Faces here. Look like tw’ins looking at each other. Body would be here and hands may be back at the sides here. (?) O nly h a lf o f them .

DM HP

1. Backbone here, ribs here. I don’t know w’h a t’s com ing down over the top o f him. Looks like he’s got his shoulders shru g g ed saying w hat the hell am I doing here?

DF-At

VIII. 15" 1. Looks like someone’s back­ bone w'ith ribs on it. Here are his shoulders here.

Anxiety Disorders / 3 2 7

R orsch a ch Sum mary

Inquiry

Scoring

1. Looks like an explosion or something.

1. Flames shooting up at top. Dust again. Dust again. Looks like a bomb going off. (?) O range color looks like flames. T he dark part (green) in the m iddle is dust. I don’t know what the pink is doing here (?) Not p art o f the explosion.

DCF.mF Ex pi

2. Looks like a volcano— like Mt. St. Helens.

2. Top o f the volcano here with dust on top, dirt, fire shooting out o f it. (?) T he red part. But really isn’t red enough to look like fire (Dust?) dark.

WCF.mF Ex pi

1. This looks like a gun stick­ ing out here.

1. Looks like a hand with a 50 millimeter gun sticking out (?) A kind o f gun.

DFHd aggr

2. This looks like blood here. Looks like the color o f blood here.

2. The color o f it looks like blood. Maybe a d rop o f water hit it. (?) It’s light on top and gets dark toward the bottom.

DCF.FK Blood

3. Tops o f trees or something.

3. (Blue) These here and here look like looking out o f a helicopter at trees from on top (?) Shape.

DFK Ldsc

4. Looks like a wishbone.

4. Looks like a wishbone or maple seed. It's exactly the shape o f it.

DFAt

Response IX.

10"

X. 20"

328 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

DISCUSSION Like most veterans with PTSD (H yer et al., 1986), Mr. W had m inim al prob­ lem s before com bat an d , in fact, initially m ade a good adju stm en t upon re tu rn . He was hospitalized for preoccupation with and reen actm en t o f com bat experiences in the context of alcohol abuse. Psychological testing was requested not to assist in the diagnosis o f PTSD, as this evaluation was based upon objective a n d clear behaviors, b u t ra th e r to assist in the overall evaluation o f Mr. W's relative strengths and his capacity for utilizing explor­ atory psychotherapy in an atte m p t to help him in tegrate the h o rrifying experiences d u rin g com bat. T h e results o f psychological testing were quite consistent co n cernin g this question. He had an average IQ an d his reality testing seem ed adeq u ate in both stru c tu red an d u n stru c tu re d testing sit­ uations. T he ability to hold onto and appreciate conventional reality seemed like a real stren g th for this m an. In contrast, it was his af fective lability and his difficulty in m od u latin g and in teg ratin g em otion th at em erg ed p ro m ­ inently in his testing. T h u s, the testing was quite h elpful in recom m ending an exploratory treatm en t with the aim o f h elping an em otionally reactive m an integrate his appalling past experiences, a therapy which subsequently succeeded. In contrast to Mr. W, Ms. B, a 34-year-old, single fem ale, was ad m itted with depression and a preoccupation with traum atic events th a t had o ccu rred in h er youth. She h ad been repeatedly beaten by h er m o th er and forced to stay in a d ark closet for hours at a time. She was sexually abused by her brothers from age 10 until late adolescence. She experienced the stig­ m ata o f traum atic stress d iso rd er involving nightm ares and intrusive day­ tim e thoughts about these events. Psychological assessment was not required to m ake the diagnosis o f posttraum atic stress disorder, b u t th e patient was referred for assessm ent after treatm en t was beg u n to evaluate the possibility o f psychotic th in k in g and to place the stress d iso rd e r into the overall context o f h e r stren g th s an d weaknesses. T his is a re c u rre n t them e in this book: D SM -III diagnoses, from a sym ptom atic point o f view, are most typically m ade through clinical interview and history. Initial treatm en t p lan n in g can begin with this. How­ ever, as the treatm ent begins and initial sym ptom atology is alleviated some­ w hat, the evaluation o f the more en d u rin g strengths and weaknesses o f the p atient becom e a necessity for m ore finely tu n e d treatm en t planning. T h e test findings were helpful in clarifying the question about the p atien ts reality testing. W hile h er test results showed mildly im p aired co n ­

Anxiety Disorders / 329 centration and suggestions o f some depersonalization and derealization and a cognitive style o f hyperalertness and vigilance, th ere was every indication that there was adequate reality appraisal with no cu rren t o r anticipated psy­ chotic thinking. T here was strong evidence from the testing, therefore, that h er sym ptom atology was indeed consistent with a post-traum atic stress dis­ order. T h e patient showed im p o rta n t th erap eu tic enab lin g factors such as an average to su p erio r intellectual ability an d qualities th at suggested the possibility o f a positive treatm ent alliance, including a wish to please others, past success in resolving bulim ia, and an eagerness for involvement with others.

CHAPTER 6

Adjustment Disorders

As im plied by the nam e, an adjustm ent d isorder is a m aladaptive and sym p­ tom atic response to specific and identifiable stressors in an individual’s life. T h e re m ust be some indication that the m aladaptive p attern is related tem ­ porally to the onset o f the stressors. This is concretely defined in D SM -III-R as the onset o f sym ptom s (o f up to six-m onths d u ratio n ) w ithin th ree m onths after the stressor. Typical stressors o f serious moment to individuals in o u r cu ltu re include divorce o r o th e r m arital difficulty, occupational d if­ ficulties, health problem s, an d stress b ro u g h t on by developm ental events such as becom ing a p aren t o r retirem ent. Sym ptom s which are typical in reaction to such stressors include anxiety, depression, physical com plaints, a n d in a p p ro p ria te behavior which violates the rights o f others.

ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT Ms. K, a 16-year-old high school sophom ore, was accom panied to the hos­ pital by h er m o th er who h ad a rra n g e d to have her a d m itte d w ithout her know ledge. She had been cau g h t by h er m o th er sneaking in from a d ate w ith som eone her m o th e r disapproved o f and she an d h er m o th er h ad a loud and angry argum ent. She had packed a suitcase and threatened to ru n away from hom e. Ms. K and h er m other h ad been a rg u in g often an d her m o th er had sent Ms. K to a therap ist to get help with h er “rebellious” a tti­ tu d e. O n the advice o f Ms. K’s therapist, the m o th er had called the police on the evening o f the t hreat. A fter the acute crisis had passed, she had again consulted Ms. K’s therapist who had recom m ended a psychiatric admission for evaluation and recom m endation o f subsequent treatm en t. Ms. K was no t told o f the im p en d in g adm ission until the m o rn in g o f the intake eval­ uation. A lthough she h ad finally ag reed to accom pany h er m o th er to the hospital, she h ad done so u n d e r protest. 330

Adjustment Disorders / 3 3 1 T he intake evaluation was conducted in a highly charged emotional atm o ­ sphere. Ms. K was by tu rn s loudly an g ry and tearf ul. She and h er m o th er a rg u e d about alm ost everything, ag reein g only th a t th in g s betw een them h ad becom e m ore conflictual in the last few weeks. She found h er m o th er’s attem p ts to enforce rules re g a rd in g telephone use, whom she was allowed to have in the hom e, w hat she could wear, and how she could decorate her room , am ong o th e r things, im possible to accom m odate. She felt decisions about these things rightfully belonged to h er an d d id not u n d erstan d h er m o th er’s recent insistence on m onitoring h er activities m ore closely. H er m o th er was by tu rn s d em a n d in g an d placating. She felt she had a right to insist on these things and claimed that her d au g h te r’s recent school probation for failing work, along with w hat seem ed to h er to have become a m orbid preoccupation with sinister and anarchic elements of Ms. K’s teen­ age subculture, ju stified h er increasing adamancy. H er m o th er acknowl­ edg ed th at these things h ad been left to Ms. K’s discretion in the past and that in some respects Ms. K’s deviance had been a source o f pride. Not long ago, her m other h ad been contacted by a family friend who asked to in te r­ view Ms. K and her “p u n k ” friends and had featu red them in a local T V news pro g ram on teen ag e lifestyles an d values. However, since separating from her husband a few weeks previously, she had become alarm ed by these very sam e elem ents an d now wished to see h er d a u g h te r a d o p t a style o f dress an d m a n n e r m ore consistent with h er own m iddle class values and attitudes. Ms. K’s m other held up Ms. K’s younger b rother as a model worthy o f em ulation in these m atters. Ms. K d isp arag ed her younger b ro th e r as “an air-headed preppy” and was disgusted at the very idea o f transform ing herself into som eone so “superficial.” A form al m ental status ex am ination revealed a young, w hite fem ale who was slightly overweight an d q u ite unusually groom ed an d attired . She sported a “p u n k ” hairstyle with her h air gathered into a short-cropped top­ knot dyed a b rig h t green on top. She wore a m etal-studded, leath er jacket and steel-tipped, leather boots, a t-shirt tie-dyed in several colors, and a pair o f faded and torn jeans. These clothes were her usual attire. H er affect and m ood were alternately angry and tearful, but always appropriate to circum ­ stances. H er general m a n n e r was som ewhat d efian t and challenging, but not unreasonably hostile, an d she co o p erated with the exam ination. She ag reed th a t h er parents’ recent separation had sad d en ed h er and was su r­ prised to find herself feeling this way as she had h oped for a separation betw een h er p arents for quite some tim e out o f an awareness th a t her m o th er and her fath er sh ared little with one another. She ad m itted to th re a te n in g h er m o th er with ru n n in g away, but saw this as representing no grave d a n g e r to h erself since she had inten d ed to stay with friends. She denied any suicidal or homicidal ideation. She gave neither

3 32 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning a history o f n or evidence o f any significant cognitive o r p ercep tu al a b n o r­ malities. She stated th a t her own reasons for e n terin g th e hospital were “to get away from hom e for evaluation” and ag reed th at a p erio d o f separation w ould help everyone to "chill o u t.” However, refe rrin g to h er m o th er’s past history o f depression and her m other’s sister’s suicide attem pt, she arg u m en ­ tatively suggested th a t h e r m other, ra th e r th an she, be offered the services o f a psychiatric hospital.

DSM-III-R Diagnosis Axis I: Axis II: Axis III: Axis IV: Axis V:

A djustm ent D isorder w ith Mixed D isturbance o f Em otions and C onduct Rule o u t B orderline personality d iso rd er None Severe— Divorce o f parents: chronic m arital conflict prior to divorce Fair— Fails to work up to potential in school; lim ited circle o f friends

Treatment and H ospital Course Following her adm ission to the unit, Ms. K quickly calm ed down. She m ade a rapid and satisfactory adjustm ent to the unit. She was able to adm it to being m ore depressed since h e r parents’ separation. She initially placed m ost o f the blam e for h er difficulties on h er m other, b u t was soon able to acknowledge th at “about o n e -h a lf’ o f the difficulties were o f h er own m ak­ ing. H er initial treatm en t plan involved individual psychotherapy sessions and additional family sessions between Ms. K and her m other as she becam e less an g ry at h er m oth er and expressed an interest in having h er therapist help effect a reconciliation. H er m o th er supplied a rep o rt o f a previous psychological testing, done when the patient was nine years old, giving evidence o f an earlier depressive episode an d em otional turm oil. T his exam ination h ad taken place shortly a fte r Ms. K’s au n t, w ho was closely involved with h er at the time, h ad been hospitalized for a suicide a tte m p t an d accom panying depression. Because o f Ms. K’s renewed depressive concerns in the context of her parents’ recent divorce, h er hospital psychotherapist requested that she be given a psycho­ logical evaluation to assess the extent o f h er depression and its relation to h er personality functioning.

Adjustment Disorders / 333

Psychological Assessment Ms. K began h e r psychological evaluation at the end o f h er second week o f hospitalization. She was given the W ISC-R, Rorschach, TAT, Sentence Completion Test, and a B ender Gestalt by the exam ining psychologist. D ur­ ing the testing sessions, she was described as cooperative, although som e­ w hat w ith d raw n a n d leth arg ic. T h e e x a m in in g psychologist also com m ented on h er u nusual style o f dress and personal ap p earan ce. She achieved a verbal IQ o f 115 and a perform ance IQ o f 131, yield­ in g a full-scale IQ o f 126 on the W ISC-R. T his placed h er in the su p e­ rio r ran g e o f intellectual functioning, with subtest scores ran g in g from the average to very superior levels. H er visual-spatial skills and h er abil­ ity to attend to detail were in stru m en tal in h elping h er to achieve her best perform ances on the Block Design, Object Assembly an d Picture Com­ pletion subscales. T hese abilities were consistent w ith h er acknow ledged interest in visual art, an area o f talent she had been cultivating for quite some tim e. She d id poorest, b ut nevertheless gave an average p e rfo rm ­ ance, on a visual-m otor test o f new learn in g ability. A m ong h er verbal subtests, h er scaled scores ranged from 11 to 14, with her best p erfo rm ­ ance given on the Vocabulary subscale an d h er worst p erfo rm an ce given on the information subscale. T hese subscale scores an d h er B ender p e r­ form ance, which showed good organizational abilities an d good recall, su p p o rted h er better-than-average intellectual abilities. Given Ms. K’s obvious intellectual abilities, perhaps the most striking fea­ tu re o f h er Rorschach, SCT, and TAT results is th eir general poverty. On the R orschach, she gives little b ette r th an one response to each card and the m ajority o f these responses are fairly global and only loosely determ ined by their form. She seems little interested in exploring the blots unless some­ th in g h ap p e n s to catch h er attention. T h e m ajority o f h er responses are b an al— the cat’s face on card I, the m onster on card IV, the bat on card V— an d show little o f h e r creative talents. T h is general sense o f im pover­ ishm ent is also in evidence on the TAT. H ere, she h ad great difficulty in d ecid in g on a context for th e story, in ascribing motivations o r feelings to h er characters, or in im agining the outcom e o f the scenes she describes. Peo­ ple are described as “w aiting” (cards 2, 5 and 12 F), p e rh a p s for the “bad new s” m entioned in h e r story to card 3GF. W hen she developed any interaction between the characters, it was some­ times consistent with the typical them e for the particular card, as for exam ­ ple cards 1 an d 10. To card 1, Ms. K told a conventional story o f a boy receiving a violin for a gift who was allowed to re tu rn it after the person who gives him the gift “sees th a t he’s not h appy with it.” H er story to card

3 34 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning 10, which usually prom pts a story concerning p eer interactions, concerned a reunion betw een a m o th er and a son who are glad to see one an o th e r again. However, in stories told to card 12M, w here she was un ab le to decide between the possibilities o f aggression and assistance, and card 13MF, where the sexual connotations o f the sem i-nude fem ale fig u re were com pletely ignored, she seem ed to be un ab le to rely on any sense o f the conventional in deciphering hu m an actions an d motivations. At times, she was not reluc­ tant to use her im agination to supply perceived, missing aspects o f her envi­ ronm ent (e.g. card IX o f the Rorschach). She seem ed, however, to be largely in the position o f the ch aracter in her story for card 14, simply mildly c u ri­ ous about the state o f the world’s affairs so as to know w hether o r not “warm clothes” and a “rain co at” would be best. T h e possibilities o f bein g abused an d m isu n d ersto o d seem ed to be b eh in d m any o f h er SC T responses. As she noted in describing h er fears, it is “pow erful idiots” o f which one must be m ost afraid . She wishes she could “be truly free to express herself,” b u t finds th a t she “wasn’t b eing lis­ tened to ” and so had developed a resistive, d istru stfu l orientation tow ards o th ers an d is wary o f th eir dem ands. She ad o p ts a p retense o f not ca rin g (e.g. items 22, 42, 46, 49, 60, 71, 72, 81, 82 an d 93) an d w hen p ressured, resorts to deceit in o rd e r to avoid beind held back by “restriction.” D espite som e tacit com pliance with ex tern al dem an d s, h er general view is th a t o th ers m ake unreaso n ab le requests o f her, a trait she finds p ro m in en t in h er m other (item 99). However, she is aware th at she needs relationships with o th e r people (e.g. item s 74 and 83) and recognizes th a t lying to them an d losing h er tem p er are problem s she m ust solve. W hen looking to solve these, o r any o th e r problem s, for th a t m atter, her basic m otivation is to look outside herself, to ch an g e h er su rro u n d in g s o r h er situation. T h ere seem s little evidence that any clear sense o f in tern al motivation for self-change is likely to spontaneously carry her through these difficulties. H er attitu d e is p e rh a p s best described by h er basic view th a t m any people are “un h ap p y ” an d her own gratification comes from finding “an expression th a t she felt com fortable w ith .” As she also indicated on the SC T (#97), she experiences a sense o f inferiority because she is not from a happy family. Ms. K’s wary attitu d e tow ards others, h er resistive an d usually o p p o si­ tional stance tow ards authority, an d , by clinical history, h er occasional o u t­ bursts are suggestive o f borderline personality disorder features. In contrast to these features were h er general lack o f impulsivity, h er self-definition, although by opposition in part, and her emotional w arm th when not feeling p u t upon. T hese latter findings, when taken together with her presentation w hen she was feeling u n d e r pressure, suggested h er difficulties were m ore reactive th a n e n d u rin g in n atu re.

Adjustment Disorders / 335

Treatment Planning and Outcome In the report m ade to the referring therapist, the exam ining psychologist sum m arized the test results as reflecting experience o f depressive m oods, b u t found this to be largely in reaction to recent events. O th e r aspects o f h er personality style were also rep o rted as m ore consistent with a reactive disturbance th an indicative o f abnorm al personality developm ent. T h e chief concern expressed by the ex am in in g psychologist was Ms. K’s self-reliance and preference for focusing on problems o f external reality, so much so that there seem ed to be little insight into her own o r others’ motivations and little interest in self-change. T h e exam in in g psychologist th o u g h t these p erso n ­ ality traits would likely m ake it difficult for h er to generate sufficient m oti­ vation for change. T hese im pressions were very m uch in keeping with those form ed by h er treatm ent team . As a consequence, Ms. K an d her m other were encouraged to work out a contractual solution to their difficulties in living together. Var­ ious responsibilities were discussed and a rra n g e d to be contingent on Ms. K fulfilling certain obligations which h er m o th er felt she could m eet. In re tu rn , h er m o th er ag reed to allow Ms. K a certain m easure o f freedom to decide things for herself. In o rd e r to facilitate this process and insure th at it continue successfully once Ms. K was discharged, she and her m other and younger b rother began to meet regularly with som eone who would con­ tinue to work with h er family following h er discharge. W ith the intercession o f an in term ed iary able to reflect b oth Ms. K and h er m o th er’s realistic concerns and u n reasonable d em an d s, she and h er m o th er were able to m ake rap id progress on outlin in g the p aram eters o f th e ir relationship to g eth er following disch arg e and Ms. K was d ischarged two weeks later. T hey continued to see the o u tp atien t therap ist for a few weeks an d then term in ate d the work when things seem ed to have resum ed a m ore stable course. Subsequently, sporadic difficulties in their relationship arose, b u t they were able to m ake use o f periods o f b rie f intervention by Ms. K ’s form er th erap ist an d a family th erap ist to quickly set these arig h t. O ver the next few m onths, Ms. K ch an g ed schools an d m ade a m ore suc­ cessful ad ju stm en t to h er new academ ic setting. H er m o th er was able to find m any things about h e r d a u g h te r’s new life an d interests th a t she could genuinely su p p o rt.

3 3 6 ! Psychological Assessment, Psychiatric Diagtwsis, a n d Treatment P la n n in g

EXHIBIT

I.

A rea of

C l in ic a l

A ssessm ent

E x a m in a t io n

1 P s y c h o l o g ic a l E x a m in a t io n

Sym ptoms/Diagnosis Adjustment disorder with mixed disturbance of emotions and conduct Reaction to identifi­ able stressor w ithin th ree m onths o f onset

Parents have recently separated

None

— im pairm ent in school functioning

Failing in school

None

— sym ptom s in excess o f norm al reaction

O verreacts with an g er and suicidal threats to m o th ers attem pts to set limits

Avoids em otional reac­ tions by preten d in g to not care while wary o f others

Not ju s t one instance and not an exacerbation o f an o th er d isorder

Fights with m other are m ore frequent and increasingly antagonistic

No evidence o f m ore seri­ ous psychopathology

Less than six m onths duration

Less th an six m onths d uration

None

Can be headstrong and quick to defend her personal values

O ppositional when con­ fronted by others, especially authority

Above average intelligence

Above average intelligence

Academic perform ance is below her ability

Preference for activity and concrete e x p eri­ ence may result in p o o r academ ic perform ance

Conflicts over autonom y and interdependence

E m pathic experience o f o th ers is avoided o u t o f fear o f entrap m en t

M aladaptive reac­ tion indicated by

II. Personality Factors

III. Cognitive Abilities

IV. Psychodynam ics

A djustm ent Disorders / 3 3 7

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

A willingness to share some responsibility for h er actions

Recognizes her own prob­ lems b u t looks to ex ter­ nal environm ental change for a solution

Recognizes a need for professional interces­ sion to establish a b et­ ter relationship with h er m other

C ooperation with trea t­ m ent is likely to be con­ ditional on a quid />ro quo negotiation

Passively resists dem ands for ap p ro p riate school perform ance

Resistance to others dem ands is seen as serving autonom y

H as friends who are cho­ sen for their social deviance

Friendships based on acceptance and nonintrusive support

V. T herapeutic E nabling Factors

VI. Environm ental D em and and Social A djustm ent

338 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT WAIS-R

2

Sum mary

Verbal Subtests

Scaled Score

Inform ation Sim ilarities A rithm etic Vocabulary C om prehension

11 13 13 14 14

Performance Sublests Picture C om pletion Picture A rran g em en t Block Design O bject Assembly C od in g

16 13 14 19 10

Verbal IQ Performance IQ Full Scale IQ

115 131 126

R o rschach Sum mary

N u m b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% W:M M :Sum C m:c V1I1-X% FK + F + Fc% (H + A ):(H d + Ad)

13 0 4 0 22" XT' 38 73 38 23 7:3 3:3 3:1 23 46 6:2

Adjustment Disorders / 339

R o rschach Sum mary

A p p e rc e p tio n

W 54% I) 31% c! 0% I)d + S 15%

340 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

3

R o r sc h a c h S um mary Response

Inquiry

Scoring

I. 48" I’m supposed to tell you what I see or som ething. I don’t know. 1. L ooks like a face or som e­ th in g like a cat— like a cat kind o f a . . . som e kind o f anim al.

(Sometimes people see more than one thing.) I don’t see anything else.

1. T h e eyes, the teeth, nose, ears. I don’t know what these things are, didn’t use them . (Cat?) T h e fact that it was shaped like one and looked like one.

W(S)FAd

Adjustment Disorders / 341

R o rschach Summary

Response

Inquiry

Scoring

II. 18" It’s hard. 1. U hm m . . . well one thing 1 know this is weird—Can I say several things? (Entirely up to you) T his looks like a horseshoe crab. (Laughs) I don’t know why.

1. T his red blotch. Strange, but it looked like it a lot. (Horseshoe crab?) The shape. (Anything else?) No.

DFA

2. This looks like two things dancing, the black part, like bear skin rugs or something,

2. And the black things were the two things dancing, and the other ones, didn’t see anything. (Can you tell me more about the idea of two bearskins dancing?) Well, at first I thought it was two bears, but they’re too dis­ figured to be bears. I was thinking o f som ething that could be large. (Were the bear skim dancing?) Yeah, they look that way. T h a t’s the way I saw it. (Bearskin rug?) The shape, I used to have a lambskin rug like that and it rem inded me of it. (Anything else?) No-

DFMA Confab

And I don’t know what that is on the bottom.

342 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

R o rschach S um mary

Response

III.

Inquiry

Scoring

3"

1. Looks like two people, two women kind of, leaning for­ ward or something and kind of— no, it looks like a woman looking in a mirror, posing or something.

1. ( Woman looking in the mirror?) Because the black fig­ ures are shaped like a woman and the fact that there are two o f them made it look that way. (Posing?) The position was the way her head was up made it look like she’s not looking down at what she’s picking up but it’s kind of a pose.

WMIIP

2. This too. A bow.

2. (Bow?) Something in the background in the room she’s in. I used it in the pic­ ture. 1 didn’t ignore it. (Bow?) I'he shape.

DFObjP

3. And the things on the top here are some kind of lamp or something.

3. (Lamp?) The shape. They’re in the background too.

DF-Obj

A djustm ent Disorders / 343

R o rschach Sum m ary

Response

inquiry

Scoring

IV. 37" 1. I think it looks like some kind o f anim al, ju s t the face and fur. It looks like it’s leaning down against som ething. Ju st the head, kind o f photography or som ething th a t uses black and white only, no gray areas and th a t’s w hat it rem inds me of, the face o f an anim al like that.

T he whole. T hese are the eyes and the nose and m outh a re a — an d this is kind o f shaggy and it kind o f looks like fu r in that kind o f photography. W hen som ething's in between it eith er decides to be black or white. T he ears would be up here and there would be m ore o f the face a ro u n d — b u t I’m ju s t talk­ ing about the general face area. (So you're saying there should be more}) I'm saying there would be more. I’m ju s t talking about the face. T h ere would be ears and more o f the body. I’m ju st concentrating on the face p art. (So in the blot you don’t see some of the parts}) Right. Looks like a tiger skin ru g th at ju st kind of sits on the floor and the head is the p a rt you see. (What do you mean bysluiggy}) I m ean the lines going o ff in different directions. (Head}) Just what I saw— the shape and the way the rugs always have sad o r stunned faces and the eyes look sad the way they go dow n— mostly the shape.

W(S)Fc-A

3 4 4 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach Sum m ary

Response

Inquiry

1. Looks like a bat or som e­ th in g like th at cause the wings are small.

1. (Bat?) It’s alm ost exactly shaped like one— I guess o th er people m ight have said butterfly b ut the wings aren’t like a butterfly, more like a bat. (Yawns)

WFAP

I. M outh. It’s like it’s howling or som ething. You know how cats have, on either side o f th eir nose, brushed back, th a t’s what this is. He’s looking up o r som e­ thing. (Nose?) Like a carica­ ture, looking up, h air falling down. My b ro th er has a book. Bloom County, and th a t’s what it looks like, sort of, Bill the cat. Two faded lines. Looks like his arm s, going down straight in front o f him . (Cat?) Looks like the cartoon cat, it’s shape.

drFM -(A )Fab

Scoring

V. 12"

V I. 18" 1. Well um , the only th in g I can see is in this p a rt— it looks like a cat. They m ust think I have a cat obses­ sion. (Wlws they?) W hoever’s going to be read in g this— shaped like a caricature of a cat— looks a lot like a cat caricature. I don’t know w hat this is in the back­ ground, I was only using this.

A djustm ent Disorders / 3 4 5

R o rschach Sum m ary

Response

Inquiry

Scoring

V II. 15" I have no idea. I. I m ean it looks like two bobby-sox type girls look­ ing back at each other, with th eir ponytails flying up (Laughs). I don’t know why, it looks like cartoon girls looking back at each other. L ooking over their shoul­ der, walking away from each other. (Their ponytails flying up}) (Laughs) It's so ridiculous, b u t you . . . (Fly­ ing up}) Like the, swinging th eir heads really fast.

1. T he bottom , kind o f their skirt or som ething. (Their bottom}) 1 don’t know w hat it is—-just kind o f when I looked at it, th a t’s w hat 1 saw, I didn't think about it very m uch so I guess you take this thing over here. (Take out}) I'm not using this p a rt here. U nun, the faces look so detailed, nose, m outh, sticking out tongues at each other, these are eyelashes com ing out.

W M (H)P

1. T his is the anim al, the pink. T his is the bank, kind of, and th e reflection, the water. (Animal}) Exactly what I saw, first thing. (Blot}) T he legs, face, even has a d o t for an eye, the back. (River bank}) W hen­ ever there’s a river, there’s a d arker p a rt where the rock has broken away and th a t’s what this looks like. (Rejec­ tion}) Because it’s the same on both sides.

W(S)FM.CEA, LdscP

V III. 12" 1. Um, looks like some anim al walking across a river bank, by a river bank. Like on a short cliff over water. T h a t’s it.

IX. 15" I. I don’t see anything. Just looks like a mess o f colors sort of. (Turns)

W CdesAbs

346 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R orsch a ch Sum mary

Response

Inquiry

Scoring

1. These are the eyes and they’re kind o f angry and yellowish and that looks like a nose or something. And that’s the evil smile and (Laughs) and has a pointed head like all the villains do in the old movies.

drF/C.M-(Hd)

(Can you try?) Doesn’t look like any figure or anything. I really don’t see anything. X. 25" 1. Upside down it looks like some kind of “Dungeons and Dragons” kind of thing like a face like an evil type person. (Yaums) D ial’s it.

Adjustment Disorders / 347

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 Well, you m ean a story like an essay? Lots o f questions. Looks like since the violin is lying on some kind o f p a p er someone gave him a violin for his birthday or m aybe some o th er reason an d he doesn’t really w ant it. H e wanted som ething else. He doesn’t look too happy at all. (Wfiat happens?) W hat d o you m ean? T h e person who gave it to him looks at him an d sees th at he’s not happy with it an d offers to let him re tu rn it an d the little boy gets som ething th at he likes.

CARD 10

U m m , u h , looks like a little boy o r a girl, you can’t even tell. I guess a little boy who’s saying goodbye to his mother. No, he cam e back from som ew here and he m issed h er an d he’s giving h er a hug. T h e reason he’s not leaving is cause he looks relieved o r kind o f happy so I was thinking he’d be com ing back. U m m an d it looks like the m o th er— h er eyes— she’s sm iling cause there’s a d im ple on h er ch in — an d she has sm iling eyes or whatever they say— 1 don’t know where the boy’s com ing back from— 1 can’t th in k — 1 don’t know w hat h ap p e n s next— the m o th er m ade a big d in n e r for him an d they’re com ing back an d the whole family will be there. He looks like M arlon B rando, you don’t have to write that. (?) I'he guy, the little boy o r girl, who it was m eant to be.

CARD 5

U m m , (Yawns) this wom an is u h , is w aiting for h er h usband to get hom e because she has some bad news to tell him o r som ething. You can tell by the expression on h er face th a t she’s not exactly looking forw ard to it and th a t’s all I can relly tell. O h, should I say w hat h a p p en s after? H er husband gets hom e early and she tells him h er news an d he (Thinks) and for some reason he wasn’t upset.

CARD 12M

U m m , looks like this person is sick o r som ething an d this guy is going to feel his h ead o r is ju s t checking on him o r else he’s going to try to suffocate him with his h a n d o r som ething b u t it looks m ore like he’s sick from the position he’s lying in, can’t tell what the m an with his hand u p is th in k in g because you can’t see his face (Puls card down).

CARD 18GF

M m m , Looks like this person ju s t stran g led this o th e r p e r­ son by the way the h an d s are g rabbing and th e expression on h er face. (Whose face?) T h e person who’s d o in g the stran g lin g — an d this person’s dy in g — looks like th ere was some kind o f fight before it because h e r h a ir’s all m essed up.

CARD 3GF

U m m , T h is person is um m , wants to be alone o r som ething

348 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

an d w ants to shut the d o o r cause she ju s t found o u t som e bad news. Som e­ th in g she d idn’t want to h ear and she wants to lie down or be alone. (Anything else?) N ope. CARD 2 I don’t know, it looks like this farm girl, o r w hatever it is, is going o ff to school. She’s w aiting for som eone to pick h er u p o r som ething. T h a t’s all I see. (What’s she thinking orfeeling?) She doesn’t look like she’s too happy about going to school b u t she looks like she’s w aiting for a while an d ju s t kind o f bored. CARD 12F U m m , I don’t know, it looks like the wom an in front is um m , w aiting to do som ething she looks kind o f nervous an d the woman behind h er is a nun o r som ething. (Yaxims) And she’s there to be reassuring for com ­ fort o r som ething and she looks kind o f w orried herself. I don’t know w hat the woman is waiting for. U m m , she looks kind o f happy actually an d I don’t know. (What happens?) I don’t know, the woman looks kind o f proud o r some­ th in g like she’s going to go u p an d get an aw ard o r som ething an d the woman behind looks happy but nervous and suspicious so I don’t know what happens. (What's she suspicious oft) No, it looks like she knows som ething that the girl doesn’t. CARD 13MF U m m , it looks like these are husband and wife o r whatever, a couple, and he’s ju s t g ettin g u p in the m o rn in g a n d the light. He’s stretch ­ in g o r som ething and the light is b o th erin g him and be has to go to work so he got dressed quickly an d he d id n’t want to wake his wife. (That’s it?) Yes.

Adjustment Disorders / 349

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

2. 7.

She often wished she could “he tru ly tree to express h erself.” She felt proud that “she h ad fo und an expression th a t she felt c o m fo rt­ able w ith.”

12.

/ was most depressed when “f felt I wasn’t b e in g listened to .”

22.

When people made f u n o f her, she “ign o red th e m .”

42.

When / am criticized, I “ignore th e criticism .”

46.

When they didn’t invite me, I “d id so m e th in g else.”

49.

People seem to think that / “d o n ’t c a re .”

60.

M y mother cdways “th in k s she’s d o in g w hat is best for m e.”

71.

Her reaction to me “d id n ’t m atter.”

72.

When she was punished by her mother, she “d id n ’t care because it was u n fair.”

74.

/ feel happiest when “ I ’m w ith my frien d s.”

81.

Most women act as though

82.

When I feel others don't like me “1 avoid th e m .”

83.

More than anything else, she needed “com pany.”

84.

Most people are “hap p y .”

“they d o n ’tc a re .”

87.

/ am afraid o f " p ow erful idiots.”

93.

When introduced to people, she “a p p e a re d happy.’’

97.

She felt inferior when “w ith h ap p y fam ilies.”

99.

I wish that my mother “w ere m ore reaso n ab le.”

350 / Psychological Assessment, Psychiatric Diagnosis, atul Treatment Planning

ADJUSTMENT DISORDER WITH DEPRESSED MOOD Mr. T, a 38-year-old, sep arated , corrections off icer, was b ro u g h t to the hos­ pital by his d e p a rtm e n t’s psychologist. He h ad n ’t rep o rted for duty an d when his landlord had gone to his ap artm en t to check on him at the request o f the duty sergeant, Mr. T was sitting with his service revolver in his lap looking dejected. Spread out on the bed before him were pictures o f his four children (aged 4 th ro u g h 10), his w edding ring, a c ard , an d a ribbon from a school athletic com petition his son h ad recently given him . Mr. T h ad the ham m er cocked and pointed the gun at his head several times, fin­ ger shaking, before his lan d lo rd was able to talk him into giving it up. T h e d e p a rtm e n t psychologist was called an d by the tim e he arriv ed , Mr. T was feeling em b arrassed an d apologetic. Mr. T had been separated from his wife a nd family for nearly three years. Recently, his wife h ad initiated efforts to extend the legal separation for a n o th e r year. P erhap s a d d in g insult to injury, his girlfrien d o f th e last few m onths h ad also decided to break of f h er relationship with him . Feeling hopeless ab o u t a resolution o f his dif ficulties with his wife an d girlf riend, an d financially b u rd e n e d by su p p o rtin g b oth his own an d his wife’s house­ hold, Mr. T h ad filed for divorce. O n the m o rn in g o f his hospitalization, he and his lawyer were scheduled to m eet with his wife and her attorney to negotiate the term s o f the divorce settlem ent. Mr. T acknow ledged th a t he had been in a low m ood the last m onth o r two and h ad at times been overwhelmed with feelings o f f utility an d despair. H e would feel a little b ette r on the two o r th re e nights a week he h ad a few drinks with his friends in the evening after work. A lthough he hadn’t missed any work, he h ad been d istracted at work an d recently his preoccupation with his personal troubles had resulted in difficulties with his d uty sergeant. His chief and fellow of ficers, however, played down these troubles. Everyone knew the sergeant had a “difficult personality.” Despite their reassurances, Mr. T rem ained concerned abo u t his serg e a n t’s evaluations. His first separation from his wife had come after she h ad filed a series o f com plaints against him for intoxication an d abusive behavior. News o f these com plaints had gotten back to Mr. T ’s coworkers, a fact th at was a source o f g reat em barrassm en t for him . Moreover, the whole situation had strongly rem inded him o f his own fath er’s difficulties. Mr. T ’s fath er had been allowed to resign his com m ission in the m ilitary some years earlier as his d rin k in g beg an to com prom ise his jo b perform ance. Mr. T h ad agreed to seek counselling when these dif ficulties b egan and he a n d his wife h ad a tten d ed a n u m b e r o f conjoint sessions w here he acknowledged his occasional difficulties with alcohol and seem ed prepared

Adjustment Disorders / 351 to address other problem s in the relationship as well. His wife, on the o ther hand, felt that all their dif ficulties stem m ed from his drin k in g and stopped atten d in g sessions and filed for a separation when it becam e a p p a re n t that n eith er the first nor the second counsellor they visited was p rep ared to a d o p t h er view that all th eir problem s could be traced to h er h u sb a n d ’s d rin k in g . At the tim e o f his adm ission to the hospital, Mr. T was em b arrassed by his behavior o f th at m o rn in g and stated th a t “ I don’t feel I can han d le it anym ore,” a reference to his situation with his wife. T his was his first psy­ chiatric hospitalization and he stated that “severe depression” was his reason for seeking adm ission at this time. He was noticeably despo n d en t, with a persistent, sad affect, and described his own m ood as “disco u rag ed .” He was oriented in all th re e spheres, gave no indications of o r history o f d elu ­ sions o r hallucinations, and showed no evidence o f either short-term or long­ term mem ory im pairm ent on exam ination. His insight and ju d g m en t were described as fair. His counsellor considered him a reliable in fo rm an t and found no reason to contradict his description of his own behavior or mental status.

DSM-III-R Diagnosis Axis 1: Axis II: Axis III: Axis IV: Axis V:

A djustm ent d iso rd er with depressed m ood Alcohol abuse, episodic M ixed personality d iso rd er with d e p en d en t an d depressive features None Severe— Im p e n d in g divorce; prolonged separation from family Serious Sym ptom s— suicidal ideation, increased alcohol abuse

Treatment and Hospital Course For the first few days af ter arriving at the hospital, Mr. T ap p eared rather su b d u ed an d isolated. H e was caref ully observed for signs of alcohol w ith­ drawal an d none were noted. Shortly, he settled into the unit routine an d gradually becam e less isolated and b etter able to interact with the hospital staff an d the o th e r patients. He felt “relieved” to be in the hospital an d was glad to have the o p p o rtu n ity to “talk with som eone a b o u t all the things on my m in d .” He focused specifically on problem s with his m arriage. A fter

352 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning he and his wile were seen together, it becam e clear th a t no possibility for reconciliation rem ained. T h e m arital relationship had been chronically unsatisfactory for both. A lthough Mr. T was clearly experiencing difficulty a ro u n d the situation w ith his wife an d ch ild ren , in all o th e r respects he a p p e a re d to be able to f unction at quite a high level. He quickly assum ed a leadership role on the unit, enjoyed his activities, an d began to particip ate in the hospital’s Alco­ holics A nonym ous pro g ram . Psychological testing was requested to help in assessing his im pulsivity an d level o f depression an d to identify any characterological issues which Mr. T m ight begin to address while in the hospital.

Psychological Assessment Mr. T received a WAIS, Rorschach, TAT, an d B en d er Gestalt d u rin g the th ird week o f his hospital stay, as well as an MM PI w ithin a week o f his adm ission. He was cooperative with the testing procedures b u t seem ed to resent being exam ined. His MMPI profile indicated a m oderate level o f denial an d efforts to m ake a good im pression (L 6; F-K = -15). His scale 4 elevation is not u nusual for law enforcem ent personnel an d indicated his inclination for activity and perhaps some impulsiveness. A history o f alcohol abuse is com ­ m on in individuals with this profile feature. His elevation on scale 8 revealed, on closer inspection, to consist o f feelings o f social alienation and m istrust­ fulness. O verall, the profile was seen as consistent with a history of alcohol abuse, po o r interperso n al relationships, and difficulty in dealin g with em otionally-charged situations in an adaptive way. Mr. T ’s WAIS perform ance yielded a full-scale IQ o f 103 with verbal and p erfo rm an ce IQs o f 108 and 99, respectively. His best p erfo rm an ce was given on the Similarities subtest w here he achieved a su p erio r score of 15 an d his worst perform an ce, which was som ew hat below average, was given on the Block Design subtest where he achieved a scaled score o f 8. A p art from these subscale scores, his WAIS profile gave evidence o f relatively little scat­ te r (scaled scores o f 9-12). Perhaps the most noticeable featu re o f his WAIS p erfo rm an ce was his relative inef ficiency on the perform ance subtests. His interchanging o f two lin g ers on one Object Assembly item , his successf ul com pletion of two block designs only in overtim e, an d his slow an d m ethodical p erfo rm an ce on the Digit Symbol subtest all suggested he was having some dif ficulty in readily m obilizing skills which a p p e a re d easily in his grasp. His B en d er p e rfo rm ­

Adjustment Disorders I 353 ance d em o n strated th a t he was aware of his dif ficulty an d m ade some p e r­ functory efforts to co m pensate for them . O n the R orschach, Mr. T ’s perform ance was ch aracterized by the same sense o f struggle and inefficiency. He o ften stru g g led to m ake som ething out o f the blots. W here he could find evidence for it, he p referred scenes of gaiety and liveliness (e.g. cards II and III). Even here, however, people need som ething to hold on to such as the ch am p a g n e glass in card III. His frequent use of shad in g (cards II, IV, VI) indicated his und erly ing anxiety and tension and lent an air o f defeat and despair to his responses. He sought refu g e in the conventional, for w hen faced with life’s problem s, he seldom feels up to the task an d is “co rn e red ” (card VI) by his own inability to act. Alcohol, because of its association with hap p ier times (card III) and tenderer feelings (cardX), offers itself as a tem porary escape from the rigors o f adult life. As with his Rorschach p erform ance, Mr. T ’s p erfo rm an ce on the TAT was infused w ith his h ope for a stable, conventional world. H e m ade no apology for his strong desire for “happy en d in g s” an d alm ost invariably attem p ted to find one. D espite this desire, there seem ed to be little sense o f how one m ight proceed from the present tragedy to the happy ending: “h opefully” things will tu rn o u t for the best (cards 3BM and 12M), o r the wisdom of age (7BM) or divine providence (I 2M) will prevail. Somehow, when things don’t seem as if they will work out well, the ch aracters simply m ust learn to “deal with th a t” in th eir lives (card 15), but now here does he specify how this task is to be accom plished.

Treatment Planning and Outcome In the psychologist’s report, Mr. T ’s struggles with his depressive feelings an d his need for n u rtu ra n c e an d su p p o rt were em phasized. T h e psychol­ ogist noted th a t Mr. T m ight wish for an older, p atern al figure who could f unction as a source o f s u p p o rt and guidance, b ut th a t his own guilt and an g ry sense of loss would probably im p air his ability to m ake use o f such a figure. T h e psychologist’s recom m endation was for a continuation o f a supportive psychotherapy which would help Mr. T to build u p his own defenses. Finally, although there were some indications o f a poorly contained im pulsivity, he was not seen as presently suicidal. Mr. T continued to work in individual psychotherapy and gradually came to accept the need for him an d his wife to follow th ro u g h on th eir divorce. With the help o f his th erap ist an d his social worker, he and his wife were able to work o u t an a rran g e m e n t for him to m aintain contact with his chil­ dren and she brought them to visit him in the hospital on several occasions.

354 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning He felt supported and aided by the hospital staff and, for the first time, began to talk about his experiences while serving with the Navy in Vietnam. He began to recognize that his experiences there had taught him to divorce him self from his feelings and had contributed to his sense o f futility and despair about m aking changes in himself or his life. T his insight helped him to begin to look at his own attitudes towards his present situation and to begin to confront his own feelings more directly. At the end o f his one-m onth hospitalization, Mr. T had m ade a rra n g e ­ m ents to continue with the divorce and to live with a fellow officer until he and his wife could come to a more acceptable financial arrangem ent. He was able to refrain from drinking while on passes from the hospital and agreed to continue with the AA program on discharge. He appeared grate­ ful for the help the hospital had given him and has not required any ad d i­ tional hospital treatm ent since his discharge.

Adjustment Disorders / 355

EXHIBIT

I.

A rea of

C l in ic a l

Assessm ent

E x a m in a t io n

1 P s y c h o l o g ic a l E x a m in a t io n

Symptoms/Diagnosis Adjustment disorder with depressed mood Meeting with attorneys for initiation o f divorce proceedings

None

— symptoms in excess o f normal reaction

Suicidal ideation with aborted attem pt

Coping strategies seem inadequate in light of assessed ability

Not ju st one instance and not an exacerbation o f another disor­ der

Only suicidal episode but drinking has increased

Persistent feelings o f inadequacy and depression concerning intimacy

Less than six months duration

Less than six months duration

Present difficulties are at odds with dem on­ strated abilities sug­ gesting a recent onset

None

U nderlying feelings of immobilization and resultant dependency which he denies

Average intelligence

Average intelligence with evidence o f some im pairm ent in p e r­ formance abilities due to cu rren t depression

Guilt and anger com­ bined im pair adaptive problem solving

Feels defeated and self­ derogatory and at the mercy o f a primitive view o f benevolent fate

Readily responds to a supportive environment

Hopefulness may assist in developing a th erapeu­ tic relationship

Reaction to identifi­ able stressor within three months o f onset Maladaptive reac­ tion indicated by

II. Personality Factors

III. Cognitive Abilities

IV. Psychodynamics

V.

T herapeutic Enabling Factors

3 5 6 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Functions best when sup­ ported in taking appropriate action

Feels more comfortable and makes better use o f his resources when in a structured setting None

Has successfully utilized psychotherapy in the past VI. Environmental Demand and Social Adjustment

Good work history despite interpersonal troubles

After initial anger and resentment, coopera­ tive if not fully engaged

Has made and kept sev­ eral friends

None

Adjustment Disorders I 357

EXHIBIT WAIS-R

2

Sum m ary

Verbal Subtests Info rm atio n Digit Span Vocabulary A rithm etic C om prehension Sim ilarities

Scaled Score 12 11 11 10 10 15

Performance Subtests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol

Verbal IQ Performance IQ Full Scale IQ

12 12 8 9 9 108 99 103

MMPI S u m m a r y K -FL/4"892-371/0: R o rschach Sum mary

N um b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+% A% W% W :M M :Sum C m :c VII1-X%

18 0 8 2 (-l) 15" 11" 56 75 44 28 10:3 3:1 1:3 33

358

/

Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o rsch a ch S um m ary

FK + F + Fc% (H + A):(Hd + Ad) Apperception W 56% D 39% d 0% D d+ S 5%

56 9:4

A djustm ent Disorders / 3 5 9

EXHIBIT

3

R orschach Sum m ary

Response

Inquiry

1. A butterfly. O r a bum ble bee.

1. It rem inds m e o f a b u tter­ fly because o f a central body, wings on either side o f it. At the fu rth est p a rt from the center there ap p ears to be a pointed part.

WFAP

2. Some kind o f flying type insect. T h a t’s w hat it rem inds m e of.

2. T he whole, the same thing almost like a shadow effect because o f d ark color.

W FM .FC'A

1. Two people dancing and touching hands and knees.

1. H ere are th eir heads, and here’s where they are touch­ ing at the hands and knees.

WMHP

2. A facial expression, nose, moustache, m outh.

2. A large moustache, m outh, nose, eyes. (Moustache?) A big, thick moustache, bushy, com ing from the center o f the nose. (Bushy?) A bushy effect— little lines, like painted, shapes.

W (S)cF-HdO

1. Two people, holding onto som ething in the center. A nd a cham pag n e glass in the center.

1. With arm s stretched out. A rm here and here, leg here and here, holding onto cham pagne glass in middle.

D(S)M H,ObjP

2. A bow, or w hatever red piece represents.

2. A bowtie in center. (?) Just shape.

DFCP

Scoring

I. 20"

It has to be viewed upright. (No). II. 15"

III.

8"

3 6 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rsch a ch Sum m ary

Response

Inquiry

1. Som ething laying down, some kind o f anim al laying down.

I. Legs, arm s, head gives me general impression o f b e ar­ skin ru g lying dow n, laying on the back as o pposed to the front. (Back of a bear­ skin?) Dark coloration.

W FC 'A P

1. Two little an ten n a e and two little legs in back.

WFAP

1. I was thinking starfish but it doesn’t even have that com plete shape.

1. T he general outline.

WF-A

2. O nly thing th at comes to m ind is th at two portions m eet and m ight be a corner o f a room.

2. An inside corner like a w’all th at comes together, see th at cam e there. T h e color­ ation, gets d ark er in corner. D arker and gets lighter going away.

W FC '-O bjO

1. Like T inker Bell looking at one another.

1. A girlish type face looking at one another. C hin, head, hair, profile.

DM (Hd)P

2. Almost looks like these are also faces. Nose, eye, m outh.

2. (Eye}) Oval— with little dot. O ver here, b ut not as pronounced.

D FHd

1. Two o f them looked like it’s got legs, several, out on eith er side.

DFAP

Scoring

IV. 25"

V. 4" 1. Back to the butterfly again.

VI. 5" (Laughs) 1 don’t know. No recognizable shape to it. I’m not sure it represents anything to me.

VII. 25"

VIII. 12" 1. Two anim als, the pink p o r­ tion on either side. Have four legs.

A djustm ent Disorders t 361

R orschach Sum m ary

Scoring

Response

Inquiry

2. l'he blue and grey. 1 don’t know why fish comes to m ind but some kind o f crustacean o r crab, som e­ thing like that.

2. Pincers on crab or lobster. T he o th e r p a rt I’m not sure why it cam e to m ind.

DF-A

3. L ungs and spinal cord, skeletal system, if these are lungs, kidneys down here.

T his would be central vertebral— these lungs, these would be organs, kid­ neys, heart. 1 don’t know. (?) A rib cage almost.

WFAt

IX. 10" 1 have no idea. I don’t see anything. Is there a heavy m eaning in all this. O u t­ lines don’t take a fam iliar shape. 1. T he grey area (Conventional nose?) Not a h u m an look­ ing nose, b u t an anim al’s nose.

DF-Ad

1. My d a u g h te r’s draw ings at home. Early watercolor by Kathy. It’s h a rd to believe people m ake money from these things. People actu­ ally see things in this?

1. Like a child’s attem p t at ex p erim enting with color. Is th at significant?

W CF A rt

2. Long blue looks like spi­ ders with all little legs but as far as anythin g else doesn’t seem to represent anything.

2. T he shape again.

DFAP

I . O nly thing that stands out is there is som ething behind green an d orange. 2 nostrils, little slits, like an anim al nose as opposed to conventional nose. W hat kind o f anim al has a flat nose— a rhinoceros? X. 11" At least 6, 7 different colors.

362 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t i o n T e s t

CARD 3BM I t’s a girl crying, sitting against a sofa, a long bench seat. Looks like som ething on floor. I don’t know w hat th a t is su p p o sed to be if she is crying. No significance to it at all (?) H opelessness, fru stratio n . (?) O verfed in cafeteria. How can you expect me to m ake a story, w hen I have no idea . . . Seems to portray someone feeling hopelessly frustrated an d gave up (?) 1 like happy endings. W hatever problem is, it will be solved. H o p e­ fully life will get better. CARD 4 (Laughs) W here d id you get these people. T h is also looks like som ething out o f 40s. She’s holding him back from d o in g som ething. C heesecake pictures in back? (?) 1 don’t know, a w ar picture. Som eone’s going to go o ff to war. She’s holding him back (?) Uncle Sam called an d he has to go. (?) She? Don’t go. (?) He’ll come back as a decorated hero. CARD 6BM Definitely a dated picture. A m other and son picture. M other looking o u t a window probably th in k in g o f w hat h a p p e n e d an d yet seem s very concerned. Young fellow seem s a little depressed. I don’t know if he ju s t offered some bad news. Ju st cam e in from outside an d gave some bad news. (Like what?) Looks like som ething from N orm an Rockwell. Maybe a son lost in the war. (M other an d son?) Maybe n ot related people. (?) O u t­ come doesn’t look too big for her. (?) I don’t know, again. L earn to deal with it. CARD 7BM It looks like a father and son having a very serious discussion. W hat was the discussion? T h e younger person has a concerned look and older person seem s m ore relaxed, not as m uch tension in the face. Almost as if he has the wisdom o f age, alm ost like he could em p athize with this person (Concern about?) I guess, m aybe some family situation o r jo b . His wife is going to have the 14th kid and he lost his jo b . You’re going to write th a t down, too? I ’m only jo k in g . (?) O utcom e seem s to be w hatever the problems are, they will work out. O lder person will provide guidance in solv­ ing the problem s. CARD 8BM An operation o f a sort, an incision m ade. Young boy being very reflective. I don’t know if it’s his father, brother, friend. He’s co ntem ­ plating w hatever fate this person is going to have. I don’t know if he was the cause o f this operation. (?) Some kind o f m edical problem , if there’s an incision. (?) A happy ending. I predict the patient will live an d the operation is a success but it looks kind o f primitive. C an you tell me a real story? Have

Adjustment Disorders / 363 T h e m a t ic A p p e r c e p t i o n T e s t

you m ade up a story? Looks like little Joseph Kerr, well groom ed and proper, w ith tie, jacket, w hite shirt. CARD 12M A young boy laying down. An o ld er m an reaching over to touch him . I don’t know why he is, his h and is not touching, probably it’s a priest o fferin g a blessing o r last rites. (?) Boy hit by car. (?) A p p ears to be unconscious, resting peacefully. (?) He’s going to be all right. I don’t know, I would never be a good script writer. I f I were d ead , I ’d expect to be straig h t out. CARD 13MF Definitely a close out. W here you get 12 for $1. Is there any titles to these? W hat do you do, m ake up your own title? T h is m an is upset with this lady who’s laying th ere partly clothed. I don’t know if this is su p ­ posed to portray d eath . Because she’s n ot moving. A rm s exten d ed and covers only partly u p the chest. Man is h id in g his eyes. I don’t know w hat em otion th a t would be. I don’t know if it’s sup p o sed to be sorrow. I f she’s dead, maybe denial. I don’t know what led up to her being in this particular situation. (?) It don’t look good. Have to call a d o cto r o r an am bulance. It doesn’t look like a happy ending. I get a sense o f som eone ex p ired and this guy can’t do an y th in g for them . CARD 14 O pening scene for Search for Tomorrow. I’his fellow is looking out the window, looking out into the world, with a sense o f hope as opposed to som eone who m ight want to ju m p out. L ooking o ut an d up as o p p o sed to down. CARD 15 W here do you get these pictures? T his looks like one o f those close outs. I don’t know if this is a destructive person o r an evil person. Seem s to be d istraug h t. He’s in the m iddle o f a cem etery with gravestones. (?) He’s there to see som eone o r a ttem p t to com m unicate with som eone. (?) I don’t know. He has stringy hair. From the g arm en t, alm ost like a dress, I can’t tell if it’s a m an or woman. (?) Someday he’ll be in the cemetery. I don’t know how I can m ake u p an o th e r story. He’ll have to deal with th a t in his or h er life.

364 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

DISCUSSION In this section, we con trast an ad ju stm en t d iso rd e r in a 38-year-old m ale to that o f a 16-year-old high school female. In the form er case, the m ajor sym ptom s are depression an d suicidal ideation, while in th e latter case the disorder is accom panied by emotional disruption and conduct disturbance, sym ptom s often characteristic o f young people. For Mr. T, the rath e r com m on stressors o f separation and im p en d in g divorce becam e an overw helm ing set o f circum stances. He was cau g h t up in a cycle o f hopelessness, depression, and alcohol abuse an d im agined th at the only “solution” was d eath . T here are indications in the psychological testing as to why this m an m ig h t be vulnerable to the stress o f m arital sep­ aration with its com m on psychological im plications o f rejection and w orth­ lessness. W hile he is m otivated tow ard adju stm en t to society a n d its norm s, there are signs o f im pulsiveness an d indications o f m istrustfulness, as well as some difficulties in in terp erso n al relations. His periodic alcohol abuse is also an im p o rtan t elem ent in this picture. D espite a sense o f u n d erly in g anxiety, Mr. T typically co p ed by denial and clung to the conventional and the routine. T h is co p in g style was seri­ ously disrupted by his m arital separation. His need for the com fortable cus­ tom s o f daily routin e was exceeded only by his stro n g er needs for nu rtu ran ce and support. While these very needs are challenged by the m a r­ ital dissolution, throw ing him into a depression, the sam e needs will most probably assist him in attain in g a positive th erap eu tic alliance. His average intelligence, orientation to seeking and accepting support, and the clear pre­ cipitan t o f upset all suggest a positive th erap eu tic alliance an d good p ro g ­ nosis in focused, supportive individual psychotherapy. T h e case o f Ms. K, like th a t o f Mr. T, also involves family relationships. In this case, the recent divorce o f h e r p aren ts serves as the stressor. E xag­ gerated adolescent tu rm o il involving issues o f psychosexual developm ent, relationship to autho rity figures, and independence propelled Ms. K an d h er m o th er into an intensely intertw ined battle over virtually everything. T he spiral o f escalation reached a climax in h er th reats to ru n away from hom e, the calling o f th e police, an d tem p o rary resolution by adm ission to the hospital. H er un u su al physical a p p earan ce would p e rh a p s m ake a psy­ chiatric evaluator w onder if the extent o f h er rage and rebellion is beyond th at o f an adjustm en t disorder. However, w hen isolated from the overstim ulating environm ent o f hom e, she was quite perceptive about her depression following h e r p aren ts divorce, an d ad m itted h er own co n trib u ­ tion to the constant battle with the mother. Notable in her psychological test­ in g is a high level o f intellectual functioning. However, this intellectual

Adjustment Disorders / 365 acum en is in sh arp contrast to h er sparse an d u nrevealing responses to the projective materials. O ne gets the sense o f a highly intelligent young person who has a striking absence o f in n er creativity an d im agination, and an impoverished developm ent o f the capacity to form m eaningful attachm ents w ith others. All o f the action is outside ra th e r th an inside for Ms. K. T his empty, vacant, in n er experience o f a person who is already 16 years o f age bodes poorly for a productive th erap eu tic relationship, especially when com bined with a suspicious attitu d e an d oppositional stance tow ards authority figures. T h e testing was useful in highlig h tin g potential difficul­ ties in individual treatm en t an d suggesting family intervention as a n alter­ native. It is possible th at th e most efficacious th erap eu tic leverage m ight be found in interventions with the m o th er an d d a u g h te r on a very behav­ ioral level, so as to re n d e r hom e life less chaotic an d frictional an d m ore organized an d stru ctu re d . O nly then w ould the possibility o f developing Ms. K’s relationship skills em erge. While the m other alm ost dem anded that the d a u g h te r be involved in individual treatm en t, the testing was used to em phasize th at the family rath er than the d au g h ter would be the most effi­ cacious focus o f treatm en t. Given the tim e constraints noted in D SM -III-R , the diagnosis o f an adjustm ent d iso rd e r is invariably a provisional one w hen the p atien t is in the m idst o f an adju stm en t crisis. I f th e ad ju stm en t d iso rd e r’s sym ptom s do not resolve w ithin six m onths, o th er diagnoses are m ade. For exam ple, if h er sym ptom s continued, Ms. K would probably be diag n o sed as having a conduct disorder, and p erh ap s an antisocial o r borderline personality dis­ order. For Mr. T, if the sym ptom s are not resolved, he m ight be given a diag­ nosis o f m ajor depression an d complications such as renewed alcohol abuse an d sexual difficulties could be anticipated.

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SECTION

II AXIS II DISORDERS

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CHAPTER 7

Personality Disorders

A. PARANOID PERSONALITY DISORDERS T his Axis 11 condition is g ro u p ed in the so-called cluster A personality dis­ o rd ers w hich include n ot only p aran o id b u t also schizoid and schizotypal personality disorder. All th ree disorders involve o d d and/or eccentric behav­ ior. T h e essential features o f p aran o id personality d iso rd er are a long­ standing and pervasive tendency to see others as threatening o r dem eaning. T his often includes an expectation that others are exploitative and harm ful. T h u s, in terp erso n al behavior is ch aracterized by m istru st a n d questioning o f the loyalty and fidelity o f others. W hile th ere are little d a ta to this effect, th ere is a question by the auth o rs o f D SM -III-R as to the relationship between paranoid personality disorder an d delusional sym ptom s and schiz­ ophrenia, p aran o id type. We present two cases o f p aran o id personality disorder, b o th involving young, single males. In b o th situations, the question arose as to the extent o f the pathology beyond simply the aloof and suspicious presentation o f self to others. Psychological testing was called for in both cases in o rd er not only to explore the exten t o f healthy reality testing versus the dim ension o f th o u g h t disorder, b u t also to get some fu rth e r inform ation about the in n er life o f these individuals. It is not uncom m on for patients to be referred for testing who, for e ith er p aran o id o r o th e r reasons, are unw illing o r unable to form a tru stin g an d o pen alliance with the therapist. In these situations, it is quite possible th a t the p atien t will be equally elusive and u n tru stin g in the testing situation so th a t the testing is m eager in its content an d p e r­ h aps u n h elp fu l. O n the o th e r h an d , it som etim es h a p p en s th a t the testing situation, with its stim uli which are in d ep en d e n t o f a personal relationship (though in the presence o f another), will elicit some clues as to th e in n er workings o f the patient. 369

3 70 / Psychological Assessment, Psychiatric Diagnosis, «w/ Treatment Planning

PARANOID PERSONALITY DISORDER Mr. R is a 22-year-old, single, black male who entered outpatient treatm ent because “I ’ve been feeling down. I don’t m ake friends easily and I ’d like to get rid o f my shyness an d be able to m ake eye contact with o th er people.” H e described him self as having difficulty m aking eye contact with o th e r people since ab o u t the age o f 11. A t th at time, his family h ad recently h ad a ra th e r serious reversal in th eir financial situation and he was sent to live for several m onths with an a u n t in a d istan t city. Since th en , he h a d several periods o f “extrem e shyness,” accom panied by a depressed m ood for which he h ad not previously so u g h t treatm en t. Mr. R worked as a clerk, a jo b he had held for a few m onths a fte r d ro p ­ p in g o u t o f college. He left college because he h ad b een u nable to attend his classes, becom ing too preoccupied with seeing o th e r people to g eth er while he rem ained alone. T his h ad been his th ird a tte m p t to p u rsu e his college education. O n previous occasions, he had always felt th at th ere was som ething about the college which did not suit him an d h ad left the area to live with o th er relatives an d enroll in a new school. H e was presently living with a cousin b u t found this situation difficult as the cousin was “too trad itio n al.” He h ad also enco u n tered difficulty at his jo b . H e becam e an g ry with his coworkers for “invading his privacy” by listening in on his telephone conversations. In interviewing Mr. R, the exam iner found it extremely difficult to obtain any clear details o f recent events. He seem ed to be som ewhat depressed and ad m itted to lacking energy and motivation for the last few m onths. He den ied any difficulties w ith his sleep o r ap p etite. A lthough he rep o rted occasional thoughts o f dying, he d enied any suicidal plan. A lthough no clear diagnostic form ulation em erged from this initial evaluation, his requests for help in overcom ing his shyness an d im proving the quality o f his social life were accepted as the basis for his treatm en t an d he began atten d in g individual psychotherapy sessions once a week. Mr. R was seen in th e o u tp atien t d e p a rtm e n t for the next four m onths with little change. An initial form ulation o f his difficulties as a mild depres­ sive reaction to his inability to succeed in school and his career, com bined with a grow ing conviction in the presence o f an un d erly in g psychosis p a r­ tially m asked by his p aran o id an d g u a rd e d style o f th in k in g and relating, led to the recom m endation o f a course o f neuroleptic treatm en t. Mr. R ag reed to a trial o f a low dose, high potency neuroleptic. He developed a severe dystonic reaction to th e first m edication an d was shifted to a second medication which he tolerated better, b u t subsequently discontinued, claim­ ing th a t it interfered with his concentration.

Personality Disorders / 371 Tow ards the end o f his fo u rth m onth o f o u tp atien t treatm en t, Mr. R raised the issue o f discontinuing his treatm ent altogether d u rin g a peri­ odic psychiatric consultation with the prescribing psychiatrist. O n inquiry, he acknow ledged th a t he had already m ade plans to re tu rn to his parents’ hom e w here he would be able to see his m o th er one more tim e before killing himself. He was transferred to the acute inpatient ser­ vices o f the clinic in o rd e r to forestall his plan and to reevaluate his fu tu re treatm en t plans.

DSM -III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV: V:

N one P aranoid personality diso rd er None M inim al— difficulties with coworkers Poor— M arked im p airm en t in social relations (no friends or social contacts outside his im m ediate family

Treatment and H ospital Course Mr. R was hospitalized for two m onths. D u rin g this time, his suicidal intentions vanished. H e was shifted to a th ird neuroleptic treatm en t and com plied with the treatm e n t sta ffs recom m endation th a t he give the m ed ­ ication trial a suitable p erio d o f time. U pon discharge from the inpatient service, he was reevaluated in the o u t­ patient clinic and was seen as little ch an g ed , a p a rt from his suicidal in ten ­ tions. H e had sto p p e d tak in g his m edication, stating th at “I don’t need an antipsychotic d ru g , I’m not psychotic.” In fact, as before, no clear evidence o f psychotic sym ptom atology could be found. He was assigned to a new th erap ist in the o u tp a tie n t d e p artm e n t an d no p h arm aco th erap y was p re ­ scribed for the tim e being. However, over the course o f the next few m onths, he m ad e little progress in his treatm en t an d his com m ents an d rem arks to his present therapist becam e m ore elliptical an d cryptic. For exam ple, he would o ften com m ent th a t his present therap ist was “differen t from all the o th e r d octors,” but could not elaborate on why this was so, in his view. H e continued to be extrem ely g u a rd e d in discussing how he sp en t his tim e o r w hat he th o u g h t o r felt. T h e th erap ist requested a psychological consultation in hopes o f gaining some insight into how Mr. R’s psychotherapy m ight be m ade to work m ore effectively.

3 72 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

Psychological Assessment Mr. R m et with th e ex am in in g psychologist on two occasions an d com ­ pleted the WAIS-R, Rorschach, TAT, an d DAP d u rin g the course o f the eval­ uation. His testing was b eg u n w ithin a few days o f his adm ission and there h ad been no change in his clinical status. Mr. R achieved a full scale IQ o f 120, with verbal an d perfo rm an ce IQs o f 130 an d 100, respectively His subscale scores ran g ed from very su p erio r (Vocabulary) to low average (Picture Arrangement), w ith relative verbal inefficiency in his know ledge o f com m on facts (Information), a finding perhaps explained by his initial anxiety as this was the first test a d m in istered an d he volunteered the correct answ er to questions hed m issed w hen he re tu rn e d for his second ap p o in tm en t. His relatively poor Arithmetic score seem ed largely accounted for by a deliberateness in his m a n n e r th a t resulted in his ju s t failing to receive tim e cred it for th re e o f his responses. A m ong th e p erfo rm an ce subtests, he had the m ost difficulty with the Picture Arrangement subtest, a m easure o f antic­ ipatory planning in social situations. He failed two o f the first four items and received only partial credit for one other. His failures on this subtest stand out from the rem ainder o f the tim ed perform ance subtests where his lowered scores d id n ot result from mistakes b u t simply from ineffi­ ciency which lost him tim e bonuses. O n the R orschach, Mr. R provided 17 responses o n nine cards, rejecting card VI. H is reality testing, as assessed from his overall ability to provide accurate an d realistic percep ts (F + % = 73) an d frequently perceived fig­ ures (P% = 24%), were ad eq u ate. However, qualitatively, there was a hes­ itancy an d tentativeness to his response style an d an unusualness to several o f his responses. He averaged over 20 seconds (24.6") betw een being p re­ sented w ith the achrom atic card s an d his first response an d on cards I a n d IV, w aited as m uch as one m in u te before o fferin g his first response. M ore­ over, his average reaction tim e nearly d oubled w hen he was presen ted with the chrom atic card s (48"), all o f which may suggest th a t he is endeavoring to censor his reactions, especially w hen em otionally stim ulated by the test m aterial. W hile nearly o n e-h alf o f his responses are h u m a n o r hum an-like, they were often peculiarly seen. For exam ple, on card II, th e p o p u la r h u m an figures were perceived “in an a rg u m e n t” because o f “cues h id d e n from view”; on card VII, he described the p o p u la r h u m an figures as “alien dwarfs with large h ead s”; on card VIII, he found a “cre atu re with a hideous g rin ” who was described as having horns and a p ro tru d in g tongue. Qualitatively, these h u m an responses suggested an idiosyncratic concern with malevolent

Personality Disorders / 373 and malicious qualities which a p p e a re d to persist in his p ercepts despite his ex tended response times. N one o f Mr. R’s test protocols contained an y com pelling evidence o f bla­ tan t disruptions in or distortions o f reality. His TAT stories stayed very close to the m anifest conten t o f the pictures. Card I p ro m p ted a story o f initial d iscouragem ent an d final triu m p h ; card 2 concerned the usual conflict betw een past security an d present am bition; card 4 focused on th e tension betw een the couple. O n the TAT, as on the o th e r tests, he g u ard ed ly hewed rath er closely to the obvious and m undane. In the details o f his stories, how­ ever, the sam e unusualness seen on the Rorschach a p p e a re d on the TAT. O n card 5, he began by seeking reassurance th a t “1 don’t have to say w hat comes to m ind, ju s t m ake u p a story?” He projected on card 2 th at the older woman in the background is “looking with som e disd ain at the girl on the left,” left h a n g in g a com m ent a b o u t the m an’s “eyes” on card 4, an d after suggesting that the young boy on card 8BM used the rifle to shoot the older m an, offered the personalized interpretation that the young boy had a look o f “satisfaction” on his face. It was only in his fig u re draw ings th a t one was im m ediately struck with Mr. R’s unusual view o f reality. He initially requested to d efer the test, which th e ex am in er did. Later, w hen p resented with the test again, in an evasive m a n n e r he asked if stick figures were acceptable and w hen asked to draw a person, he asked if a “sen tien t” would do. His first figure was o f a “m ale sentient, capable o f th o u g h t processes b u t not like a ro b o t.” T he ex am iner questioned him abou t this distinction an d was told th a t a sentient “could be m an -m ad e b u t not at the p resent tim e” an d th a t “h u m an s are sentient, to o .” T his figure, with its exaggerated shoulders an d proportionately tiny legs, was also draw n w ith a p o in ted chin, slanted, tria n g u la r eyes and sq u a re d -o ff head an d gives the ap p earan ce o f a ro b o t o r robot-like figure despite Mr. R’s wish to distinguish it from a robot. His second figure, a fem ale, was b etter p ro p o rtio n ed an d h er facial features seem less sinister. H er lack o f sexual characteristics was explained by his p o in tin g o ut that, as sentients, “it doesn’t m ake sense to differen tiate th em .” Mr. R’s “sentients” a p p e a re d to represent a com prom ise view o f h u m an beings and their complex relationships. P referring to relegate h u m an rela­ tionships to the m echanical an d logical as protection from the em otional an d m alevolent a p p e a re d to be th e central issue for him . His suspicion o f the motives and intentions o f o th ers was a d o m in an t preoccupation an d he struggled with the desire for emotional union and interaction which conflict with his p rom inent fears o f in frin g em en t an d annihilation.

374 ! Psychological Assessment, Psychiatric Diagnosis, and Treatinent Planning

Treatment P lanning and Outcome A fter his psychological evaluation while an in patient, Mr. R was co n fer­ enced an d a decision was m ade to tran sfe r his psychotherapy to a fem ale therapist in hopes th at he would be able to develop a m ore tru stin g rela­ tionship w ith her. His refusal to continue taking a neuroleptic m edication was respected an d it was ag reed th a t pharm aco th erap y would no longer play a role in his treatm en t. H e rem ained in the hospital for a few m ore days and then was readm itted to the outpatient clinic to begin working with the new therapist. T h ro u g h o u t the rem aining six m onths o f his treatm en t, Mr. R rep o rted h im self as less depressed, although he still rem ained, for the m ost p art, g u ard ed and emotionally unavailable. He did, however, come to see his new th erap ist as “differen t from the o th er d o cto rs” and related this to h er w arm th and interest in him . He could retu rn her interest only by inquiring into her personal life. T h is effo rt was tu rn e d to advantage by his th erapist as she indicated th at Mr. R m ight wish to know o th ers b ette r if he felt com ­ fortable with them and believed th a t they were interested in his welfare and respectful o f his views. His th erap ist h o p ed th at this form ulation would encourage him to b ro ad en his efforts in seeking o ut o th e r friendships, b u t he proved unable to m ake this transition successfully. A t the beg in n in g o f the next sum m er, Mr. R began to m ake plans to re tu rn to live w ith his p aren ts an d reenroll in school. He revealed th a t he h ad b eg u n to occasionally use Valium, which he p u rch ased on the street n ear w here he worked, in o rd e r to help him “relax .” He was unw illing to consider o th e r form s o f m edication, b u t d id ag ree to consult with a phy­ sician after his move. He did not wish a referral to a psychotherapist, stating th at he w anted his present th erap ist to be “my last th erap ist.” Mr. R carried o u t his plans to re tu rn to his parents’ hom e an d reenroll in school. A lthough his im provem ent was ju d g e d to be m inim al, he d id ap p e a r to find some relief in the reduction o f his feelings o f depression and his suicidal ideation and, at least with his therapist, was able to dem onstrate some slight im provem ent in his in terp erso n al functioning.

Personality Disorders / 575

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

— guardedness/ secretiveness

Provides few details o f his experiences

Adheres closely to m ini­ mal test requirem ents

— hypervigilance

None

Dilated response times; m uch attention to detail

— overconcern with hidden motives

None

Preoccupied with what may be “hidden from view”

— inability to relax

Com plains o f constant tension

Tension and vigilance interfere with fluidity o f perform ance

— exaggeraton o f difficulties

His failure as a student could bring his life to an end

H um iliated by aspects o f his initial perform ance and corrects them at the first o p p ortunity

Avoids feelings or any em otional turm oil

Intellect and rationality are o f great im portance

-lacks a sense o f hum or

None

Avoids spontaneity and is unsettled by surprise

II. Personality Factors

None

Extrem ely limited capac­ ity to tolerate and/or express affect

Above average intelligence

S uperior intelligence b ut limited ability to p ut his abilities to use

I. Sym ptom s/D iagnosis Paranoid personality disorder U nw arranted suspi­ ciousness and m istrust

H ypersensitivity

Restricted affectivity — app ears unem otional

III. Cognitive Abilities

376 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning A rea of

C l i n k :a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

IV. Psychodynamics

None

Experiences others as potentially threatening

V'. Therapeutic Enabling Factors

Recognizes his difficulty

Conflict over putting his mistrust of others aside to develop a working alliance with his therapist

VI. Environmental Demand and Social Adjustment

Functions best with mini­ mal interaction with others

Has little understanding o f his own or others’ motivations

Long history o f poor social adjustment

Social relationship skills are very impaired

Personality Disorders / 377

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests Info rm atio n Digit Span V ocabulary A rithm etic C om prehension Sim ilarities

Scaled Score 10 13 16 11 14 15

Performance Sub tests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly Digit Symbol Verbal IQ Performance IQ Full Scale IQ

10 8 12 10 9 130 100 120

R o rschach Sum mary

N um b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+% A% H% W.M M :Sum C m:c V III-X % FK + F + Fc% (H + A ):(H d + Ad)

17 1 (C ard VI) 4 0 48" 25" 59 73 29 47 8:5 5:2.5 2:0 47 65 12:1

378 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o r s c h a c h S u m m a ry

Apperception

W D d Dd + S

47% 41% 0% 12%

Personality Disorders / 3 7 9

EXHIBIT

3

R o rschach Sum m ary

Response

Inquiry

Scoring

I . 1 '6 "

T his is m eaningless to me. I don’t see very m uch. (Try to see something.) 1. Shape rem inds me som e­ w hat o f a bat.

1. Whole thing. Not really shape o f bat, b ut rem inds me o f it. (Anything else}) Not really.

WFAP

2. T h ere m ight be a person in the m iddle.

2. In the m iddle— hands, legs down here. (Person}) Shape. (Anything else}) Not really. (Male or female?) Female. (Female}) T he shape.

DFHP

I. H ere— head, hands. They have some sort o f cloak o n — some sort o f covering with red splotches th at the black doesn’t totally cover. (Argument}) I guess the red makes it look th at way. T h e ir hands, what looks like hands, are together. T h e cues h id d en from view are they are going to swing. T here’s sweat com ing o ff th eir faces, those little dots.

W M .FC(H)P

II. 33" 1. I guess it looks like two— well there’s . . . (Laughs) . . . two, 1 guess beings— not exactly h u m a n — opposite each o th e r with red heads— hands touching, right and left I guess, like in an argum ent.

3 8 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

Rorschach Summary Response

Inquiry

2. A nd then there's this wing shape taking o ff in the m id d le— the w hite p art like a space . . . I don’t know if I should use that p art. (It's entirely up to you).

2. Some sort o f space ship, could be alive, I don’t know. (Space ship or animal?) Guess space ship and exhaust is com ing out. (Where?) Red part. (Exhaust?) T h a t’s where exhaust comes o ut o f back and the color 1 guess. It’s w hat makes it look like the space ship is going.

S(D)Fm.CF O bj,Fire

1. Forearms, legs I guess— raised like they’re arm s. (Head, arms?) Like a h u m an insect— those black spots there. Ju st top, waist up. (Looks like human insect?) Yes, waist up. (What makes it look like?) T he sort o f sharp points at the ends o f the arm s and w hat I saw as eyes. (Waist here and arms here?) Well body here and curve starts here— not elbow I guess. Do you give cards in same orientation? (Yes)

WF-A/H

1. H ead, eyes, horns. Rest o f it, an ill d efin ed shape. T h a t’s why it has to be aquatic. C ouldn’t fly.

WF(A)

Scoring

I I I. 40" 1. Okay to see upside down? (Yes) Looks like some sort o f giant insect with the card upside down.

IV. 60" 1. U pside dow n 1 see some m onster thing. I guess aquatic probably.

Personality Disorders I 381

Rorschach Summary Response 2. Some sort o f relative o f Bigfoot.

Inquiry

Scoring

2. Feet, big tail, small arm s, back o f h e a d — can see a spine down there. (Spine}) Ju st looks like it. (Anything about blot}) I don’t know, ju s t rem inded me o f a spine.

WF(A)

Shape. (Anything else}) Well— n ot really. (Why upside down}) Ju st the shape looked b etter to me th at way.

WFAP

V 11" 1. T h a t looks like a b a t— as soon as you took it o u t— o f course upside down.

V I. 2' I don’t know, doesn’t look like anything. V II. 38" 1. U pside down looks like some sort o f . . . like an alien d w arf with a rath er large head.

1. Legs, arm s, h e ad — this whole th in g is the body. A whole piece is m issing from the center. N othing quite like th at on e a rth right now. (Dwarf}) Well, the hands and the arm s are stubby, I guess.

W(S)F(H)

382 ! Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

Rorschach Summary Response

Inquiry

1. Sideways— there’s some sort o f body— would be feline— and head looks like a ro d e n t— o f course, there’s a piece m issing, b ut

1. I f the head wasn't like a ro d en t’s it could be o f the cat family— a feline. (Feline?) Way it was— looks. (Rodent’s head?) Just does. Must be a reflection o f it over here. (Reflection?) Maybe it’s reflecting in the water. Got to be some sort o f reflection for two images to a p p e a r like that. (Any­ thing else?) No. T h a t’s it. Well, maybe because I see this water over here makes me think o f a reflection.

2. T h e blue is water.

2. Ju st th a t it’s blue like water.

DCF' Water

3. L ooking at it I also see a creature with a hideous grin.

3. Eyes, m onstrous tongue, horns. Ju st the face, o r I guess it could be p a rt o f it-could be hands here. T h e white looks like teeth. (Tongue?) Just this oval shape in here. (Hideous?) Ju st looks tria n g u la r and looks like . . . the way the head is shaped and this could be the rest o f the body.

W (S)M(H)

1. H ead, eyes, arm s, legs. T h e size o f the head in relation to the body. It’s sitting down. Looks like it’s not old enough to talk. (Eyes?) T h a t’s w here they should be.

DMH, Obj.

Scoring

V III. 52" DFA

IX . 64" 1. I guess this th in g here looks like a ra th e r pudgy baby.

Personality Disorders / 38 3

Rorschach Summary Response

Inquiry

Scoring

2. Looks like a separate figu re from the infant. T he head here. (Trimmers}) It looks like it’s holding som ething— some kind o f tool. H edge trim m ers ju st came to m ind. T h a t’s all.

D M H,Obj.

3. T h ird thing looks like a figure th at is falling dow n holding som ething.

3. T he ro und bottom m ade it look like those things kids punch th at fall down and come up. They shape them in figures like clowns and things. T his is some kind o f figure like that. (Holding something}) An arm stick­ ing o ut makes it seem like that.

DM .Fm,(H)

4. O f course, this could be water.

4. Just because sym metrical. It’s sort o f the form o f a pool o f w'ater.

D(S)FYVater

1. W hite p a rt— these are eyes— nose— here would be. (Anything else}) Not really.

dr(S)F-H d

T his m iddle th in g looks like a figure holding a . . . some sort o f a . . . som ething— the only thing th at comes to m ind th at would be held like th at is a hedge trim m er.

X. 50" 1. T h in g in the m iddle looks like a face.

384 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT T

h e m a t ic

A

p p e r c e p t io n

4 T

est

C A R D 1 Okay a . . . I guess lie was a, well he’s feeling dismayed about prac­ ticing the violin. L ater he gets over it and goes on to be a g rea t violinist. C A R D 2 I guess this woman on the rig h t is looking with some disdain at girl on the left w ho has some book. I guess she’s going to school. She’s th in k in g th a t she should be content to stay on the farm . O f course the girl feels dif ferently and goes on to leave them all b ehind on the farm . (Feel?) Well she feels like she’s d o in g th e rig h t thing. C A R D 4 A h, I guess this guy’s looking at som e o th e r fem ale an d she’s tying to get him to look back at her. (Who are they?) A . . . hu sb an d an d wife o r boyfriend and girlf riend. (Happens?) I guess he finally tu rn s aro u n d and they have some sort o f fight, o r q u arre l, b ut she doesn’t look like she w ould— as if she wants to q u a rre l— I don’t know. T hey en d up sep aratin g for a few weeks. (?) Well this guy looks like his eyes are really like, I don’t know, looks like some, looks like he’s like, I guess sort o f stubborn. He doesn’t like to be told w hat to do. H e thinks his looking is insignificant an d she’s m aking a big deal o u t o f it. C A R D 5 I guess this is a . . . I don’t have to say w hat comes to m ind? Ju st m ake u p a story? (Yes) I guess I could say— th a t’s a m o th er th a t’s feeling sort o f it’s time to go to bed— looking in seeing the light on. (Who?) C hildren o r child— whoever’s playing the violin in the o th er picture. (Happens?) They go to bed. C A R D 8BM I guess this guy in the foreground, he’s th in k in g — th a t’s his fath er— he’s th in k in g th a t if th e o peration’s not successful— o f the resp o n ­ sibility he’ll have to carry. T h a t looks like a rifle o r som ething there. Maybe he shot him . He wouldn’t be there though. I don’t know. (?) I guess the o p er­ ation doesn’t work an d th a t’s th at. (What operation?) C an’t tell. I ju s t see a scalpel, th a t’s all. He m ust have p u t the rifle th ere prom inently for some reason. I m ean the people w ho designed it. I guess they w ant m e to think th a t o r som ething. G uy looks like he has satisfaction on his face, now th a t I look at him . C A R D 12M I guess this guy looks like he’s d e ad o r som ething . . . a h . . . ah . . . I don’t think he’s d ead . His knee is lifted on the rig h t side.

Personality Disorders / 385

PARANOID PERSONALITY DISORDER Mr. H , a 25-year-old, single m ale, h ad been living in his parents’ house for the last year an d a half. He was n ot employed d u rin g this tim e; in fact, he left the house on only two occasions for periods o f an h o u r o r two. Mr. H had re tu rn e d hom e to live after working for two years as a proofreader, a job he took a fte r d ro p p in g o u t o f college d u rin g his sophom ore year. He had done well d u rin g his freshm an year g ettin g straig h t As in an e n g in ee r­ ing p ro g ram at an Ivy L eague university. However, he ch an g ed his m ajor to philosophy and his grades had plum m eted. He was finally forced to w ith­ draw from school. His family had little contact w ith him in the two years following his w ith­ draw al from school an d before his re tu rn in g to live at hom e, b u t they were aware th a t he h ad developed an interest in “m etaphysical sciences.” T his interest led Mr. H to “u n d e rstan d some th in g s psychically which before I had only com prehended intellectually.” U nder the sway o f this “un derstan d ­ ing,” he had called his parents, “sounding terrified,” and they had told him he should com e home. D u rin g the first year o f his re tu rn in g hom e, he becam e progressively m ore isolated from his family. In the last few m onths before his adm ission, he was preoccupied with his need for “space.” He com m unicated with his family exclusively by letter, notin g th at “my state o f beingness at this tim e is such th a t I can n o t harm oniously interact with anyone on a social level.” His rem onstrations to his family to recognize his need for complete physical isolation gradually took on m ore tyrannical overtones. He carefully observed the custom ary p atte rn s o f his family’s movem ent an d w rote out detailed schedules o f their activities, which he expected them to follow, in o rd er that th ere would be no chance o f having to “physically interact” with them . He ju stified these schedules in long letters which he left for them abo u t the house d u rin g the night. T hese letters spoke o f his need to have “total and u n restrain ed access” to various areas in th e house at specific times o f day His parents finally decided that he was in need o f psychiatric attention and a rra n g e d for him to be a d m itted to the hospital. Mr. H n eith er shared his parents’ concern over his social isolation nor agreed with their suggestion th at he lie adm itted for psychiatric evaluation an d treatm en t. At th e tim e o f his adm ission, he presen ted his view o f the situation as one in which his position was very m uch like th a t o f “a political o r ideological p riso n er” in th a t he was forced to su bm it to the wishes o f his p arents w ho felt th a t they were acting on his b e h a lf when the real issue was one o f a fu n d am en tal disagreem ent over his personal freedom . A t the tim e o f his adm ission, Mr. H was a tall, thin , pale young m an with

386 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning long h a ir an d a long b eard . His general ap p e aran ce was disheveled, m al­ odorous an d unkem pt. He described his m ood as “fine” an d his af fect was noted to be flat and b lu n ted . His speech was m eticulous an d precise an d he clearly took some pleasure in using words, playing with th e ir m eanings an d nuances, and seem ed to be of su p erio r intellectual ability. T h ere were no abnorm alities o f attention, orientation, concentration, and mem ory noted d u rin g the m ental status exam . He d enied any present o r past percep tu al disturbances, includ in g hallucinations, an d gave no history o f delusional thinking, suicidal o r hom icidal ideation. H e evidenced significant im p a ir­ m ent in his capacity for insight in th a t he was com pletely unaw are th a t his behavior was in any way u nusual. His ju d g m e n t was grossly im paired in th a t he utterly failed to recognize the im pact o f his behavior on his family an d h ad no idea o f how they felt in response to his dictates re g ard in g th e ir use o f th e ir own hom e an d restriction o f th eir freedom .

D SM -III-R D iagnosis Axis Axis Axis Axis Axis

I: II: III: IV : V:

Rule o u t S chizophrenia, p aran o id , unspecified P aranoid personality d iso rd er G enital herp es, in rem ission N one— no obvious psychosocial stressor in the last year Grossly im p a ire d — m arked im p airm ent in allareas o f functioning— does not leave the house, is not em ployed, and avoids all social contact w ith his family.

Treatment and Hospital Course Although Mr. H did not feel his admission was in any way w arranted and he was adm itted involuntarily, he m ade no attem p t to petition for his release from the hospital. In fact, d u rin g his first m onth, he becam e m uch less reclusive th an he had been at hom e an d b egan to socialize with the o th er patients an d even m ad e some friends. His hygiene im proved an d he re g u ­ larly atten d ed his individual an d g ro u p psychotherapy sessions which he seem ed to enjoy. D u rin g this period of evaluation, he was not b eg u n on any m edication. His psychiatrist wished to conduct the initial evaluation prior to b eg in n in g pharm acological treatm en t. At th e tim e o f his adm ission, his diagnosis was som ew hat in doubt. His history revealed no clear evidence th a t he h ad any positive psychotic sym ptom s such as hallucinations o r delusions. However, th ere h ad been a clear decline in his functio n in g since his late adolescence

Personality Disorders I 387 an d possibly som e tran sien t d istu rb an ce in his sense o f reality, related to hallucinogen abuse d u rin g his two years away from hom e an d college. T h roughout his precollege years, he had been an extremely good student an d g ra d u a te d from a p rep school w here he was an active p articip an t in an in tram u ral athletics p ro g ram an d generally well liked by his peers. He portrayed this perio d o f his life as significant in th at until he had been sent to prep school by his father, he felt he h ad been m erely an extension o f his p arents, conform ing to th e ir expectations ra th e r th a n developing his own philosophy o f life. T here was no history o f psychiatric d isorder in Mr. H ’s im m ediate family o th e r th a n som e occasional alcohol abuse on the p art o f the mother. H er father had died u n d e r som ewhat questionable circumstances, a possible sui­ cide, about one year after the d eath o f his wife. Possibly he h ad suffered from a late-life depression in the context of his wife’s death. Mr. H ’s paternal g ra n d fa th e r had also been a heavy drinker, an u n u su al behavior p a tte rn for Jewish m en o f his generation. His family history, therefore, m ight give some reason to suspect a possible depressive illness.

Psychological Assessment C onsidering the available inform ation, Mr. H ’s trea tm e n t team was u n ab le to arrive at a clear form ulation o f his diagnosis. His history o f declining an d , finally, grossly im p aired functioning suggested a schizophrenic illness; how­ ever, th ere was no perio d o f frankly psychotic sy m ptom atology t h a t h ad been observed o r rep o rted . His fam ily history suggested the possibility o f an affec­ tive disorder; however, no persistent disturbance in m ood was seen and no asso­ ciated features o f a m ajor affective disturbance were evident. Consequently, he was referred for psychological testing in th e second week o f his hospital stay, with a request for help in the differential diagnosis o f a schizophrenic or affec­ tive disorder so that p ro p er pharm acological treatm ent could begin. T h e psy­ chologist adm inistered the WAIS-R, Rorschach, TAT, SCT, and B ender Gestalt in o rd e r to ad d ress th e diagnostic differential. Consistent with the impression o f his intellectual abilities reported d u rin g the m ental status exam , Mr. H achieved a full scale IQ o f 134, a score in the very superior range o f intellectual functioning. His verbal and perform ­ ance IQs were 143 an d 118, respectively. T his discrepancy o f 25 points betw een his verbal and p erfo rm an ce IQs reflects a g reat deal o f intertest scatter. His verbal scores were all in e ith er the su p erio r o r very su p erio r ran g e o f intellectual functioning, while his p erfo rm an ce subscale scores ra n g e d from average to very su p erio r levels. Mr. H ’s relative stren g th s were to be found on the Digit Span, Vocabulary,

388 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Comprehension, and Block Design subscales; his comparative weaknesses were on the Picture Completion, Picture Arrangement, and Digit Symbol subscales. T his pattern o f subscale scores suggests an absence o f anxiety (Digit Span and Block Design) and social withdrawal o r disinterest (Picture Arrangement and Information) characteristic o f a schizoid style o f relatedness. A lthough he was cooperative with the examination, in an intellectually detached fash­ ion, he repeatedly attem pted to engage the exam iner in a debate concern­ ing the validity o f psychological testing. O n the oth er hand, he frequently asked the exam iner to confirm the correctness o f his responses. Mr. H ’s Rorschach perform ance dem onstrated the same absence o f a n x ­ iety in that there were no shading or black/white contrast responses. His test perform ance was quite good, with an adequate n u m b er o f total responses (24) and with seven o f these offered in response to the chromatic cards. His form level and num ber o f p opular responses, both general mea­ sures o f reality testing ability, were quite satisfactory (F + % = 86; P% = 33) and consistent with his intellectualized style and intellectual ability, he produced several h um an movement responses (six), all o f good form. A lthough he produced a form- and m ovem ent-dom inated record, there were also responses where color was used, although these responses were principally o f the less m ature CF variety, as for exam ple on card IX where the green areas are described as “bushes” in front o f the deer. T he com parative lack o f affective integration im plied by this response where the foliage serves to hide the d eer was seen more prom inently in his TAT responses. To card 15, a card which typically provokes a story with a them e o f depression o r isolation, he produced a story o f “an older person, maybe 40s or 50s, who doesn’t look very happy standing in a cemetery.” He reported th at the m an feels a “kinship” with the people in the cemetery because he feels “alienated” from the world. However, in a peculiar tu rn o f phrase, he went on to say th a t “He feels alienated from the world and people he comes in regular contact with and feels more in contact with peo­ ple he lives with who don’t u nderstand him or her.” This TAT story was one example in the test record where Mr. H gave evi­ dence o f peculiar thinking. O th er examples included the WAIS C om pre­ hension subscale item requesting reasons for why m any foods need to be cooked (“people prefer to d en atu re the food”) and the WAIS Similarities subscale item requesting why air and water are alike (“elem ents in the mys­ tical sense”). O n the Rorschach, he referred to the central white area o f card II as the “negative im age” and referred to card VI as “a leaf with maybe a dragonfly com ing ou t o f the top, or the leaf is lying over the bottom p art o f the dragonfly.” T here were places in the test protocol, particularly the SCT, where the problem o f “contacting” others was also specifically raised. His usual

Personality Disorders / 389 response to contact with o th ers is to set him self in opposition to others’ wishes or to react with a passive, b ut begrudging, compliance. For example, on the SCT, he noted th a t he used to feel he was held back by “my parents’ restrictive influence.” He com pleted the sentence stem while he was speaking to me with the phrase “I wasn’t listening,” an d w rote th at: if I had my own way, I would “do as I pleased”; when he was completely on his own, he “enjoyed his freedom ”; his greatest wish was “to have more freedom ”; more than anything else, he needed “to be fre e.” D em ands m ade by o thers were rep o rted as annoying (e.g. I was most annoyed when “they wouldn’t let me do w hat I w anted to d o ”) and, as he n oted, taking orders “is n ot my cup o f te a .” In fact, th ere was little sense o f who Mr. H is o r w hat he thinks o r feels about most things on the S C F H e him self rem arked on this fact w hen he w rote a note at the end o f the test explaining th a t “these sentences don’t necessarily represent m y tru e feelings o r my beliefs. Some things represent my personal situation o r feelings, while o th ers are ju s t com pletions o f the sentence for lack o f an y th in g b ette r to w rite.” Such sentence com pletions as being asham ed th a t “I h u rt th a t p erso n ,” feeling guilty abo u t “having done th a t,” an d feeling he could m u rd e r a m an who “could do som ething like th a t,” were exam ples o f his g u a rd e d ness a b o u t him self even as he alluded to th ere b ein g som ething to be revealed.

Treatment Planning and Outcome T h e e xam ining psychologist d id n ot feel th a t there were significant indi­ cations o f eith er schizophrenic o r affective d iso rd e r in Mr. H ’s test record. T h e preservation o f basic reality testing ability an d , occasional ideational peculiarities aside, the absence o f any serious examples o f thought d istu rb ­ ance served to rule out a schizophrenic disorder. 'H ie predom inant affective tone and intellectualized approach o f the record were more in keeping with g u ard ed n ess, secretiveness, an d em otional avoidance ra th e r th a n with depression. His hypertrophy o f identity developm ent and his defensive reac­ tion o f sep aratin g him self as a step tow ards p e rh ap s b u ild in g a m ore cohe­ sive sense o f him self were offered by the ex am in in g psychologist as the central issues to be a d d ressed in his treatm en t plan. Mr. H was discharged from the hospital after a three-m onth stay. Towards the end o f his stay, he explained his reclusiveness a n d generally g u ard e d style as solutions to his personal insecurity: “First, I m ust secure my p e r­ sonal integrity against outside forces, th en I can be creative. I t’s like this: people who don’t have enough to eat can’t be philosophers. First they’ve got to solve the food problem . I t’s th e sam e w ith me. I’ve got to secure my own bo rd ers before I can e x p a n d .”

390 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning Mr. H was d isc h a r g e d a n d retu r n e d to live w ith his p a ren ts w h ere h e qu ick ly r eesta b lish ed his o ld m a n n e r o f liv in g . H is paren ts o n ce a g a in h a d h im h o sp ita liz ed a n d o n th is o cca sio n , h e was treated w ith n eu rolep tics in an effort to add ress a possible u n d erly in g psychotic process. H e resp on d ed no b etter to th is c o u r se o f trea tm en t th a n h e had to his last. A s b e fo r e , he was d isc h a r g ed as u n im p ro v ed a n d a r ra n g em en ts w ere m a d e for h im to resid e in a halfw ay h o u se rath er th an retu rn to live w ith his parents.

Personality Disorders / 391

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

I. Symptoms/Diagnosis Paranoid personality disorder U nw arranted suspi­ ciousness and m istrust — guardedness/ secretiveness

Revealed little about him self

C arefully g u ard e d his thoughts and feelings

— avoidance o f blam e

Acknowledged no responsibility for his parents anger

Accepts no responsibility for his present circum stances

— loss o f apprecia­ tion o f context

Could not see how his behavior conflicted with the social reality o f family living

A rgues about the validity o f tests; wants only to provide “w hat you are looking for”

— inability to relax

Could not relax suffi­ ciently to sleep with others in the house

Inordinately vigilant; m arked absence o f anxiety

— readiness to counterattack

Tenacious in defense o f his own “rights”; met all criticism with an assertion o f these “rig h ts”

G u ard s against attack.

— takes pride in being rational and unem otional

Avoids any discussion o f feelings

Largely restricts him self to the obvious and com m onplace; ade­ quate reality testing

— ap p ears cold and unem otional

A ppears cold and unem otional

Endeavors to control his affectivity

Prim ary interest is in avoiding all anxiety

W hen emotionally aroused, he adopts an air o f intellectual detachm ent

H ypersensitivity

Restricted affectivity

II. Personality Factors

392 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

III. Cognitive Abilities IV. Psychodynamics

V. Therapeutic Enabling Factors

VI. Environmental Demand and Social Adjustment

Above average intelligence

Superior intellectual abilities

None

Severe identity disturb­ ance, emphasizes boundaries with others, noncompliant with authority and avoids intimacy

Receptive to supportive efforts to allay anxiety

Reality appreciation is largely intact; occa­ sional idiosyncratic thinking

Passively cooperative with treatm ent if his “rights” are respected

None

Emphasizes need for social withdrawal

Could perhaps function in a highly structured setting with minimal social contact

Assumes no responsibility for self-care

None

No externally directed ambitions

None

Personality Disorders / 393

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests Inform ation D igit Span Vocabulary A rithm etic C om prehension Sim ilarities Performance Tests Picture Com pletion Picture A rran g em en t Block Design O bject Assembly D igit Symbol Perform ance Score V erbal IQ P erfo rm an ce IQ Full Scale IQ

Scaled Score 13 193 16 14 16 14

11 11 19 12 13 63 143 118 134

R o rschach Sum mary

N u m b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% W:M M :Sum C m :c V III-X % FK + F + Fc% (H + A ):(H d + Ad)

24 0 8 0 6" 6" 46 86 33 33 6.6 6:2.5 4.1 29 46 15:1

394 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning R o rsch a ch Sum m ary

Apperception

W D

d D d+S

25% 67%

0% 8%

Personality Disorders / 3 9 5

EXHIBIT

3

R orschach Sum m ary

Response

Inquiry

Scoring

I. 2"

1. A rm s sw inging o u t o f each— like holding in the m iddle and so n o f swing­ ing around.

VVMH

2. It looks like a person in the m iddle with arm s raised up,

2. A rm s up here reaching up like this.

DMHP

3. and two C hristm as trees on the side.

3. You know how when you draw a C hristm as tree, it looks like (Demonstrates), well th at d id too. (Anything else}) Ju st the an g u lar up and out.

DF-Nat.

1. Two people touching at the h an d and at the knee and leg.

1. H ead, arm s, legs, and knees touching, touching from knee down.

YVMIIP

2. If you like— im agine it looks like a plane or je t

2. Some sort o f flying object with p ointed front wings and je t blast and

SFmObj

3. with rocket blast, pointed out at bottom .

3. redness com ing o ut the back.

DCF.mF Fire

1. Two people holding some­ th in g between them

1. Looks like two women here. T h e re are their breasts.

DMHP

2. which m ight look like a large crab. Two females

2. (Crab}) Shaped like a crab and two things com ing out like th a t could sort o f be claws.

DFA

Looks like two people dancing.

II. 3"

T h a t’s it. T h ere are 10? Are the sam e cards used all over the world? III. 1''

3 9 6 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

R o rsch a ch S um m ary

Response

Inquiry

Scoring

3. {Bowtie}) T h e shape.

DFClothP

4. T his could also be a big butterfly.

4. Same p a rt looks like a butterfly— the shape. Doesn’t m ake sense. Doesn’t fit in logically b ut if you take it in an d o f itself, piece by piece, it looks like that.

DFAP

5. A nd these could be two lam ps here.

5. It’s on a cord. T he redness represents illum ination relative to the blackness o f the rest.

DFC-symObj

3. with a big bowtie in the m iddle. (?) Have nothin g to do with each other, b u t p a rt o f the sam e picture.

IV, 2" 1. A m an with a jackham m er. B eing taken from right down in front o f feet and he’s holding som ething in front o f him that goes down to the ground. Shape o f a jackham m er. 2. A m an on a motorcycle. Taken from in front o f the m an, looking up.

Like you are looking up, two feet, head, and feet m uch larger. Id ea o f p e r­ spective and this thing looks like a jack h am m er

W M H ,Obj

2. Same m an on a motorcycle. T his is the front wheel and this is the handlebar.

W FH .O bj

1. T he shape.

WFAP

1. T h e outline o f a leaf, sort o f a m aple leaf.

DFP1

V 3" 1. Some sort o f butterfly or moth. V I.

22"

Doesn’t look like any th in g much. 1. A leaf

Personality Disorders / 3 9 7

R o rsch a ch Sum m ary

Response 2. with maybe a dragonfly com ing out o f the top, or leaf is lying over th e b ot­ tom p a rt o f the dragonfly

Inquiry

Scoring

and this looks like a head. (Coming out of lop?) Kind o f m erged into one, like no division between them . T hen it looks like the back o f the dragonfly is lying on top o f a leaf. I f you con­ sider the d a rk p a rt a con­ tinuation o f the dragonfly. (Kind of merged into one? I ’m not sure what you mean?) Vis­ ually, it looks like th a t— not realistic. Looks as if— it’s an abstract picture. Looks like no separation between the two.

DFMA

T his would be hand coming out. T he dancing. T he reason I say dancing peopie, a lot o f these, it’s the symmetry. It looks like a g ran d m o th er cause o f the facial ch aracter from the sides and cause h air on the side seem s like som ething I’ve seen on older ladies, maybe on TV. Reminds me o f a g ran d m o th er type.

WMHP Peculiar verbalization

VII. 3" 1. Two Indian squaws’ g ra n d ­ m other’s dancing.

VIII. 15" 1 Two anim als, I don’t know what type, polar bears, or anything, four-legged, could be a bear,

1. T he shape o f them looks like they’re stepping o ff a rock.

DFMAP

3 9 8 ! Psychological Assessment, Psychiatric Diagnosis, am i Treatment P la n n in g

R orschach Sum m ary

Scoring

Response

Inquiry

with one foot on a rock. T h e rest doesn’t look like an ything to me.

2. T he jag g ed edges and solidness o f it. (Solidness?) Aside from jaggedness it looks like a big thing. Craggy. (Craggy') T he indent on the side looks broken off, the way rocks look at times.

DCFN

1. Two d e e r o r antelope

1. T he ro unded ru m p and horns.

DFA

2. with a bush in front o f each one

2. G reen, and relative to the antelope on the g round level. See, it’s undefined, am orphous.

DCFPI

3. Not related, it looks like a nose with two nostrils.

3. Shape

D(S)F-Hd

1. Insects, o r close-up o f insects o r bugs, or m icro­ scopic creatures you m ight see in a sam ple o f pond water.

1. T hese two things and these in here. Microscopic cause don’t look like any insect I’m fam iliar with. I'd say microscopic cause 1 rem em ber biology and looking at creatures you see in pond water.

drFA

2. Maybe a couple o f spiders dow n below.

2. Shape o f body and legs coining out.

DFA

IX .

8"

X. 2"

Personality Disorders / 399

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 T h ere is a boy looking at a violin. He doesn’t w ant to practice b u t his Mom wants him to. He’s looking bum m ed out. (?) He will reluctantly pick up the violin, practice for a little bit, ju s t as long as he can to satisfy his Mom, leave, an d go o ff to d o w hat he wants. CARD 3BM T h e re is a perso n , p erh a p s a fem ale, who seem s quite sad abo ut som ething an d is sitting on the floor holding h er head on h er arm upon a couch and th ere is som ething on the g ro u n d by her. 1 can’t tell w hat it is. It looks sort o f like a gun. T h a t’s it. (?) A fter a while, she gets over h er m isery an d she’ll get u p an d go a ro u n d in h er norm al way. Pain an d sorrow won’t go away immediately, th a t will take a longer time. T h e worst is over an d she will be able to function in h er n orm al way. CARD 4 There’s this guy, a handsom e movie star like Clark Gable, without a moustache, in the 30s. T here’s this lady, an attractive movie-star-type lady, movie stars o f the 50s p erh ap s. A nd he looks like lie’s going to go som ew here— determ in atio n in his eyes, his m ind set. A nd she doesn’t w ant him to go. She is holding o nto him and looking at him . (?) He’s saying he’s going to go and he’ll go. CARD 15 'ITiere is a m an, at least it looks like a m an, I think. T h en again, it could be a fem ale. A n o ld er person, m aybe 40s-50s. Doesn’t look very happy. Standing in a cemetery. Perhaps he is depressed and gets solace from being in a cem etery in the sense th at p e rh a p s he feels a sim ilarity o r a k in­ ship with the people. It’s h a rd to phrase this, because it represents how he is feeling inside. He feels alienated from the world and the people he comes in reg ular contact with and he feels more in contact with the people he lives w ith who don’t u n d e rsta n d him o r her.

4 00 ! Psychological Assessment, Psychiatric Diagnosis, and. Treatment Planning

EXHIBIT

5

S e n t e n c e C o m p l e t io n T e s t

1. 6. 9.

When he was completely on his own, he “enjoyed his freed o m .” I used to feel I was being held back by “my parents’ restrictive influence.” My father always “hassles m e.”

19.

I was most annoyed when “they w ouldn’t let me d o w hat I w anted to

24.

d o .” When I think back, I am ashamed that “I h u rt th a t p erso n .”

29. His greatest wish was “to have m ore freed o m .” 36. Taking orders “is not my cu p o f tea.” 37.

If 1 had my way, I would “do as 1 pleased.”

55. He fell he could murder a man who “could do som ething like th a t.” 59. While he was speaking to me I “wasn’t listening.” 69. I feel guilty about “having done th a t.” 83. More than anything else, he needed “to be free.”

Personality Disorders / 401

DISCUSSION Mr. R was a young, single, black m ale who readily a d m itted to his shyness, an inability to m ake friends, an d a fear o f eye contact. His lack o f a trusting th erap eu tic relationship with an o u tp atien t th erap ist was clim axed by his responding only on inquiry, and in a rath er bland way, th a t he was retu rn in g to his parents’ hom e and saying goodbye to his m o th er before killing him ­ self. T his is precisely the type o f clinical situation where one would be struck by both the g u ard ed n ess an d the u n tru stfu l relationship with the patient and the fear th a t th ere is m uch m ore serious pathology th an m eets the eye. T h e first positive result o f th e testing is the relatively high IQ o f this young m an with a full scale IQ o f 120. Secondly, and quite im portantly, real­ ity testing seem ed ad eq u ate as reflected in accurate an d p o p u la r p ercep ­ tions on the R orschach. His long reaction times are quite consistent with a pervasive sense o f m istrust and screening o f w hat he reveals about himself. T his sam e pervasive need to n ot reveal was m anifested in his TAT stories w here he does little m ore th an simply describe th e details on the cards. It was only in a task th a t d em anded his total creativity, the DAP, th at we obtain some glim pse o f his in tern al perceptions. H e revealed a som ew hat chilling one o f robot-like h u m a n interactions ch aracterized by th o u g h t and little o r no feeling. In com parison to Mr. R, Mr. H , a younger, 23-year-old male, seems more d ep en d en t upon his hom e base, m ore isolated, an d m ore overtly involved in un u su al ideas ap p ro ach in g schizotypal proportions. U pon adm ission to the hospital, he was in m ore overt conflict with o th ers— in this case his paren ts— describing h im self an d his object representational world as akin to that o f an ideological prisoner being forced to subm it to hostile and intol­ eran t others. As w ith Mr. R, the treatm en t team raised questions as to w hether o r not Mr. H ’s presentation hid m ore pathological sym ptom atology, in this case a question o f schizophrenic symptomatology, th an ap p eared at the suspicious surface. Like Mr. R, Mr. H is an extrem ely b rig h t young m an with a full scale IQ o f 134. A gain, like Mr. R, his R orschach protocol, which was m ore extensive th an th at o f Mr. R, showed some idiosyncratic associations, but an absence o f severe th o u g h t d iso rd er an d generally ad eq u ate reality test­ ing. In his TAT stories, he articu lated his sense o f alienation from others. In fact, his TAT productions portrayed a core them e o f m eeting contact with others by setting him self in opposition with passive b u t b e g ru d g in g com ­ pliance. His own verbalizations suggest th a t this way o f relating to others is correlated w ith a p rofound sense o f a n eed to shore u p his own identity and integrity at the expense o f p u sh in g o thers away.

402 / Psychological Assessment, Psychiatric Diagnosis, aiul Treatment Planning

B. BORDERLINE PERSONALITY DISORDERS T h e history o f the b o rd erlin e personality d iso rd er concept is a long an d torturous one. However, with the introduction o f D SM -III, explicit an d rel­ atively behavioral criteria were consensually chosen, thus enabling clinicians to com m unicate reliably about patients who m eet these criteria. T h e b o r­ derline patient as described in D SM -III-R is characterized by the relatively e n d u rin g traits o f identity distu rb an ce, labile m oods, unstable a n d intense interpersonal relationships involving idealization and devaluation, impulsive an d self-destructive acting o ut in the areas o f sexuality, d ru g abuse, shop­ lifting, in ap p ro p ria te an d intense a n g e r o r lack o f control o f anger, an d intolerance o f being alone. These patients generally do not get hospitalized for stable and en d u rin g “borderline” traits, b ut rath er for acute events, such as suicide attem p ts an d /o r severe depressive episodes.

BORDERLINE PERSONALITY DISORDER For the last two years, Ms. J, a serious stu d en t o f music, has been u nable to p u rsu e h er career plans because o f several psychiatric hospitalizations. H er difficulties began almost three years ago, when she was 17, d u rin g h er senior year in high school. She was intensively p re p arin g for a series o f o rchestral auditions. She lost weight, in p a rt intentionally, an d sp en t all h er spare tim e at a local recital hall w here she h ad worked since she was 13. H er academ ic p erform an ce declined, she w ithdrew from h er friends an d family, a n d she began to cu t h er classes to have m ore tim e to practice. She began to abuse am phetam ines in o rd e r to give h er the energy she n eed ed to practice several ho u rs each day. H er auditions went well, b u t h e r family an d h er music teacher becam e concerned about her weight and encouraged h e r to seek psychiatric help. She d id consult a psychiatrist an d h er w eight stabilized. She was able to spend the sum m er after graduation from high school to u ring with a cham ­ b er music group, b u t she could not eat regularly. W hen she was able to eat, she experienced frig h ten in g feelings o f som eone dying. She continued to lose w eight an d by the late w inter h e r weight h ad d ro p p e d 23 p o u n d s to 77 pounds. She was severely em aciated. She was hospitalized for th ree m onths and regained 18 pounds. O ne m onth later, she had lost nine pounds an d , discouraged with h er progress, she m ade a serious suicide attem p t, resulting in com a and a second hospitalization. A fter being disch arg ed , she rep o rted th a t she was very depressed an d constantly preoccupied w ith thou g h ts a b o u t food an d h e r weight. She also

Personality Disorders / 403 ex p erienced several intense an d protracted episodes o f depersonalization an d again attem p ted to take h er life. She was found com atose the next m orning by her room m ate and rehospitalized. Despite a course o f ECT and treatm ent with several anudepressants, she continued to feel depressed and began to cu t herself. She was now plagued with obsessions abou t food and developed several compulsive rituals to w ard o ff her feelings o f depres­ sion and depersonalization. W hile in the hospital, she m ade a serious suicide attem pt by severing the arteries in both arm s. A fter this attem pt, her family d em an d e d a tran sfer to a n o th e r hospital. T hey were thoroughly discour­ aged with h er lack o f progress an d an g ry at h er hospital psychotherapist whom Ms. J claim ed h a d taken to refe rrin g to h e r as “Miss F rankenstein” because o f the prom in en t su tu res on b oth h e r forearm s req u ired to close the d eep w ounds left from h e r suicide attem p t. A t the tim e o f h er adm ission, she was d escribed as an attractive, petite young w om an with partially healed, b ut nevertheless noticeable, scars on both forearm s. A lthough she was cooperative with the interview, she was d isd ain fu l in h er attitu d e, especially on learn in g th at she would not be treated by the hospital’s senior psychiatrists. She spoke in a d ro n in g m on­ otone an d claim ed to have no active suicide plans at present although she expressed a strong wish to die. She d escribed her m ood as “okay” now. T h e exam in in g psychiatrist noted no disturbances in attention, concentration, memory, o r o th e r intellectual functions. She could give no reason for requesting adm ission o th e r th a n to state th a t because o f h er failure to im prove at the previous hospital, she was requesting adm ission “because I have to .” She was accom panied on adm ission by h er m other, who co rro b ­ orated h er history.

DSM -III-R D iagnosis Axis I: Axis II: Axis 111: Axis IV: Axis V:

M ajor depression, re c u rre n t, with psychosis Obsessive com pulsive diso rd er B orderline personality d iso rd er (P rim ary diagnosis) None Severe— g rad u atio n from high school; rep eated psychiatric hospitalizations Very p o o r— m arked im p airm en t in both social relations an d occupational fu nctioning

404 I Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

Treatment and H ospital Course A lthough Ms. J ’s obvious d isturbances in a p p etite, weight, a n d m ood regulation h ad resulted in previous diagnoses o f anorexia an d m ajor depres­ sive disorder, the progression o f h e r illness an d h e r failure to respond to previous treatm en ts h a d led to the im pression o f severe ch aracter d iso rd er as the p rim ary psychiatric difficulty. She was adm itted to the hospital and im mediately gave notice o f w anting to leave. She was info rm ed th a t the hospital sta ff felt very strongly th a t she was a d a n g e r to h erself an d , if necessary, would take h er to c o u rt an d request that she be retained in the hospital against her wishes. She retracted h er notice, b u t rem ain ed sullen an d unw illing to engage actively in her treatm en t. T h u s, the first weeks were taken u p with g a th e rin g a history from h er and h er family and o b tain in g the records from h e r previous hos­ pitalizations and o u tp atien t therapists. Ms. J an d h er family, in cluding h er two o lder sisters, h ad little to co n trib ­ ute to helping the hospital staff to un d erstan d her difficulties. For her fam ­ ily, the onset o f h er difficulties was a g reat surprise. She was described by them as a happy child who m ade friends easily, was active socially, did re a ­ sonably well academically, and excelled at music, which she loved. She h ad taken u p music at age four an d h er m o th er h ad been a constant source o f encouragem ent and su p p o rt since then. As her interest in music had grown, h er attach m en t to h er teacher h ad grow n as well; in betw een hospitaliza­ tions, she h ad been living alternately with h e r teacher an d h e r family. A lthough the family could find no reasons for Ms. J ’s difficulties, her fam ­ ily history was interesting on two accounts. First, there was a g re a t deal o f psychiatric illness on b oth the p atern a l an d m atern al sides o f the fam ily A paternal cousin and a m aternal great-uncle had both com m itted suicide; a p a tern al a u n t an d the p a tie n t’s m o th er had m ad e suicide attem p ts, with h er m o th er’s a tte m p t o ccu rrin g when Ms. J was 8 years old an d after h e r fath er h ad learn ed o f Mrs. J ’s ex tram arital affair from Mrs. J ’s “close frien d .” A m atern al g reat-au n t an d a m aternal great-uncle were psychiatrically hospitalized for bip o lar d iso rd er an d “hom icidal tendencies,” respectively. Secondly, Ms. J an d h e r m o th er bore a close physical resem blance to one a n o th e r and it becam e quite clear th a t Ms. J ’s success in music was o f im m ense gratification to Mrs. J, who had w anted to become a musician h er­ self b u t instead m arrie d Mr. J when she found h erself p reg n an t. At th at tim e they h ad moved in with h e r h u sb a n d ’s p aren ts where they rem ained until their d au g h ter’s graduation from high school. Mrs. J found this living a rra n g e m e n t convenient as Mr. J ’s m o th er was “sickly” an d she devoted a

Personality Disorders / 405 great deal o f tim e to carin g for her. She found taking care o f h er m otherin-law d ra in in g b u t g ratifying as she an d h e r h u sb an d fought a good deal an d d id not seem to have a p articularly close o r g ratifying m arital relationship. Ms. J provided little inform ation about herself except to make it clear that she felt no one “really care d ” about h er an d she was convinced th a t she would be b e tte r o ff d ead . T h e records o f her previous treatm en t m ade it clear th at it would be difficult to engage her in psychotherapy. She previ­ ously h ad stated quite clearly th a t h er illness g a \e h er a special status that m obilized the concern o f o th ers an d she was ad am a n t in h er wish to retain h e r special status at w hatever risk to herself.

Psychological A ssessm ent Ms. J had been extensively assessed by the psychology sta ff d u rin g her previous psychiatric hospitalizations. Overall, she was found to be o f average intelligence, b ut with cognitive inefficiencies evident in her inability to exe­ cu te plan fu l activity an d a dim inished ability to benefit from task-derived feedback. T h e possibility o f frontal lobe dysfunction was raised b u t finally ruled out because o f the absence o f confirm atory neurological findings and the presence o f p rofound depression. T h e presence o f psychom otor re ta r­ dation, a listless, apathetic and indifferent attitude towards the exam ination, difficulties in concentration, an d profound hopelessness about the fu tu re were felt to be the prim ary factors com prom ising her perform ance and best u n d ersto o d in the context o f h er depressive disorder. T h e final sum m ary suggested a diagnosis o f m ajor depression in the context o f a b o rderline personality disorder. H er present psychological exam ination was carried out three weeks after h er adm ission an d two m onths after h er previous exam ination. She was given the WAIS-R, M M PI, SCT, an d B enton Visual R etention tests to help in establishing her diagnosis and in determ ining her capacity to profit from an intensive exploratory psychotherapy. T h e ex am in er also adm in istered the R orschach, which Ms. J initially refu sed to take, b u t subsequently com pleted. H er present intellectual functioning was in the average ran g e, with fullscale, verbal and perform ance IQs o f 90, 85 and 100, respectively. H er sub­ scale scores indicated a significant am ount o f intertest scatter, ran g in g from borderline to high average levels o f intelligence. H er relative strengths were on those subtests w here h e r p erfo rm an ce could be en h an ced by careful attention to details o f th e test m aterials. H er relative weaknesses were on those subtests which req u ired h er to m ake use o f previously learn ed infor­

406 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning mation, particularly as it applied to conducting conventional social relation­ ships. H er perfo rm an ce on the WAIS-R was m a rre d by h e r inability to ex p en d any effort in those instances w here she could n o t im m ediately find the correct answer. As a consequence, th ere was a significant am o u n t o f intratest scatter in the m ajority o f h er subtests. H er WAIS-R perform ance was consistent with a profound depressive dis­ turbance and h er sym ptom atic presentation on the MMPI also revealed sig­ nificant affective distu rb an ce. Two o f the clinical scales were extrem ely elevated (scales 2 and 8 > 90) an d th re e add itio n al clinical scales were su f­ ficiently elevated to w arran t clinical atten tio n (scales 3, 4 an d 1 > 70). H er m ain sym ptom atic difficulties included depression, alterations in her sense o f reality, em otional disorganization and lability, and difficulties in im pulse control. T h e severity o f h e r d istu rb an ce is clearly evident on exam ination o f h er SCT. Ms. J rep o rts th a t most of all 1 want “to be d e a d ,” th a t / felt most dissatisfied when “I didn’t die,” and that I feel happiest when “I think I’m going to d ie.” T h a t h er en tren ch ed desire to be d ead is related to h e r affective state is clearly attested to w hen she notes th at I was most depressed when “I tried to kill m y self’ an d / am afraid o/ “feeling.” W hile h e r self-directed aggression seem s clearly related to h e r affective state, it seem s rooted in h e r relationship w ith h er m other. In h e r previous psychological exam ination, she was given the TAT and told a story o f a des­ perate young wom an who com m its suicide. Yet from the organization o f the story it was clear th a t th e focus o f th e story was n ot on the suicide itself, b u t ra th e r on the im pact o f th e young woman’s d e a th on th e m other. T h e SCT from the cu rren t exam ination included her observation th at when with her mother, shefelt “as if she h ad to p u t on a n act a b o u t how she was feeling.” H er m o th er is described as som eone who always “tries to m ake everyone happy,” b u t she does n ot see h er m o th er as a happy p erson (e.g. / wish that my mother “was happy.”). It would a p p e a r th a t Ms. J feels h e rse lf cau g h t betw een living h er life in a way th at would satisfy and please h er m other or, instead, leading a more independent and perh ap s less gratifying life. H er wish to please her m other shows up in h er acknow ledgm ent th a t as a child h er greatest fear was “not being able to play as well as my cousin” an d expresses h e r p rid e th a t “she could play well,” although not as well as h e r cousin (i.e. she felt inferior when “she accom panied h er cousin”). H er am bivalence a b o u t h er music is m ade evident w hen she asserts th a t she often wished she could “be a dancer.” C hoosing an alternative c areer is one avenue o f independence from her m o th er an d h er family. A second avenue th a t m ight help to shore u p h er identity would be a m an. Ms. J feels th a t most women “behave according to w hat th eir m an says” an d she feels th a t she couldn’t succeed unless “she had him stan d in g by h er side.” W hat sort o f m an to choose, however, seem s to

Personality Disorders / 407 be a problem . Som eone like h er fath er would a p p e a r to be a p o o r choice since she feels “uncom fortable” around him an d “disappointed” in him gen­ erally. A dditional difficulties seem likely to crop u p as well. A lthough more than anything else, she needed “to know she was loved,” she feels th a t most mar­ riages “end in divorce” and th a t most people are “very self-centered.” Perhaps this explains why she finds it very difficult to actually carry th ro u g h with the com pliant and obedient posture th at would earn her the love she so des­ perately seeks (e.g. taking orders “makes m e a n g ry ” an d I dislike to “be told w hat to d o ”). Based on the exam ination o f these results, the diagnostic pictu re which em erged seem ed most consistent with a m ajor affective disorder in the con­ text o f severe bo rd erlin e personality disorder. Additionally, th ere were strong narcissistic an d antisocial elem ents present in the test findings.

Treatment Plan and Outcom e Ms. J ’s treatm ent plan was developed with three treatm ent goals in mind. First, given h er initial level o f cognitive disorganization and lack o f e n th u ­ siasm for the hospitalization, her individual psychotherapy an d milieu m an ­ agem ent would focus on establishing a supportive relationship w ithin the context o f appropriate limits on self-destructive behavior. Subsequently, she and h er p arents would be involved in family therapy, with b o th h er indi­ vidual psychotherapist an d a family therapist sharing responsibility for the treatm en t. T his stage o f h e r treatm en t was plan n ed to help h er an d her family to effect a productive separation an d to develop m utually satisfying m eans o f su p p o rtin g one an o th e r while w orking tow ards this goal. Finally, Ms. J ’s individual psychotherapy would then be developed along m ore exploratory lines as it becam e evident th a t she was b ette r able to m onitor h e r own affective state an d could tolerate a m ore intensive exam ination o f h er own m otivations an d goals. T h e first stage o f this plan occupied the first five m onths o f Ms. J ’s twoyear hospitalization. D u rin g these months, she continually com plained that the hospital sta ff were unresponsive to h er needs and em otionally unavail­ able to her. She frequently becam e enraged an d attem pted to h arm herself, which req u ired the sta ff to intervene in o rd e r to protect her. She evaded h er sta ff escort while away from the hospital for an o p to m etrist’s a p p o in t­ m ent an d p u rch ased a n u m b e r o f over-the-counter m edications which she used in an attem pt to kill herself. Medical attention was mobilized by a pass­ erby. Following the attem p t, she revealed th a t she had p lanned it weeks in advance and felt no rem orse. She h ad w anted to express how an g ry she felt w ith the hospital sta ff for “b ein g too professional with m e.”

408 / Psychological Assessment, Psychiatric Diagtiosis, and Treatment Planning Following this attem p t, Ms. J rep o rted a m arked reduction in h e r feeling o f anxiety and tension and also dim inished suicidal ideation. H er obsessive rum inations reg ard in g food and eating and their relationships with death, nightm ares with violent them es an d a recu rren ce o f episodes o f d e p e rso n ­ alization all o ffered o p p o rtu n ities for interventions which she experienced as helpful. She was given a re g u lar p ro g ram o f activities o ff the unit an d expressed some feelings o f pleasure in p articip atin g in them . H er family work b egan shortly after this with an initial focus on h er role in the family. It quickly becam e clear th a t Ms. J h ad always been an em o­ tional su p p o rt for her m o th er who tre a te d her m ore as a close friend an d confidant th an as a child. H er m other frequently tu rn e d to her for comfort an d friendship to com pensate for Mr. J ’s perceived unavailability. Mr. J was portrayed by Ms. J an d h e r m o th er as “ty rannical,” b u t on closer exam i­ nation, neither she nor h e r m o th er could provide any convincing exam ples o f his tyranny. T h e m yth o f Mr. J ’s unavailability was a p p aren tly largely p ro p ag ated by the m o th er an d believed by Ms. J ; the two women h a d for years o p erated th e ir own closed em otional system, leaving Mr. J to fend for him self. As this becam e clearer to Ms. J an d h er family, Mr. J began to look for­ w ard to the family sessions as they provided his only avenue for an emotional engagem ent with his wife an d daughter. Mrs. J beg an to develop a closer relationship to h er h u sb an d , b u t was fearfu l o f acknow ledging this to h er d au g h ter for fear that it would “h u rt” her. In a com plem entary fashion, Ms. J cam e to the conclusion, after taking a pass for the weekend to h er parents’ hom e, th a t re tu rn in g to live at hom e would n ot be good for her. A fter in fo rm in g h er p aren ts o f h e r decision, she w orried th a t she h ad “deeply h u r t” h er mother. N either m o th er no r d a u g h te r were able to address in the family sessions their fears o f h u rtin g one another. Instead, they both successfully m anaged to engage the hospital sta ff in ru sh in g a h ead with plans for Ms. J ’s dis­ charge. T h e staff was anxious to capitalize on Ms. J ’s ap p a re n t im provem ent an d to avoid the anticip ated d isru p tio n which would ensue in a few weeks as her individual therapist, to whom she had become quite attached, would be leaving the hospital an d would be u n ab le to continue w orking with her. In this context, two m onths afte r b eg in n in g the family therapy, Ms. J m ade another suicide attem pt. Allowed to attend off-unit activities without a sta ff escort, she h ad signed out to a scheduled activity and gone instead into town, b o ught several cleaning products, an d ingested them . She later rep o rted th a t after ingesting the cleaning products, she realized th a t she h ad n o t w anted to die b u t only to relieve h er anxiety an d dysphoria, an d so h ad called the hospital. D ischarge plans were su sp en d ed . She was tra n s­ ferred to a new th erap ist an d h e r family work continued.

Personality Disorders / 409 For the next year, Ms. J ’s hospital course was characterized by her struggle to achieve an effective separation. A lthough progress was m ade by both her an d h er m o th er in expressing th eir guilt an d anxiety abo u t such a sep ara­ tion, Ms. J did not seem ready to actually proceed with her discharge plans. She was tra n sfe rre d to an o th er in p atien t unit w here she could continue to work with her c u rren t hospital psychotherapist. A lthough initially agreeable to the transfer, she quickly began to idealize the treatm en t sta ff o f her for­ m er u n it despite h er e arlier and continued devaluation o f them p rior to her transfer, and to devalue the treatm en t sta ff o f h er new unit. H er family becam e alarm ed at h e r renew ed a n g e r a n d dysphoria an d en couraged her to leave the hospital ag ainst the advice o f the hospital staff. Ultimately, the family was persuaded o f the need for continued hospitalization but, as they h ad previously done with h e r tran sfer to the present hospital, insisted that her treatm en t be continued at a d ifferen t hospital.

4 1 0 / Psychological Assessment, Psychiatric Diagnosis, atul Treatment P la n n in g

EXHIBIT

I.

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Sym ptom s/D iagnosis Borderline personality disorder Two unpredictable or im pulsive and potentially self­ dam aging behaviors

Prefers action-oriented problem solving; poor im pulse control

— substance use

A m phetam ine abuse

— self-injury

M utilated forearm s

U nstable and intense in te rp e r­ sonal relationships

R apid shifts in relation­ ships with treatm ent providers

Easily feels exploited and used by others

Lack o f control o f anger

Easily angered and then inflicts self-injury

None

Identity disturbance

U ncertain career choice and uncertain family loyalty

Relies on others for selfdefinition and direction

Affective instability

Marked em otional lability

Prone to em otional over-reaction

I ntolerance o f being alone

Feels desperate and em pty when alone

Depends on others' praise for em otional gratification

Self-mutilation and suicide gestures

4 suicide attem p ts— twice by overdose, twice by cutting

None

Able to persevere to achieve long-term goals

None

None

Difficulty integrating feedback and sustain­ ing goal orientation

Symbiotic relationship with mother, with an g er and resentm ent at fulfilling her m oth­ er's narcissistic needs

Ambivalent relationship with m other with death o f self seen as only m eans o f separation and individuation

II. Personality Factors III. Cognitive Abilities

IV. Psychodynamics

Personality Disorders ! 411

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

V. T herapeutic Enabling Factors VI. Environmental D emand and Social Adjustment

None

None

Highly reactive to environment

Relies on external appearances to fit in

Dislikes rules and orders

Rebellious and obstinate

Aware o f secondary gain from her disruptive behavior

Risks her life to get others to care for her

412 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

W A IS -R S u m m a r y

Verbal Subtests Info rm atio n Digit S pan Vocabulary A rithm etic C om prehension Sim ilarities

Scaled Score 6 12 6 7 5 9

Performance Tests Picture C om pletion Picture A rran g em en t Block Design O bject Assem bly Digit Symbol Verbal IQ Performance IQ Full Scale IQ

12 12 10 10 8 85 100 90

MMPI S u m m a r y F 'L K : 28*34" 1'7069-5 R o rsc h a ch Sum m ary

N u m b er o f Responses Rejections Populars O riginals Average R /T C hrom atic Average R /T A chrom atic F% F+ % A% H% W:M M :sum C m :c V III-X %

20 0 9 1 18 21 70 89 55 20 3:1 1:1.5 3:1 30

Personality Disorders / 413

R o rsc h a ch S um mary

FK + F + Fc% (H + A ):(H d + A d ) A ppercep tio n W 15% D 70% d 5% Dd + S 10%

70 12:3

4 1 4 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

3

R o rschach S um m ary

Response

Inquiry

Scoring

I. 7" !. T h e whole thing rem inds me o f a butterfly.

1. T he whole thing. (Butter­ fly?) I don’t know, it ju st d id. Shaped like a b u tte r­ fly, like it h ad wings and a body in the middle.

WFAP

2. I see like a body from the back.

2. Right in the m iddle, with hands and feet. (Body?) I don’t know, it looked like it had feet. Like a body from the back, like looking at it from the back, with like two hands.

D FHP

1. I see an o th er butterfly

1. Right here, the red. (Butter­ fly?) Same th in g as the other, like it h ad wings and like a body in the m iddle. (Anything else?) T h e color.

DFCAP

2. and a spaceship

2. T he white. (Spaceship?) It was ju st sort o f sh ap ed like some sort o f satellite, and like the red on the bottom m ade it look like it was tak­ ing off.

SFmObj

3. with fire com ing out the bottom

3. (Fire?) Just because it is red. (Anything else?) No, th a t’s all. Looks like flames bu rn in g .

DCF.mF Fire

4. and two animals. I don’t know what kind o f anim als, b u t two animals.

4. T his, the red, like an an i­ mal stan d in g up on its back legs. (Look like two animals?) T hey h ad two legs, and stan d in g on its back legs, like when a dog begs. Just rem inds me o f some ani­ mal, b ut I’m not sure w hat one.

DFMA

T h a t’s it. II. 10"

Personality Disorders I 4 1 5

R o rschach S um mary

Response

Inquiry

Scoring

1. I see two people facing each other. They look like they’re alm ost like standing over a fire, like trying to warm their hands.

1. Right here. W hen they make these up, do they make them so you see a cer­ tain th in g o r ju s t p u t ink on the page? (Questions later.) OK. (People}) A head and arm s, and legs, and shoes. (Fire}) Right here. It doesn’t really look like fire. It looks like smoke, b ut it looks like they’re trying to warm th eir hands. (Smoke}) It looked like smoke to me, I don’t know. (Smoke}) I don’t know.

W M .K FH, SmokeP

1. I see two feet, two boots I guess.

1. R ight here. (Boots}) It looked like it had feet and a heel. (Anything else}) No. (Feet and a heel}) Yes, like a foot and a heel, ju s t like a boot.

DFClothP

2. Two ears, like o f an anim al. T h a t’s it.

2. Here. (Ears}) It looked like how anim al ears flop down.

dF-Ad

1. T he whole thing. (Butterfly}) T he same as the others; it looked like it had wings and a body in the m iddle. (Anything else}) U h-uh.

WFAP

III. 18"

T h a t’s all. IV 41"

V 15" 1. Looks like a butterfly.

T h a t’s it.

41 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R o rschach Sum mary

Response

Inquiry

Scoring

1. I see a cross with a body oil it.

1. Right here. T h e body is th at dark p art in the m id­ dle, and it looked like it’s got a cloth like hanging. (Body?) T h e d ark area looked like an abstract body, like a head and a body b ut not, like not o u t­ lined, ju s t an abstract. {Cloth}) Sometimes they h an g a cloth on a cross, like a poncho type. (Cloth}) It was like light, and it was like white.

D FC '.H ,C loth

1. O ne here, one here, one here, and one here. (Four heads}) Each o f them looked like they had a nose and a m outh, and two o f them had eyes. (Only two had eyes}) Yeah, and two to me looked like women

DFHd

2. and two looked like they were pigs to me. (Look like pigs}) H ad a nose like a pig.

DF-Ad

3. Down at the bottom , right here. (Butterfly}) It had a body and wings.

DFA

1. Right here and right there. (Bears}) Just the shape o f the body, like the head looked like the head o f a bear, and it had like four legs.

DFAP

VI. 26"

T h a t’s it. V II. 19" 1. 1 see two heads, no four heads

3.

and a butterfly.

V III. 1.

10"

I see two bears

Personality Disorders / 4 1 7 R o rsch a ch Sum m ary

Response 2. and like a backbone o f a body, an d like ribs

Inquiry

Scoring

2. H ere, and there’s ribs here. Like itju st looked like the inside o f a body to me. (Backbone and ribs}) I don’t know how to explain; itju st looked like a backbone to me. (Blot reminded you}) Just that d ark area looked like a backbone, looked like a backbone, th a t’s all I can say.

di(s)FAt

I . Blue, this whole th in g right here. (Pelvic bone}) To me, like what I rem em ber from books and stuff, like it seem ed like it was sort o f shaped the same way.

DFAt

1. Blue, this looked sort o f like a crab or a lobster. (Crab or lobster}) 11ju st looked like it had a lot o f legs and claws. (Anything else}) U h-uh. 2. T he black hue 3. and the black up here is like some kind o f bug, maybe like a roach or . . . I don't know, b u t they looked like bugs. (Bugs}) They looked like they had legs too, and antennas. (A nything else }) (No.) (I noticed you sort of cringed when you described tilt- crabs a nd bugs, what was you rfeel­ ing}) 1 see so m any cock­ roaches on the unit. They make me c rin g e . . . 1 don't like them .

DFAP

T h a t’s it. IX. 35" 1. T he only thing 1 see is, 1 think they call it your pelvic bone. I’m not sure.

X. 18" 1. 1 see a lot o f bugs, insects.

T h a t’s it.

DFA DFA

418 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

S e n t e n c e C o m p l e t io n T e s t

2.

She often wished she could “be a dancer.”

7.

She felt proud that “she could play well.”

8.

As a child my greatest fear was “n ot being able to play as well as my cousin.”

12.

I was most depressed when “I tried to kill myself.”

36.

Taking orders “m akes m e angry.”

37.

I dislike to “be told w hat to d o .”

39.

Most women “behave according to w hat th e ir m an says.”

44.

She felt she couldn't succeed unless “she h ad him stan d in g by h er side.”

52.

Most of all I want “to be d e a d .”

58.

Most marriages “end in divorce.”

60.

M y mother always “tries to m ake everyone happy.”

70.

When my father came home, I “was d isa p p o in ted .”

74. 83.

/ felt happiest when “1 th in k I ’m going to d ie.” More than anything else, she needed “to know she was loved.”

84. 87. 88.

Most people are “very self-centered.” I am afraid of “feeling.” When with her father she felt “u ncom fortable.”

94.

When with her mother, shefelt “as if she h ad to p u t on an act abo u t how she was feeling.” I wish that my mother was happy.”

99.

Personality Disorders / 419

BORDERLINE PERSONALITY DISORDER In the six m onths prio r to h er adm ission, Ms. W h ad been seen in psychi­ atric consultation on th re e previous occasions. Each o f these consultations followed h er rep o rt th a t she h ad been attacked by a black m an. O n the first occasion, she reported an atte m p te d rap e which she was able to thw art by assaulting her attacker. T he second occasion involved her being held at g u n ­ point by h er original attacker, who b u rn ed her with cigarettes and punched h er after fin d in g h e r alone at hom e. Finally, she subsequently rep o rted a b rie f abduction by this sam e m an, who proceeded to set fire to several o f her stuffed anim als an d who th reaten ed to do the sam e to h e r if she revealed the incident. At each consultation she acknow ledged being em o­ tionally upset by the incident, b u t h e r parents, strangely, found her u n u su ­ ally calm otherw ise. A fter th e first two incidents, she refu sed the psychiatrist’s recom m endation o f additional consultations, statin g th at she was fine an d could m an ag e on her own. Following th e th ird incident, the psychiatrist and h er family convinced h er to e n te r a local hospital to u n d e rg o fu r th e r evaluation. T hese events unfolded against a background o f a seem ingly welladjusted, well-liked, an d physically gifted 17-year-old girl who, prio r to these events, h ad given no evidence o f psychological difficulty. A lthough she was an indifferen t stu d en t with average grades, she was active in school athletics an d would have been elected captain o f h er high school district’s women’s athletic league had not hospitalization prevented h er from re tu rn ­ ing to h er senior year. She belonged to m any d ifferen t social groups and always h ad friends, although she a d m itted feeling close to no one. Two fea­ tures o f interest were noted in h er personal and family history. O ne involved a suicide a tte m p t by one o f h e r o ld er b ro th ers two years p rio r to the onset o f h er difficulties an d the o th e r was a history o f d ru g abuse in a younger sister. In h er personal history, b o th sleepw alking and sleeptalking, which d u rin g ch ild ho od had been associated with “bad d re am s,” h a d persisted well into adolescence. Ms. W cam e from an u p p er m iddle class background and had developed a p a tte rn o f d ru g abuse typical for her p e e r group. She used d ru g s occa­ sionally, p referrin g stim ulants such as cocaine an d am p h etam in e to hallu ­ cinogens, and periodically used m arijuana. Although she denied any history o f d ru g use at the tim e o f adm ission, routine urinalysis for d ru g s was car­ ried o u t because o f su d d en behavior changes in the week p rio r to her adm ission. D u rin g th e week, she had becom e increasingly hyperactive and irritable, w ith p eriod s o f restlessness a n d distraction altern atin g w ith p e ri­ ods o f social withdrawal and despondency. She had b egun to talk about tak­

420 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning ing h er own life. No d etectable level o f d ru g s was found in h er urine. D u rin g h e r hospitalization, h e r p aren ts pressed for a clear diagnosis an d rap id recovery. B ecom ing dissatisfied with th e ir d a u g h te r’s progress an d unable to tolerate the am biguity reflected in the hospital staffs form ulation o f th eir d au g h ter’s difficulties, they had her transferred to a large teaching hospital w here they h oped she would receive a m ore th o ro u g h evaluation.

D SM -III-R D iagnosis Axis I: Axis Axis Axis Axis

II: III: IV : V:

Rule out A m p h etam in e delusional d iso rd er R ule out B ipolar disorder, m anic B orderline personality d iso rd er None E xtrem e— rep eated physical an d sexual abuse G ood— slight im p airm en t in social functioning, i.e. no close friends

Treatment and H ospital Course At the tim e o f h e r tra n sfe r to th e teaching hospital, Ms. W p resented as a th in , very well groom ed girl who a p p e a re d to be th e epitom e o f good health an d clean-cut good looks. H er m a n n e r was som ew hat cool an d dis­ d ain fu l, leaving the interview er w ith th e im pression o f a m atu rity beyond h er years. She stated th a t she h a d ag ree d to come to the hospital because “m y d o cto r recom m ended it,” b u t she h ad no com plaint herself. She ex p ected to be released afte r a b rie f p erio d o f evaluation since she d id not see herself as being in need o f any fu rth e r treatm ent. Most rem arkable was the bland m an n er in which she carefully recounted the details o f her sexual a n d physical abuse. As p a rt o f h er evaluation, she was given a battery o f psychological tests d u rin g the th ird week o f h er hospitalization. The results o f h e r psycholog­ ical exam ination were felt to su pport the treatm ent staffs clinical impression o f Ms. W as a ttem p tin g to presen t a tightly knit facade o f m a tu re fu n ctio n ­ ing which masked significant emotional turm oil. L ong-term inpatient tre at­ m ent was recom m en d ed in o rd e r to confront h er p o stu re o f denial and establish a treatm en t situation in which she could begin to address h er underlying emotional distress. U pon being presented with this recom m en­ dation, Ms. W ra th e r blandly accepted the o ffer o f long-term hospitaliza­ tion. In the m onths following, h er facade began to crum ble. As she revealed m ore o f herself, she began to speak o f a “d ark side” to h er personality which

Personality Disorders I 421 she h ad always kept concealed from others. Significant difficulties in m a n ­ aging sexual, aggressive, and depressive experiences becam e ap p aren t and often led to p eriods o f depersonalization an d derealization d u rin g which she m ad e frantic attem p ts to inflict in ju ry on herself.

P sychological A ssessm ent Ms. W was given the WRAT, B ender Gestalt, Rorschach, TAT, an d Object Sort Test shortly after admission. Because she had been given the WAIS only two m onths previously, this procedure was not repeated. However, the results were available and were incorporated into her evaluation. T he exam iner was asked to provide a diagnostic assessment, including an evaluation o f possible residual effects o f am p h etam in e abuse, an d treatm en t recom m endations. A lthough Ms. W was generally cooperative with the exam ination, she expressed the fear th a t “testing will be used ag ainst m e this tim e as well because if the tests don’t come o ut good an d the evaluation doesn’t come o u t good, th en I ’m stuck h e re .” H er efforts to control h e r anxiety over the outcom e o f the evaluation were expressed in an aloof, b u t superficially ch a rm in g an d flip p a n t attitu d e tow ards the exam ination. H er previous exam ination with the WAIS revealed a full-scale IQ o f 116 with verbal a n d perfo rm an ce IQs o f 114 an d 116, respectively. H er scaled subtest scores ranged from average to very superior levels, indicating a m od­ erate degree o f intertest scatter and reflecting some intellectual inefficiency. H er perform ance on the WAIS was consistent with her lackadaisical attitude tow ards school, with h er Vocabulary an d Information subscale scores am ong the lowest. T he results o f the WRAT provided fu rth er support lor this view as h e r achievem ent scores in read in g , spelling, an d arithm etic were all noticeably below the 12th g ra d e level. H er know ledge o f social conventions (WAIS Comprehension subscale) represented a relative stren g th consistent w ith h er ability to m ake a good im pression. H er approach to the u n stru ctu red tests in the battery, the Rorschach and TAT, was characterized by rigid and virtually unrelieved attem pts at avoid­ ance, em otional w ithdraw al, an d blatant denial. For exam ple, seven o f the 16 TAT' card s adm inistered resulted in stories in which the m ain ch aracter is tired , asleep or unaw are. H er R orschach protocol, consisting o f only 14 percepts, is replete with efforts to avoid having to give any response, reflect­ in g h er fear th a t it will again be “used ag ain st” h er to keep h er in the hos­ pital. W hen confronted about her attitude, she continued to avoid engaging with the test by rep o rtin g w hat she saw d u rin g h er previous testing and rem ark in g th a t “it doesn’t look like th a t now.” H er ra th e r tra n sp a re n t attem p ts to m ain tain an im age o f h erself as a

422 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning “nice g irl” by denyin g th e possibility o f any negative feelings a b o u t herself or others raised questions about her potential for transient psychotic regres­ sions u n d e r em otional stress. H er compulsive efforts to b ring o rd e r an d con­ trol to h e r experience were evident in such an em otionally u n d em a n d in g task as the Bender. In copying th e nine designs, she n u m b ered each and drew a line dow n the lower m iddle o f the page to separate the last two designs from the rem ainder. In the m ore em otionally d e m a n d in g an d less stru c tu re d testing situation o f the R orschach, she attem p ts to control the experience an d m inim ize its im pact on h erself by lim iting th e n u m b e r o f her percepts. However, despite her inhibiting efforts, she is unable to make a convincing presentation. H er percepts are o ften som ew hat at o d d s with the consensual reality appraisal m ad e by healthier individuals a n d suggest a ra th e r fragile hold on reality. T h e energy involved in w ard in g o ff negative aspects o f h erse lf an d o f h er experience served as a source o f interference in h e r intellectual p e r­ form ance. She was at h er best w hen she was able to keep an em otional dis­ tance from the test stim uli a n d from th e exam iner, especially w hen she felt she h ad en g ag ed the ex am in er in viewing h e r as she would like to be seen. T h u s, concern over h er ability to tolerate a closer look at h erself form ed the basis for the recom m endation for co n tin u in g h e r tre a tm e n t in a stru c­ tu re d in p atien t setting. H er test results were seen as m ost consistent with a diagnosis o f borderline personality d isorder with narcissistic and paranoid features. Ms. W was tested a second tim e, th re e years afte r the testing rep o rted above. She was preparin g for discharge an d the exam ination was requested to assess the degree o f change in her psychological functioning and to com ­ m ent on those issues which rem ained to be ad d ressed in h e r o u tp atien t treatm en t. T h e exam ination consisted o f a WAIS-R, R orschach, TAT, and M M PI. At the tim e o f the second testing, she was fu nctioning in th e average ran g e o f intellectual ability w ith a full scale IQ o f 109 an d verbal an d p e r­ form ance IQs o f 96 and 127, respectively. C om pared to h er previous results, h er full-scale IQ was five points lower, h er verbal IQ 10 points lower and h e r perfo rm an ce IQ 11 points higher. T hese disparities rep resen t sizable, b u t not uncom m on, shifts in intellectual p erfo rm an ce u n d e r the im pact o f an extended treatm ent intervention aim ed at a m ajor reorganization o f p er­ sonality dynam ics. As before, the subscale scores ran g ed from Average to Very Superior. A m ong th e verbal subtests, the m ost noticeable shifts (lower on second testing) are on the Arithmetic an d Comprehension subtests. T hese shifts were interpreted as indicating th at at th at time emotional factors were having an im pact on h er ability to concentrate an d , in o th e r respects, problem-solve. Previously, h er ability to ward o ff emotional factors had con­

Personality Disorders I 423 trib u te d to h er h ig h er scores. D u rin g the second testing, once she began m aking errors, she becam e d istracted and preoccupied an d h ad difficulty shifting h er attention to new items. Additionally, she indicated th at she had been considering correct responses b u t had w ithheld them because o f h er uncertainty. O n the projective tests, the weakening o f h er formerly rigid and com pul­ sive defenses allowed th e occasional eru p tio n o f fantasy m aterial which she was stru g g lin g to master. T h e potential for depersonalization and d ereal­ ization experiences w hen confronted with h e r own aggressive wishes was also m irro red in her p erform ance. Such experiences w ould m ost likely occur in the context o f loss w here her guilt over such wishes was easily mobi­ lized. H er efforts to m aster these feelings and incorporate them into a view o f h erself which she could accept rem ain ed tentative. She d em o n strated a b ru p t shifts in affect, relied on disavowal an d rep u d iatio n o f such wishes w hen consciously recognized, an d otherw ise re tre a te d into h er form er dis­ d ain fu l an d devaluing stance. T h e latter p o stu re, however, was less in evi­ dence th an formerly. T h e overall im pression o f this exam ination, w hen contrasted with h er previous exam ination, was o f a young woman still having significant d if­ ficulty in establishing a well articu lated self-definition. T h e availability o f previously denied aspects o f herself and the sporadic direction o f her efforts to incorporate these aspects were seen as positive trends. T hese tren d s can be noted in two exam ples. In the first test protocol, h er response to card II o f the Rorschach featured a response o f “some kind o f b ottle” (central w hite space) from which some liquid (the u p p er and lower red areas) was seen as squirting o r spilling. H er second testing produced a response to the sam e area, b u t was now reported as “a scary h o rro r movie m ask” with bloody eyes an d a hole for the actor w earing the m ask to b reath th ro u g h . H er form er em phasis on em ptiness and depletion has been replaced with a recognition o f an in n e r life which is as yet poorly integ rated , b ut nevertheless able to m ake contact with the su rro u n d in g world. T h e second exam ple is taken from the TAT, card3GF. W hen first tested, she saw the young wom an in the picture as having been in ju red w hen the w ind blew a d o o r against h er face. H er second testing p ro d u ced a story in which the young woman was seen as holding h er head after awakening with a hangover. T his shift from a disclaim ed in ju ry arising from adventitious circum stances to one which conveys a greater sense o f personal involvement in the face o f p o o r im pulse control indicated the general tren d tow ards acknow ledgm ent o f responsibility for h e r own behavior.

424 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

Treatment P lanning and Outcome T h e results o f Ms. W ’s first exam ination focused the tre a tm e n t sta ffs attention on h er concealm ent o f significant em otional tu rm o il and led to the recom m endations o f long-term hospitalization and intensive individual psychotherapy. As she was repeatedly co nfronted with th e discrepancies betw een h er self-reports an d h er behavior, she was forced to acknow ledge aspects o f h erself which she h ad previously concealed from h erself an d others. T his eventually provoked a severe behavioral regression associated w ith m ultiple episodes o f attem p ted self-injury. W hen necessary, the hos­ pital sta ff intervened to in su re h e r physical safety b u t continued to insist th a t she explore the im pact o f h e r behavior on h erself an d o th ers an d assum e responsibility for it. Ms. W rem ained in the hospital for 3'/2 years, d u rin g which she rep e at­ edly altern ated betw een periods w hen she was able to assum e h e r form er p o stu re o f aloof m atu rity and o th e r periods w hen she was eng u lfed by the “dark side” o f her personality. H er efforts to reconcile these various aspects o f h erself were at the cen ter o f h e r psychotherapy and progress h ad been m ad e at the tim e o f discharge. She was b etter able to m anage h er d estru c ­ tive im pulses an d h ad given u p h er form er d ru g abuse an d self-m utilation. H er tru st in others gradually increased and she finally ad m itte d she had m ade u p the attacks which h ad first b ro u g h t h er to psychiatric attention. She was able to com plete high school and accum ulated some college credit d u rin g h er hospitalization. T h e determ in atio n o f the hospital sta ff to deal directly with h er “d a rk side” w ithout collaborating with her in its suppression and denial was in stru ­ m ental in h elping h er learn to increase h er tru st in o th ers an d , ultimately, in herself. As a consequence, she m ade progress in being able to acknowl­ ed g e an d accom m odate aspects o f h erself th a t h ad been disavowed com ­ pletely. At the tim e o f h er discharge, significant difficulties in adaptively in teg ratin g these aspects rem ained, b u t the balance o f forces had indeed shifted in favor o f realistic efforts to address these difficulties in the context o f a relationship on which she had come to rely and in which she had placed a g reat deal o f tru st. She was d ischarged to a stru c tu re d living situation an d continued o u tp atien t treatm en t with h e r hospital psychotherapist.

Personality Disorders / 4 2 5

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

I. Sym ptom s/D iagnosis Borderline personality disorder Two unpredictable or im pulsive and potentially selfdam aging behaviors — substance use

Stim ulant and m arijuana use

None

— self-injury

M ultiple contusions

None

Identity disturbance

Struggles with values, loy­ alties and self-image

A ttem pts to ward off, repudiate, and deny unw anted thoughts and feelings

Affective instability

Marked mood shifts

Integrative efforts dis­ ru p te d when em otion­ ally stim ulated

Self-dam aging acts

(a its on neck, torso, arm s and legs

None

II. Personality Factors

No intim ate relationships

Avoids emotional involvement

Average intelligence

Average intelligence

Difficulty integrating positive and negative aspects o f self-image

Struggles with in tegra­ tion and m anagem ent o f aspects o f self

Difficulty tru stin g others

Difficulty tru stin g others but has some insight into h er difficulty

Academic work below ability

Academic work below g rad e level and ability

Family prizes em otional restraint

Prefers to rem ain u n in ­ volved and detached

Active participation in athletics

None

III. Cognitive Abilities IV. Psychodynam ics

V.

T herapeutic E nabling Factors

VI. Environm ental D em and and Social A djustm ent

426 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

2

WAIS-R S u m m a r y Verbal Subtests

Scaled Score

Inform ation Digit Span Vocabulary A rithm etic C om prehension Similarities

10 10 8 7 11 10

Performance Subtests Picture Completion Picture A rrangem ent Block Design Object Assembly Digit Symbol

11 11 15 18 13

Verbal IQ P erform ance IQ Full Scale IQ

96 127 109

Rorscha ch Summary

N um ber o f Responses Rejections Populars O riginals Average R/T Chromatic Average R/T' Achromatic F% F+ % A% H% W:M M: sum C m:c V III-X % FK + F = Fc% (H + A ):(H d +A d)

14 0 3 0 39" 1'47" 43 90 29 21 6:1 1:4.5 4:2 36 43 5:2

Personality Disorders I 427

R o rsc h a ch S um mary

A ppercep tio n

W 43% D 43% d 0% Dd + S 14%

4 2 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

EXHIBIT

3

R o rschach Sum m ary

Response

Inquiry

Scoring

(Patient recognizes Rorschach. E. tells her instructions and adds that it doesn’t matter whether she sees now the same thing as before, but to tell everything that it looks like to her now.) I. 38" 1. I guess it looks like a bat or a butterfly. More like a bat.

I. Doesn’t include these. (A bat?) T h e way the wings or w hatever are out. A nd it was black.

W FC 'A P

(Silkscreened}) Because it was not a d a rk picture on a white background b ut a white picture with a d ark outline.

SFC 'O bj

I ’m done. I don’t see any­ th in g else in it. (If you lake your time, there may be other things that it might look like.) It looks like an inkblot to me. 1 really don’t see any­ th in g on that one. II. 1 ’5" (Smiling slightly) Now th a t’s the one I saw th a t was a seal before (tu rn in g rin g on hand). I. All right. Here’s a new one for you. T his one here, the w hite space looks like some kind o f bottle an d it looks like it was silkscreened so th at the white is the shape. T h e color isn’t the shape but the white part.

Personality Disorders / 429 R o rschach Sum mary

Response

Inquiry

2. All right. Here’s a good one. And it’s squirting stuff up here (pointing to upper red) and some o f it has spilled underneath it.

2. (Squirting?) The different color, I guess . . . (Anything else}) No. Just that It was a different color.

3. T he seals. (What about the seals'?) Oh, 1 don’t know

3. Here’s the head, the neck, the flippers. (Seals}) The shape. (Anything else}) No.

(rubbing eyes).

Scoring DCF.mFObj.

Fluid

DFA

(Patient sits back in chair, rolls eyes back, and looks disgusted.) I don’t see anything else. III. 59" I . I guess that looks like two people on either side o f a washing basin throwing up clothes, the red thing right there (pointing), and work­ ing or preparing food or something. T h a t’s it. IV. 2'10"

(Patient sitting still and star­ ing at card with chin resting in hand.) I don’t see anything (pushes card away). (Are you afraid to say what you see or are you afraid to see anything})

1. Two people here— head, body, legs. It looks like they are doing som ething like washing clothes, m aking food or som ething like that.

VVMHP

4 3 0 I Psychological Assessment, Psychiatric Diagnosis, an d Treatment P la n n in g

R o rsch a ch Sum m ary

Response

Inquiry

Scoring

I rem em ber w hat I saw the last tim e and I don’t know why I saw it. I really don’t see m uch o f anything. T here’s no good shape. I don’t know. I rem em ber w hat 1 saw last tim e on this one but it doesn’t look like it. (And you don’t see anything else now}) No. (What did you see the last time}) It looked like som ething from a . . . th a t looked like a cartoon character or a m onster o r som ething. I rem em ber seeing one o f them from before that looked like a cartoon c h ar­ acter monster. I don’t even know if it was this one. 1. T his one has th ree legs.

W hat if I tu rn e d it upside down? C an I do that? But it still doesn’t look like anything.

1. Whole thing. T he cartoon m onster character had two legs b ut this one doesn’t even have a head, an d th a t’s an oth er leg. (What would this one be?) I don’t know. It didn’t look like the cartoon Figure. It had th ree legs. I don’t know.

WF(A)

Personality Disorders I 431 R orsch a ch Sum m ary

Response

Inquiry

Scoring

I don’t understan d . Do you have to give a response? Can’t I say nothing? I don’t see an ything on it and I don’t w ant to m ake u p any­ thing if I don’t see anything. (Examiner interrupts testing and asks patient to disctiss her feelings about the test. Patient relates how the test could be counted against her, as it was during her last hospital stay, where “they thought I saw too many things that weren’t what I um supposed to see. ” E. briefly discusses purpose of testing encourages patient to relax.) V 27" I. That one looks alm ost like the first one, like a bat o r a butterfly, except for the two outside things.

1. (Bat or butterfly?) T h e little antennaes on the top and the wings. (The antennaes made it look more like a bat or butterfly?) More like a butterfly.

WFAP

1. T h a t’s the sun cu t in half. I don’t know w hat’s over it (running f inger up and down area covering it) and these are the rays com ing out. (Haifa sun?) Ju st th at it was h a lf a circle. (And the rays?) Ju st because they were com ing o ut o f the h a lf cir­ cle. (Looks very irritated at E.) (Anything else?) No.

DFNat.

I don’t see an yth in g else. VI. 3'46" 1. I don’t see m uch. I ju s t see a little thing b u t it doesn’t look right. (Do you want to tell me what it is?) T h a t looks like h a lf o f the sun and these are the beam s com ­ ing out o f it, but I don’t know w hat’s over it or around it. 1 can’t m ake any­ thing o ut o f it.

4 3 2 I Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g R orschach Sum m ary

Response

Inquiry

Scoring

V II. 1'55" 1. 1 guess ju s t two faces. T his is the nose and the m outh here. O ne face here and one here.

(Runs finger around.) 1 guess this could be a hat, but 1 d id n ’t think o f th at before (smiles). (Are you including it now?) No. Just this here. H ere are the eyes, the nose, the m outh.

DFH

Here’s th e top and here’s the stem. (A tree?) I guess the shape and the color.

DFCP1

(Pushes card away) W hen I see it, I rem em ber w hat the old im ages looked like, and I ju s t don’t see anym ore w'hy I saw them . T h e o th er psychologist ju s t said okay and flipped it over and that was that. V III. 1" 1. T h a t and that and the two greens look like a tree. T h a t’s the to p o f the tree, a C hristm as tree or som ething. 2. A nd that looks like it’s some kind o f rocky m o u n ­ tain, the rocks u n d ern eath it, the yellow and red there.

T h a t’s it. IX. 12" T h a t still looks the same as the last time.

2. Probably ju st the color, the yellow or brownish color. (The color of rocks?) T h e yel­ low was kind o f brownish and th a t rem inded me o f rocks. I don’t know. (Any­ thing else?) (Nods no.)

DCFGeo.

Personality Disorders / 4 3 3 R orsch a ch Sum m ary

Response

Inquiry

1. It’s a UFO o r some kind o f flying saucer. It’s like in “Close Encounters o f the T h ird K ind.” Did you ever see it? It’s a movie. And th a t’s a dom e on top, and it’s like taking off, and all the rest is like the flames, like after a spaceship takes o ff to the m oon, th ere are always big clouds and dust and stuff.

1. (UFO?) Ju st the dom e on the top, and the shape like round. (Show me where dust and flames.) All o f it. All o f it is dust and flames. (Dust and taking ofp) Because o f the line in the m iddle, it looked like it was going off. A nd it was on the top o f the card. (“It’’ is the dome}) Yes, and there are clouds o f dust and flames aro u n d it. (Fingering mouth, yaums.)

W Fm .C EK F Obj, Fire, Cloud

1. T h at looks like a m ous­ tache with two eyes there and there.

1. (Where are the eyes}) Just the orange here. (Moustache}) Just the way it was shaped. (And the eyes}) Cause the moustache and the nose were there, the eyes were there.

d rF-H d

2. A nd the whole th in g looks like fireworks. All different colors.

2. Just because there were so m any differen t colors. (Fireworks}) Because Explo­ sion fireworks are usually splattered like th a t with all sorts o f b right colors and different shapes. (Splat­ tered}) Just because there was space in between all the d ifferent colors.

WCF.mF Explosion

Scoring

T h a t’s it. (Yawns.) X. 59"

434 / Psychological Assessment, Psychiatric. Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t i o n T e s t

C A R D 1 5"A11 right. T h is is a little boy who . . . (Someone enters room). . . is practicing his violin an d he couldn’t seem to get some o f the notes so he p u t it dow n an d rested for a while . . . u h m m m . . . picked it up, got the notes, played his song, and . . . was h appy again. (Thoughts?) Well, he was u p set because he couldn’t get the notes th a t he h ad g otten before so he was ju s t concentrating on g ettin g the notes an d he d id it, so he was happy. C A R D 2 11" All rig h t this is a city girl who cam e to the co u n try for the su m m er to work on h er A unt and Uncle’s farm an d she’s feeling scared because it doesn’t look like m uch fu n an d she doesn’t th in k th a t she can do it. But after a few days o f w orking on the farm she likes it so she stays there all sum m er. (Why does she. decide she likes it?) Because she’s used to th e city and not really working outside and she’s not used to d oing any physical labor so she thinks it’s fun. C A R D 3G F 6" Okay. T his lady . .. ju s t came into a room from a d ark hall­ way an d when she was o p e n in g the d o o r the wind from the windows was blow ing it back. (?) Like the w ind from the windows blew the d o o r back at her. A nd the d o o r hit h er in the side o f h er face a n d she’s holding it because it h u rts so she goes to th e b ath ro o m an d p uts som e ice on it an d (grimaces upturned nose and mouth— like “so that’s all”). All she ends u p with is a little lu m p on h er face. T h a t’s it. (Any particular thoughts?) It h u rts. (What led up to it, her coming into the room?) I guess it was the kitchen an d she was h u n g ry and she w anted to get som ething to eat. (Yaums) C A R D 5 4" All right. T his lady ju s t cam e hom e from work a n d when she o p en ed the d o o r she was su rp rised to see the flowers on the table th a t h er h u sb an d sent her. W hat? Do I need an end? (Pushes blouse sleeve up arm). She p u t the flowers in the vase and went to cook dinner. (Thoughts?) She was su rp rise d an d happy. C A R D 8BM 14" (Holding thumb in hand bent backwards) Okay. T h is little boy ju s t g o t o u t o f the hospital. (Talking in a little girl voice) He had his appen d ix removed. A nd he’s thinking about w hat h ap p en ed in the hospital o r w hat could have h ap p en ed to him in the hospital. He couldn’t rem em ber th e ir cu ttin g him o r an y th in g . He was u n d e r anaesthesia. A nd he feels h ap p y because he’s o ut o f th e hospital an d he’s got his clothes back an d he’s on his way back to school. (He’s happy because he got his clothes back?) Usually

Personality Disorders / 435 T h e m a t ic A p p e r c e p t i o n T e s t

in the hospital you have to w ear pajam as and he’s all dressed u p so he looks like he likes to w ear nice clothes. C A R D 9G F 24" T h is lady is stan d in g on the ledge o f the first floor of a building on the porch looking o ut at the water where someone ju st caught a really big fish an d all the people are ru n n in g to see the fish and she’s excited because she h e ard som ething h a p p e n in g and heard a lot o f people ru n n in g and so she went o u t o f h er room to see w hat was going on. (Any particular outcome}) I guess th e guy on the beach caught a really big fish an d she saw it and all the people w ent back to th eir houses an d hotels, went back to w hat they were doing. (Excited because she heard something?) She heard people ru n n in g an d talking o r whatever. (Why do you think that made her excited?) Because she w anted to see w hat was going on. (Any thoughts}) No, she ju s t w anted to see what was hap p en in g and then she went back to w hat­ ever she was doing. (What was she doing}) She had a book in her hand. Maybe she was read in g or w riting a letter or som ething. C A R D 10 26" (playing with bracelet on left hand) All right. This is a kid who ju s t got back from uh . . . a basketball gam e (said quickly) and is really tired and on his way to bed so he gave his, I guess his father a kiss an d a h u g good n ight and went to bed. A nd he’s feeling tired because he ju s t played basketball an d hencely (unclear) upset because he lost. (Didyou say hencely}) No, ju s t upset. C A R D 12F 10" u h m m m m . . . . T his girl is with h er g ra n d m o th e r and they’re in a store shopping for a w edding dress because she’s going to get m arrie d and the g ran d m o th e r is really happy and so is the girl an d they buy one they b oth really like an d go hom e to try it on. T h a t’s it. C A R D 12M 7" T his guy ju s t got back to his room w here his room m ate is sleeping and he’s asking him if he’s awake and he’s ju s t about to touch him on the shoulder and shake him to wake him up cause he wants him to get u p to help him do his homework. (Playing and mouthing gold chain with cross on i t ) . . . (Shrugs shoulders). . . A nd he’s feeling bad because he has to wake u p his friend who had a h a rd day at school ju s t because he needs him to help him with his homework. (Yawns and is playing with ring). A nd his friend gets up an d helps him with his homework and they both go back to bed and (shrugs and grimaces) th a t’s it. (Laughs, starts playing with hair, yaums.) (Why does he need him to help him with his homework}) I guess because he prom ised him he would help him after he got back . . . It’s like a college dorm or some­ thing. (And what kind of a hard day did the other one have}) H e h ad a lot o f

436 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

classes an d w hen he got back to the d o rm he h a d a lot o f hom ew ork to do so he was tired an d w ent to sleep. (And didn’t do his homework.}) W hich one? (The one who slept) T h e one w ho is sleeping d id his an d the one who isn’t d id n ’t do his an d is asking th e guy who is sleeping to wake up. (Looking at E fixedly) (In what field is the homework in do you think.}) S pelling (laughs, rubs hands over eyes and stretches). (They have to go back to bed}) A fter they finish th a t guy’s homework. C A R D 13MF 5" Okay. T h is is a p ictu re o f a guy who ju s t got up an d got dressed to go to work an d he’s still tired so he’s ru b b in g his eyes an d try in g to be q u iet so his wife can sleep. A nd he’s feeling like he w ants to go back to bed because he’s tired. T h a t’s it. (What’s the story}) (Looks back at examiner hard) (You’ve given more of a description of a scene than a story) He went out to a p arty the night before, got hom e late, an d had to get u p early and go to work; (Shrugs shoulders) and he’s tired. (The outcome}) T h e wife gets to sleep till 10 an d he has to be at work at 9. (And his thoughts}) T h a t he shouldn’t have stayed o u t late because he h ad to get up for work. CA R D 14 15" U hm m . . . This is a guy who’s in a d a rk bedroom an d he woke u p an d went to the window because it was so light outside but when he got to the window it tu rn e d out, it was ju s t a sp o tlig h t. . . th at was tu rn ed on outside o f his window so he felt tired, closed the window an d went back to bed . . . (stops) (Is that it}) (Nods) (Thoughts and feelings}) He wondered w hat the light was and when he found out he ju s t went back to bed. (No particular thoughts}) No. He ju s t found o u t w hat the light was because he was w onder­ ing because he was in a d a rk room . CARD 15 9" U hm m m . All right. ITiis guy is in u h . . . a veteran’s cem etary w here his best friend was shot an d killed in the w ar so he’s praying at his grave. A nd he feels sad . . . th a t’s it. (Outcome}) O h . . . u h . . . he p u t flowers in front o f the grave an d w ent hom e to go to bed. (Any thoughts}) A lready said he was sad. C A R D 16 7" (laughs) U hm m m . (Laughs and stretches back in chair with arms spread out) T his is a story o f one piece o f a cloud. It doesn’t have a silver lining. It’s not a d ark rain cloud. It’s ju s t th e everyday, average w hite cloud w ho blocks the sun so you can’t get a good tan. A nd the cloud doesn’t have any feelings an d . . . ju s t floats on by. Bet you never h eard th at one (smiling at E.). (Picks up card, turns it over and puts it back on the pile herself). (One piece of a cloud}) It doesn’t have the rims. (Motioning with hands) It’s like you cut

Personality Disorders / 437 T

h e m a t ic

A

p p e r c e p t io n

T

est

it o u t (Chopping motion with sides of hands) and because it’s ju s t one white piece o f paper. T h e only reason I said it was a cloud was because it was white. C A R D 18GF 28" (arms folded against chest) U hm m (scratches head). T his is a lady’s m other . . . who ju st fell down and is having a little trouble standing up so the d a u g h te r is h elping th e m o th er stand up an d she’s w orried th at the m o th er’s so old th a t she m ig h t have broken a bone b u t she stands up an d walks aro u n d a little bit an d she’s fine, (scratches elbow) (Why did she fall down}) I guess she ju s t slipped because she was having trouble walking. (Scratches hand) (Any particular thoughts the daughter is having}) She was wor­ ried th a t m o th er was so old th a t she m ight have broken a bone b ut she real­ izes w hen she walks aro u n d again th at n o th in g really h ap p e n e d . (Said in monotone voice, though not irritated, just repeats what she said before.)

438 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

DISCUSSION Ms. W, a 17-year-old, single fem ale living w ith h er p aren ts, an d Ms. J, a 20-year-old, single female m eet criteria for borderline personality disorder. As is typical o f m any b orderline patients, both are young, single females. A lthough similar, it is th eir differences th a t are im p o rtan t for trea tm en t planning. Ms. W h ad no clear-cut Axis I d iso rd er an d h ad a relatively go o d p rio r adju stm en t as noted on Axis V. W hile borderline, she m et only five o f the eight criteria for the diagnosis. She was not actively suicidal, nor d id she have a past history o f suicide attem p ts as m any BPD patients do. However, her physically self-destructive behavior was extrem e. Ms. W’s treatm ent was intensive, with m uch investm ent o f th erap eu tic tim e an d expense. She was treated on a long-term , inpatient unit followed by individual, long-term , dynam ic psychotherapy with relatively am bitious goals. T h is was due, apparently, in large p a rt to a relatively good prognostic picture. H er p ro ­ jective tests were m arked by avoidance, em otional w ithdraw al, an d denial, and a rigid and desperate attem pt to keep a “nice girl” image. T his became the focus o f treatm en t, which resulted in a m ore relaxed an d in teg rated sense o f self w ith som e acceptance o f the o th e r aspects o f herself. Ms. J was m ore seriously d istu rb e d th an Ms. W. in diverse ways. She m et all eight o f the criteria for borderline personality disorder on clinical exam ­ ination, including a history o f anorexia and serious suicide attem pts. In addition, she h ad a clear diagnosis o f m ajor depressive d iso rd e r with psy­ chosis on Axis I. H er Axis V ra tin g was very poor, indicating m arked im p airm en t in social an d occupational functioning p rior to the present episode. I'he treatm en t o f Ms. J was long an d difficult, m arked by im provem ent and then declines when she would reengage in self-destructive behavior. T he testing m aterial suggested overinvolvement and fusion with the mother, and this becam e a m ajor focus in the family treatm ent. A central family therapy goal was some growing differentiation from o th er family m em bers. In ad d i­ tion, she received individual psychotherapy d u rin g her inpatient treatm ent. H er relationship with this th erap ist created intense feelings an d it would a p p e a r th a t she began to see the therap ist m uch as she saw h er fa th e r— a negative person in h er environm ent. In asm u ch as h e r treatm en t could not be com pleted successfully at the ad m itting facility, fu tu re therapeutic efforts would need to take into account h er capacity for the developm ent o f intense transference feelings and plan h er treatm en t accordingly. T h is m ight include a tre a tm e n t plan w hich co m b in ed in d ivid u al w ith g ro u p psychotherapy.

Personality Disorders / 439

C. NARCISSISTIC PERSONALITY DISORDERS Narcissistic personality disorder is characterized by a longstanding pattern of grandiose fantasy an d behavior, a lack o f em p ath y tow ard others, an d a hypersensitivity to the evaluation o f self by others. T h e specific diagnostic criteria involve reacting to criticism with rage an d shame, taking advantage o f o thers, an ex aggerated sense o f one’s own self-im portance an d co m p e­ tence, preoccupation with fantasies o f unlim ited success, a sense o f en ti­ tlement, eliciting constant attention and adm iration from others, an inability to recognize the needs an d experience o f others, an d preoccupation with feelings o f envy. Individuals with these characteristics seem d estined to encounter dif ficulties in in terp erso n al relations.

NARCISSISTIC PERSONALITY DISORDER W ITH ORGANIC DELUSIONAL SYNDROME Mr. C was 28 years old at th e tim e o f his first psychiatric adm ission to a large, u rb a n psychiatric hospital w here he was first seen in the em ergency room by the psychiatric resident on call. He was driven to the hospital by his father who had received an incoherent phone call from Mr. C in the early hours o f the m orning. T h e fath er went to his son’s ap a rtm en t and after rep eated reassurances to his son th at he was alone, he was ad m itted into the apartm ent. Mr. C told his father a ram bling and largely incoherent story about being “spied o n ” by people on the street. H e would not leave the a p a rtm en t, b u t his fath er eventually p ersu ad ed him to accom pany him to the hospital. He rode in the back o f his father’s car, keeping well o ut o f view until they arrived at th e em ergency room . T he father was quite surprised to find his son in such a disorganized and “paranoid” state. Mr. C worked in his father’s business and so had daily con­ tact with him . They had been arg u in g a great deal lately and Mr. C seemed unusually irritable. His irritability and a ra th e r dram atic w eight gain o f some 10-20 pounds in th e last few weeks were, however, the only significant changes noted by his father. He a ttrib u te d both these changes to his son’s distress over the d eath o f his mother, in unexpected an d traum atic circum ­ stances, a few m onths earlier. A lthough Mr. C lived alone in his own a p a rt­ m ent, he h ad spoken with his m o th er daily an d h ad frequently visited his p aren ts in th e ir nearby a p a rtm e n t before h e r d eath . W hen seen in the em ergency room , Mr. C could give little pertinent infor­ m ation about his recent life. He spoke at length about his conviction th a t som eone was “spying” on him an d , on fu rth e r questioning, connected this

440 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning fear w ith his concern th a t “certain p eople” from w hom he h ad been p u r ­ chasing large am ounts o f cocaine m ight be “o u t to get him .” He was ad m it­ ted to the inpatient psychiatric ward for fu rth e r observation and evaluation w ith a provisional diagnosis o f organic delusional syndrom e resulting from his extensive (in excess o f one g ram p e r day) cocaine abuse. W ithin 72 h ours o f his adm ission, his m ental status h a d cleared su ffi­ ciently for him to provide a m ore co h eren t account o f his recent activities and for his paranoid delusions to have completely evaporated. H e adm itted to a history o f escalating cocaine abuse since the d e a th o f his m o th er in an effort to w ard o ff th e d esp a ir he felt over losing her. She h ad d ied o f kidney failure which she developed after falling from a stepladder. She had sp en t fo u r m onths in a com a before h er d eath . Mr. C, against th e advice o f his father, h ad his m o th er tran sferred from hospital to hospital as he found each new team o f doctors “a b u n ch o f in com petent assholes.” D u rin g th e perio d o f his m o th er’s com a, Mr. C freq u en ted prostitutes w here he was introduced to cocaine. He found th a t cocaine heightened and prolonged his sexual p leasure an d , as the weeks wore on, his cocaine abuse escalated since little else gave him any pleasure. In the final weeks before his admission, his life consisted o f desultory periods in which he attem pted to work, p u n ctu ated with episodes o f binge e atin g a n d vom iting a n d sad o ­ m asochistic sex an d d ru g orgies with m any d ifferen t prostitutes. As he becam e increasingly irritab le a n d p aran o id , he spent less a n d less tim e out o f his a p artm en t. In the final few days before his adm ission, he left his a p a rtm e n t only to p u rc h a se food and cocaine. Finally, he took to his bed where his daily life consisted o f 5-10 episodes o f binge eating and vomiting interspersed with cocaine ingestion. Television was his constant com panion; he was too “w ired” to sleep. Developing, first, ideas o f reference and, finally, frank paranoid delusions, he called his father when he becam e certain that som eone was try in g to break into his a p a rtm e n t to steal his cocaine.

D S M -III-R D iagnosis Axis I: Axis II: Axis III: Axis IV: Axis V:

O rganic delusional syndrom e Narcissistic personality d iso rd er Rule o u t D ependent personality d iso rd er None E xtrem e (death o f m other) G ood

Personality Disorders / 441

Treatment and Hospital Course Mr. C quickly recovered from the acute effects o f his cocaine abuse and his delusions rap id ly abated. As they d id so, however, he becam e increas­ ingly depressed. B ecause o f this, his psychiatrist recom m ended tran sfer to a n o th e r hospital w here he could receive a m ore ex ten d ed perio d o f in p a­ tient evaluation an d tre a tm e n t for his depression. Mr. C accepted the rec­ om m endation o f his psychiatrist and five days after his em ergency room adm ission was tra n sfe rre d to a n o th er psychiatric facility. At th e tim e o f his adm ission there, he presen ted as a som ew hat overw eight young m an with an outw ardly jovial m anner. H e recounted the events lead in g to his adm is­ sion and tran sfer with a som ew hat ironic air an d a bem used expression as if to help the psychiatrist u n d e rsta n d th a t such behavior was h ard ly c h a r­ acteristic o f him . W hen asked about his m o th ers death, he was able to elaborate on his feel­ ings o f a n g e r tow ards the m edical staffs who had been u n ab le to help her. He acknowledged the sadness he felt at her death. Initially, he was reluctant to explore his feelings abo u t his m o th er in any detail, always re tu rn in g to his an g ry feelings. H e was an g ry at the doctors who h a d cared for his m o th er an d he was an g ry at his father who, w ithin a few m onths o f his m o th e r’s d eath , h ad b eg u n a relationship with a widowed frien d o f his m o th er’s. Mr. C required m uch encouragem ent before he reluctantly agreed to dis­ cuss his mother. As he did so, his jovial m an n er dissipated and was replaced with an air o f sadness an d g reat longing. His m o th er had been his “best frien d .” As far back as he could rem em ber, she h a d known his innerm ost thou ghts an d feelings, alm ost before he h im self h ad known them . She had been a constant source o f en couragem ent an d su p p o rt an d it was h er love for him a n d h er faith in him th at had c a rrie d him th ro u g h the rough times in his life. Since losing her, he h ad felt em p ty an d asham ed th a t he had m ad e so little o f himself, considering h e r hopes for and faith in him . O n this an d o th e r occasions w hen Mr. C could be p ersu ad ed to speak about his mother, a genuine sense o f melancholy seem ed evident. However, at all o th er times, he seem ed to have no difficulties. He went about his daily routine in the hospital w ith a lig h th earted air. He ate and slept well and o ffered no com plaints. H e enjoyed sp en d in g tim e with the staff o r o th er patients. Puzzled by th e strik in g difference betw een his public ap p earan ce an d his in n e r grief, th e psychiatrist referred him for psychological testing to help h er b e tte r u n d e rsta n d th e discrepancy.

442 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

Psychological Assessment Mr. C was given an M M PI, WAIS-R, Rorschach, TAT and DAP. T h e exam ination began th re e weeks after his em ergency room adm ission. T h e referral form requested help with his Axis II diagnosis. T h e psychiatrist felt Mr. C had both narcissistic and d ep en d en t personality features, b ut was u n su re as to w hether he indeed had a personality disorder. T h e psychiatrist also requested an evaluation o f Mr. C ’s “m ood d isorder.” Mr. C cooperated with the exam ination which began with the MMPI. His MMPI profile was prim arily rem arkable for the relative absence o f any indi­ cations o f severe psychopathology. All the validity and the clinical scales had T-scores below 70, except for M f scale. His profile peaks were o b tain ed on scales 6 (Paranoia) and 9 (Alania) (T-scores o f 67 an d 68, respectively), co n ­ sistent with some m istrust an d irritability noted in his clinical presentation and p erh ap s related to the residual effects o f his cocaine-induced psychosis. O n the WAIS-R, Mr. C achieved a full-scale IQ o f 98, with verbal an d p erfo rm an ce IQs o f 107 an d 87, respectively. T h is 20-point discrepancy betw een Mr. C ’s verbal an d p erfo rm an ce IQs is ra th e r large an d can be traced prim arily to his very p oor perform ance on the Block Design and Object Assembly subtests (scaled scores o f six). A p a rt from these two subtests, his scaled scores all fell betw een nine an d 12. W hen one inspects the details o f his p erform ance on the Block Design a n d Object Assembly subtests, it a p p e a rs th at Mr. C ’s difficulties are traceable to tim e pressure difficulties. O n the easier item s o f b o th subtests he was able to quickly g rasp the final p ro d u ct req u ired an d com pleted each design well w ithin the tim e allotted for the item. However, on the last th ree items o f the Block Design, he required an additional 1- 10” beyond th e allotted tim e lim it for the item, thus losing credit for his correct perform ance. Similarly, on the Object Assembly subtest, he rapidly com pletes the first th ree items but, although he knows the last item is an elephant, cannot m an ­ age to correctly assem ble m ore th a n the head an d the tru n k in the tim e allotted for the item. Finally, in b o th subtests, there were m inor difficulties (e.g. inverting the e a r on item two o f the Object Assembly subtest) which fu r­ th e r red u ced his score. In th e ex am in e r’s notes for these two subtests, Mr. C a p p e a re d to be red u ced to a ra th e r inefficient trial an d e rro r strategy w hen his initial attem p ts m et w ith failure, and he persisted in this strategy on later items. O n the projective tests, Mr. C showed the sam e persistence noted in his WAIS-R perform ance. H e p ro d u ced 51 R orschach responses. T h e record is notable for its m ultiple indications o f overproductivity. T hese include a low n u m b e r o f responses using the whole blot, few p o p u la r responses, a

Personality Disorders I 443 sizable proportion of unusual detail responses, and yet an overemphasis on easily perceived anim al responses. T h e u n derutilization o f d eterm in an ts other th an form also testify to the inherent impoverished quality o f the rec­ ord , despite his o u te r productivity. T hese quantitative indices suggest an individual w hose am bitions overreach his abilities and indicate a p red isp o ­ sition to em phasize quan tity over quality in his p erform ance. His em phasis on quantity is, in fact, purchased at the expense o f quality. His deem phasis o f the com m onplace an d usual (e.g. low P% an d W%) and his attention to the un u su al represent the countervailing trends in this reg ard . Qualitatively, his am bitions are represented in b oth the content and sequence o f his responses. For exam ple, he begins his Rorschach with the response “Butterfly. No, actually like a bee com bination. T h e m iddle looks like a bee an d the outside looks like a butterfly.” T h ese them es of the d a n ­ gerous (the bee) and the harm less (and at o th er times, comically so) are con­ stantly reworked in his nine responses to card II. His initial response to card ¡1 relies on the large, black details to becom e “two m en slap p in g hands together, or som ething stran g e in the m irror. In fact, som eone looking at his own reflection.” T his response is followed by “witches” in the u p p e r red details, a “pig o r rabbit” in the large, black details, “a face . . . with a big nose” as an edge detail and the sam e face (inverted) as “a clown” on the o p posing side. R etu rn in g to an u nusual area in the large, black details, Mr. C next reports “a little boy. Very interesting, I see a m an inside.” It is the red in the black th a t rem inds him o f the boy because o f “the expression on his face.” T u rn in g his attention to the lower red detail, he next reports “a sad face, m aybe a c rab .” T h e form er because o f “sad eyes an d looks like tears. It looks like he is crying.” Finally, “two black b ears” because o f “the black an d the sh ap e.” T his sequence o f responses illustrates Mr. C's fluidly shifting euphoricdysphoric m ood state with elem ents o f grandiosity and exhibitionism inter­ tw in e d w ith d e n ig r a tio n a n d a p o w e rle ss p a ss iv e -d e p e n d e n c y . Fundam entally, Mr. C sees the world as having a kaleidoscopic, unstable flavor, with the relatively innocuous readily tran sfo rm ed into the th re a te n ­ ing. T he initial butterfly on card I becomes a bee and, later, his rats on card VIII chan g e into m uch m ore form idable m ountain lions. T hese p ro tean , conflictual aspects, while m ore subtle on the Rorschach, come into prom inence in his TAT stories. In his First story to card 1 , Mr. C moves im m ediately from m astery concerns related to the young boy’s “worry about w hat his parents think about him ” to “standing ovations” and an ultim ate outcom e as “a w orld-fam ous m usician.” H e concludes the story by no tin g th at “happy endings are g re a t.” In fact, in 12 stories, eig h t end happily. H is p referred them e is th a t o f an epic triu m p h in the face o f over­

444 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning w helm ing adversity: a young m an from a sm all town moves to the big city and becomes “president o f the U nited States o f Am erica” (card 14); the son o f a used car salesm an is accepted to m edical school (card 7BM ); a young servicem an survives the war and retu rn s home with his foreign lover whom he “sweeps o ff h er feet an d takes h er back to the U.S. to get m a rrie d ”; a young boy m iraculously recovers after a three-day com a th ro u g h the in te r­ cession o f his father’s prayers an d the father is “en ra p tu red . . . as he thanks Gi;d for the retu rn o f his son.” A lthough cast as sweeping d ram a, these sto­ ries are nevertheless trite and cliche-ridden. All h u m a n interaction described in the stories is forced to come a b o u t by th e press o f ex tern al forces an d the characters in these stories are described as m erely reacting, albeit m ost often heroically, to these forces. T h e stereotypy o f these stories also a p p e a rs in Mr. C ’s presentation o f m ale an d fem ale responses to these n a tu ral tragedies. M en, as noted in the exam ples o f heroism cited above, triu m p h . W omen, on th e o th e r h an d , are characterized by their frightened forbearance. For exam ple, the m other on card 10 is “p ro u d ” an d “h ap p y ” th a t “h er little boy has grow n u p to be a m a n ” b u t now th a t he is m arry in g an d moving o u t on his own, h er only real solace lies in her son’s “retain in g m any o f the values th a t his m o th er tau g h t h im .” A nd p o o r solace it m ust be, for in the conclusion o f the story she “dies o f n a tu ra l causes.” Mr. C ’s characteristic denial o f the om inous is to be found in his story to card 5 in which a wom an hom e alone at n ight bravely o pens a d o o r into a room w here she suspects a b u rg la r is present, only to discover th a t she had “left the window open an d to find a tree b anging on the open window.” Finally, when w ar again provides the back d ro p for a story o f a heroic son enlisting “after h earin g news th a t his cou n try is u n d e r attack by foreign enem ies,” the m o th er is presented as “w orried an d very scared o f the unknow n forces o f the war th at may take her son’s life an d shatter her ideals and age her terribly . . . the only th in g th a t is left in h er life will disappear.” In these stories, Mr. C ’s preoccupations with boundless success, entitled achievem ent in the face o f overw helm ing odds, an egocentric assum ption o f b eing at the focus o f all forces, n a tu ra l and u n n a tu ra l, an d an exhibitionistic display o f his astonishing talents are all interwoven into his presentations. In the face o f such relentless self-aggrandizem ent, th ere is little room for an em p ath ic appreciation o f others. His em p ath ic disability can easily be gleaned from his h u m a n fig u re draw ings. Both figures are mere primitive sketches rushed o ff in a h aphazard m anner. T he male figure shows no identifiable gender-specific characteristics. Its nonfunctional hands, nonexistent feet, an d total absence o f bodily articulation suggest an ineffective child m uch in need o f n u rtu ra n c e an d su p p o rt. T h e fem ale fig­ ure, with her bald head and tiny lower appendages, is shown in profile, p e r­

Personality Disorders / 445 haps to em phasize h er only noticeable sexual characteristics, her full bosom an d skirt.

Treatment Plan and Outcome T h e rep o rt o f Mr. C ’s psychological exam ination results ru led o ut the presence o f a significant m ood disturbance and em phasized the narcissistic and d ep en d en t elem ents to his personality. His rap id recovery from his cocaine-induced delusions an d the absence o f a prom inent Axis I mood dis­ o rd er led his treatm ent team to form ulate a treatm ent recom m endation for an o u tp atien t psychotherapy ra th e r th a n to ex ten d his in p atien t stay. U pon being presented with this treatm en t plan, Mr. C could identify no reason for co ntinuin g u n d e r psychiatric care. His fath er was o f the sam e opinion. H is psychiatrist atte m p ted to p o int out th a t to the extent th at he was un ab le to resolve his g rie f over his m o th e r’s d e a th , he rem ained at risk for fu rth e r decom pensations such as the one which had led to his hospi­ talization. Mr. C acknowledged the relationship between his m other’s death an d his d ecom pensation b u t felt th a t he now knew how to avoid fu rth e r episodes o f decom pensation, by refrain in g from fu rth e r cocaine abuse. U nable to p e rsu ad e Mr. C to accept the recom m endation for o u tp atien t treatm en t, the psychiatrist suggested th a t the ex am in in g psychologist go over the results o f his evaluation with Mr. C. T h e psychiatrist h o p ed th a t by do in g so, Mr. C could be h elped to see m ore clearly the ineffectiveness o f his coping strategy. T h e psychologist reviewed his results with him and pointed out his tendencies to blame his problems on things outside himself, his indifference to anyone’s problem s b u t his own, and his inordinate needs for adm iration an d attention. In d o in g so, the psychologist was careful to also su p p o rt Mr. C ’s real needs for attention an d im p a rt to him a sense o f encouragem ent. Mr. C appreciated the efforts o f the psychologist and the psychiatrist and d id feel as if he h ad been u n d ersto o d . He ag reed to accept the recom m en­ dation for o u tp atien t treatm en t an d was disch arg ed from the hospital. O n followup contact two weeks later, Mr. C h ad not contacted the psychiatrist to whom he had been referred . W hen called by his form er hospital social worker, he reluctantly ad m itted he h ad b eg u n abusing cocaine again. W ithin a few weeks, he had deco m p en sated again and was ad m itted to a n o th e r hospital for detoxification an d referral to a substance abuse p rogram .

4 4 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

E X H I B I T

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm ent

E x a m in a t io n

E x a m in a t io n

Focuses on the unique n a tu re o f his relation­ ship with his m other

Constant them es o f unm itigated victory in the face o f adversity

None

Preoccupied with u n lim ­ ited success

C. Exhibitionism

Admits to “clowning around" to get attention

Self-esteem overly dependent on the approval o f others

D. Cool indifference or m arked reaction to indifference, criticism o r defeat

None

D enigrates the goal when d efeat is im m inent

— entitlem ent

None

Expects to be the con­ stant focus o f others attention

— lack o f em pathy

Fails to un d erstan d fath er’s wish to rem arry

Unable to appreciate others’ needs except as they relate to his own

None

Poor use o f ego resources; relies on m aking a good im pression

Average intelligence

Average intelligence

Idealized bond with his m other

Expects su p p o rt and adm iration regardless o f accom plishm ents

Poor im pulse control

Relies on ex tern al affec­ tive controls; very prone to shifting m ood states

I. Sym ptom s/D iagnosis Narcissistic personal­ ity disorder A. Grandiosity

B.

Preoccupation with fantasies

E. Relationships dis­ tu rb ed by:

II. Personality Factors

III. Cognitive Abilities IV. Psychodynam ics

Personality Disorders / 4 4 7

V.

A rea o f

C l in ic a l

A ssessm ent

E x a m in a t io n

T herap eu tic E nabling Factors

VI. Environm ental D em and and Social A djustm ent

P s y c h o l o g ic a l E x a m in a t io n

Acute, relatively b rief period o f m ajor sym p­ tom atic disturbance

Q uick recovery with acknow ledgm ent o f difficulties

Prefers to get by with the m inim um am ount o f effort

Exploits the environm ent to serve his own needs

No close personal rela­ tionships outside his im m ediate family

M arginal adjustm ent to external dem ands to avoid confrontation

448 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT WAIS-R

2

Sum m ary

Verbal Subtests

Scaled Score

Inform ation Digit Span Vocabulary A rithm etic C om prehension Similarities

12 12 10 12 11 12

Performance Subtests Picture Completion Picture A rrangem ent Block Design O bject Assembly Digit Symbol

Verbal IQ Performance IQ Full Scale Score

10 11 6 6 9 107 87 98

MMPI Summary LK/F: 5 '9 6 -4 2 3 1/87:0#

Rorschach Summary N um ber o f Responses Rejections Populars O riginals Average R/T Chrom atic Average R/T Achromatic F% F+ % A% H% W:M M:Sum C

51 0 8 1 4" 3" 62 84 45 27 9:6 6:3

Personality Disorders ! 449 R orsch a ch S um m ary

V11I-X% FK + F + Fc% (H + A ):(H d + Ad) A pperception W 18% D 45% d 10% Dd + S 27%

33 65 25:12

(Pure S)

4 5 0 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

EXHIBIT

3

R orschach S um m ary

Response

Inquiry

Scoring

I . 1"

Butterfly. No actually like a bee. C om bination o f the m iddle looks like a bee and outside looks like a butterfly.

2 . M iddle looks like bee o u t­ side like butterfly. Maybe it’s a housefly. No wings o f housefly go backwards. No it is not a housefly.

1. T he shape, the wings.

WFAP

O nly the m iddle, the shape, the head, the eye and the stinger.

DF-A

T he connection between the hands, the arm m eet­ ing on the center. (Anything else}) T h e shape o f the shoulder, o th e r shape o f th eir bodies, could have been th eir body. (Reflec­ tion}) T h e way it looked like a draw ing cu t in h a lf b ut when I studied them closely they are two distinct drawings.

W MHP

T he shape o f nose and chin. (Old}) Well all witches are old.

DF(Hd)

II. 5" Two m en slapping hands together o r som ething, looking in the mirror. In fact, som eone looking at his own reflection is about it.

Do I have to say m ore about it (As you wish). How did they m ake these cards? Well they m ust have m ade it with ink. I f I p u t the pic­ tu re together it looks like som eone in reflection b u t if I look at it separately the red looks 2. like an old witch, two o f them and the black looks like

Personality Disorders / 451

R orschach Sum m ary

Response

Inquiry

Scoring

3. a rabbit or like a grown pig o r rabbit

3. T he ears, shape.

4. but if I tu rn the card I see a face over here with big nose.

4. T he nose, the chin.

5. A nd the bottom on the oth er side could be a clown.

5. Looks like he is smiling. (Smiling}) Shape o f m outh.

d rM H d

6. I see a little boy. Very in ter­ esting I see a m an inside.

6. It looks like a boy, the expression o f his face. I saw the head an d the nose. (Man inside}) 1 thought that. I m ean the boy looks like a boy and a man.

d rM H d

7. 1 see a sad face

7. Sad eyes, tears, looks like it’s crying.

8. or maybe a crab.

8. T h e shape.

9. T he two blacks can be two bears.

9. T h e black and the shape.

DFC'AP

I . I see two monkeys han g in g upside down.

1. T he tail, the draw ing, looks like they are h a n g in g from a branch.

DFMA

2. A butterfly.

2. Wings.

3. A skull, no a mask.

3. Looks like a religious mask. I do not know w hether it has a sad o r happy face. T h e shape has openings and someone could look into it.

4. Also a crab.

4. T he shape. Claws.

WFA

5. Two people talking.

5. H ead, legs, body.

WMHP

III.

DFA drF H

DM-Hd DFA

2"

DFAP D(S)FMask

IV. 6" 1. T his one is interesting. I see two hands.

1. T he shape. A finger here and here.

dF H d

4 5 2 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g

R orschach S um mary

Response

Inquiry

Scoring

3. Face like Jim m y D urante.

3. T he nose.

d rF H d

4. 1 see a dog.

4. H ead, nose, front paws.

DF-A

1. A bat, a butterfly.

1. (Bat or butterfly}) T h e shape makes it look like either.

WFA

2. A horses leg.

2. Actual shape o f it.

dFAd

3. A h a lf m an and h a lf horse.

3. l e g like horse but the head looks like a m an, m ytho­ logical character.

drF H /A

4. A bull. 5. Clouds.

4. T he outline looked strong. 5. T he white and the dark, the white against the black.

DF-A W C 'FCIoud

1. Again like a crab, no not like a crab. A n anim al with a claw, not a snake.

1. Eyes, the shape, the claws.

drFA

2. I see a lam ppost.

2. T he black color, the separa­ tion and the light and the darkness, the separation o f light and dark.

DFCObj.

3. 1 also see a penis.

3. T he shape o f it. It is erect also, the head is.

drFm Sex

4. A nd if 1 see that, here 1 see a vagina symbol.

4. T he open in g looks like an ass and vagina.

drFSex

1. A .river through a valley.

1. Ix>oked like setting o f sun on landscape. An opening, the gray area looked like water o r reflection o f the sun.

dFm .FK N at.

2. A vagina again.

2. T he opening.

dFSex

3. An angry dog’s face.

3. T he nose, he has a thick nose. (Angry}) Looks like it’s growling.

DFMAd

4. A wolf.

4. T he m outh, the eyes.

DFAd

V. J"

VI. 5"

VII. 1"

Personality Disorders / 4 5 3

R o rschach Sum m ary

Response

Inquiry

Scoring

3. An angry dog's face.

3. T he nose, he has a thick nose. (Angry?) Looks like it’s growling.

DFMAd

4. A wolf.

4. T he m outh, the eyes.

DFAd

5. Two people.

5. Not people only two faces, the shapes.

D FH dP

1. Two rats o r m ountain lions.

1. Just the shape.

DFAP

2. H um an heart and veins from heart.

2. Shaped like h u m an heart. T h e red is the veins o f the heart.

diFCA t

3. A m an’s face o r body.

3. I saw the whole body, the legs, arm and the face.

diFH

4. I see a baby, a fetus.

4. T h e outline is the shape o f the baby. T h e full form a­ tion had not o ccurred, he is waiting to bust out.

drF m (H )

5. A nim al head.

5. T h e shape, a prehistoric anim al.

DFAd

1. I see a h u m an skeleton, like a pelvis.

1. The way it’s shaped.

DFAt

2. A rein deer on top.

2. Well I did not see the d eer only it’s antler. (Antler!) It has the shape o f a d e e r’s antlers.

dFAd

3. Looks like a forest landing deep in som ething. I also see the core o f the earth . 1 see different coloration.

3. I was im agining a cross sec­ tion o f the earth . Color looked like draw ings from a textbook showing an oil drill going dow'n pushing things. (Forest landing?) I don’t know w hat m ade me say that, maybe the colors rem ind me o f the forest.

WKF.CFGeo.

VIII. 6" H m m , m uch m ore detail here.

IX. 6"

4 5 4 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P lanning

R orschach Summary

Response

Inquiry

Scoring

4. Ocean with land around it.

4. Shape, looks between Europe and North Amer­ ica, the land is around the ocean. (Anything else?) Color blue.

DFC-Geo.

5. A lady upside down.

5. (A lady upside down?) Shape, arm s, legs and body.

drF-H

X. 3" (This is the last card) O h I’ll see all kinds of things. 1. I see parrots.

1. 'I'he shape, their tails.

DF-A

2. I see tulips.

2. Shape o f the buds on the top.

ddFPI

3. Overall a butterfly.

3. Put it together, the overall shape would be butterfly, all the colors.

WFC-A

4. Helicopter and tank.

4. The shape and the color, Army helicopter.

DFCObj

5. Rabbits.

5. The shape o f the ears.

DFA

6. Crab.

6. T he overall shape.

DFAP

7. Monkey in a tree.

7. The tail. It looked that it was on a tree inside the tree eating som ething o ff the tree. (Tree?) Branches stick­ ing out.

drFM A.PIO

Personality Disorders / 455

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 2" T h e young p ro tég é stu d y in g his new piece o f music th a t he wants to play in rehearsal next Saturday night. He is very concerned w hether he can m aster this b u t he learns to m aster it and will get a standing ovation on the concert. T hey live happily forever after. (Who it they}) Him and his parents. (Feelings}) He feels worry about w hether he can accomplish this on Saturday and w hat his parents think about him but he ju s t motivates him self and he goes on to become a world famous musician. H appy endings are great.

CARD 3BM

5" Looks like, this is a sad, cruel sort o f woman who is about to take h er own life. H er husband and children were killed in a car accident leaving h er all alone, broken h earted , alone an d scared. Feeling th at she has n o th in g to live for, she is about to pull the trig g e r an d broke down cry­ ing and she discovered th at she does not have the courage to pull the trigger to take h er own life. She realizes th at life m ust go on an d she is strong enough to e n d u re these h ard sh ip s, b ut she en d u res the pain. I would say she is happy b u t she realizes the challenges an d is ready to m eet the challenge.

CARD 4

3" T his is a love story in Italy d u rin g W W II w hen a young se r­ viceman falls in love with the hospitality o f young Italian woman. T h e ir love and passion were stro n g in times o f war. News cam e in th a t w ar was over, th a t he is com ing back to A m erica an d she does not w ant to let him go, she pleads her case for the love she has for him an d th at their love is very strong. He is to rn betw een his love for h er o r w h eth er his feelings a re tru e o r ju s t flaring u p d u rin g the war. Passions are h ot d u rin g the war. H e then picks h er up, I m ean he sweeps h er o ff h er feet an d takes h er back to the US to get m arried . T hey b oth are very happy now.

CARD 5

3” She was hom e alone last night. She th o u g h t th ere was a b u r­ glar in the o th e r room . She o pened the d o o r quickly to su rp rise the would-be in tru d er. She is very scared an d nervous th a t h e r life may be in danger. W hen she open ed the d oor she was startled th a t she left the window open and to find a tree banging on an open window— she was relieved that there was no b u rg la r in the house.

CARD 6BM 11" O.K. W hat do I do with this one? I have not decided w h eth er this is going to be good news o r bad news. L et’s see. . . . young G eorge comes hom e after h e a rin g news th at his cou n try is u n d e r attack by

4.56 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning T h e m a t ic A p p e r c e p t io n T e s t

foreign enem ies. H e went by the recru itin g station on th e way from hom e an d enlisted to do his p a rt as his fath er an d his fa th e r’s fa th e r before him d id to protect the g reat land. His m o th er on the o th e r h a n d is very w orried an d very scared o f th e unknow n forces o f the war th at may take h e r son’s life an d shatter h er ideals and age h e r terribly. Now the guy is c o n fro n ted w ith the tru e tragedy o f the w ar an d ab o u t th e d e a th o f his fath er th a t he never knew. She is scared, lonely, th a t th e only th in g th a t left in h er life will disappear.

CARD 7BM

5" Son you are old enough I w ant you to com e into th e used car business. I am p roud an d e a g e r th a t my own flesh an d blood will be stan d in g next to m e selling cars th e way I have for th e past 35 years. Now som e one will carry on th e family nam e for generations to come. T h e son h ad bad news for the father. He said I d o not know how to b reak the news b u t I am n o t going to sell cars. I was ju s t accepted in MD school which fu l­ fills my dream as a doctor. He is very happy and excited to fulfill his dream s and goals b ut concerned an d sad th at he let his father down. But his d ream is final. He will go to medical school. T h e father, he was excited b u t becam e disappointed but then he tu rn ed out to be happy because his son’s fulfilling his dream .

CARD 10

10" T his is the story o f Joe an d his m other. Jo e is very h appy an d very sad at the sam e tim e. You see. . . . (pause). T h is is the day th a t he is sup p o sed to get m arrie d . H is m o th e r is so p roud o f him she is so happy th a t h er little boy has grow n u p to be a m an an d he is boy enough to seek advice an d assurance from his m other. It is a very h appy day. He gets m a r­ ried a n d lives happily ever after. H e will retain m any o f th e values th a t his m other thought o f him . She dies o f n atural causes. (Patient appears very anx­ ious moving in his chair)

CARD 12M

5" T his one is terrible, this is the worst possible th in g to h a p ­ pen in life. A p aren t th in k in g abo u t b u ry in g a child, th a t his child will die before him and the task o f b u ry in g the child is inconceivable for him as he worked an d strug g led all his life so ch ild ren will live a b ette r o r longer life th a n he d id . ITie son has not been awake for th ree days but his fath er has not left his bedside praying th a t he will save th e life o f his child. T h e son o p ens his eyes finally an d says to his fath er th a t he is hungry. T ears o f joy eru p te d from the fa th e r’s eyes as he th an k ed G od for re tu rn o f his son.

CARD 13MF

7" TTiis is a terrib le sad story m ark in g th e d e a th o f one’s loved ones. T hey have been m arrie d 50 years w hen a su d d e n h e a rt attack

Personality Disorders ! 457 T h e m a t ic A p p e r c e p t io n T e s t

took the life o f th e ir beloved one’s. {What do you mean?) Well she h ad a h eart attack. She d ied at hom e in his arm s h appy an d content. He is trying to decide w hat to do, who to call, w restling with his family. O n the one hand he is m iserable an d in agony th a t his wife is gone. O n th e o th e r h an d he is happy an d g reatfu l th a t they shared 50 years.

CARD 14

3" T his is the story o f a young m an n am ed Jim who ju s t g ra d ­ u ated from college. H e is very excited to start his new life. He decided to leave th e sm all town w here he was raised an d leave to go to a big city to try his chance in fam e and fortune. He was happy an d excited abo u t the chance o f startin g his ad v en tu re b ut at the sam e tim e he was scared an d nervous ab ou t the obstacles an d unknow n th a t may lie ah ead , a fight for which he was not p rep a red to win b ut he m ust win them . H e is a cham pion an d a w inner. H e m ust overcom e the o d d s to prove his destiny. He will becom e the president o f the U nited States o f Am erica.

CARD 15 10" T his was devil’s n ig h tm are on Halloween night. This guy is very happy an d excited th a t he finally gets his chance to wake up the d ead. There he stood c h a n tin g th e poem . {Patient is smiling and laughing) T h a t gives him a charg e, excitem ent which sends chills th ro u g h his body. Period an d p a rag rap h . It d id not work, he felt terrible. You see he was nuts to begin with. H e froze to d e a th , a very ironic story (smiling).

458 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

NARCISSISTIC PERSONALITY DISORDER Mr. A was a 21-year-old stu d en t who h ad ju s t re tu rn e d to college for his ju n io r year. D espite a chronic history o f academ ic underachievem ent an d a sophom ore year at college th a t had resulted in academ ic probation, he anticipated no problem s d u rin g his ju n io r year. A lthough he resolved to b rin g up his grades u n d e r p ressure from his father, he quickly fell into his usual p a tte rn o f ap p ly in g him self only in those classes which he enjoyed. Shortly after the beg in n in g o f the semester, he was accused o f having b ro ­ ken into several dorm ito ry room s an d stolen stereo eq uip m en t and was p u t on probation again p ending the outcom e o f the police investigation. He ad a ­ m antly den ied any involvement in the thefts. His family was u n p e rsu a d e d by his denials and unm oved by his consternation. T hey h ad suffered th ro u g h several such th efts an d denials d u rin g his high school years w hen he h ad n eed ed to su p p o rt his com pulsive g am bling habits. Feeling rejected by his family and recognizing the inadequacy o f his aca­ dem ic p erform ance, Mr. A began to feel increasingly hopeless. H e began to have difficulty socializing as word o f his alleged involvement in the thefts b eg an to circulate aro u n d cam pus. H e lost all interest in women an d sex, a m atter o f som e concern to him since he h ad always p rid ed him self on his sexual abilities and was given to boasting o f his sexual exploits. In fact, d u r­ ing his senior high school year, his sex life had been a fairly reliable m eans o f bolstering his self-esteem . For a p erio d o f several m onths, he h ad been fascinated w ith prostitutes an d had o ften used his fa th e r’s cred it card s to rent hotel room s w here he could act o u t his ra p e fantasies w ith them . He becam e bored with these adventures an d tu rn e d to aggressive an d a n o n ­ ym ous hom osexual encounters from which he derived “an anim al-like relief .” He discontinued these escapades only because he feared th a t e x p o ­ su re o f his activities m ight je o p a rd iz e his chances o f using the college’s ROTC p ro g ram to gain adm ission to o fficer’s can d id ate school after g ra d ­ uation. A lthough he d id jo in the ROTC, a congenital h e a rt defect, which he had neglected to report, resulted in his rejection from the program after his first week. Things continued to go poorly for Mr. A. A fter he learn ed o f form al charges being brought against an accomplice in the stereo thefts, he became m ore hopeless about im proving his own situation. At abo u t this tim e, he w rote to his parents describing his feelings and telling them that his present problem s were all th e ir fault. Finding it difficult to sleep, he consulted the school physician and was given 20 tablets o f a sleeping pill. However, he left the office w ith the im pression th a t he had been given tran q u ilizers and w ithin a p erio d o f two hours had consum ed them all. H e was found com-

Personality Disorders / 459 atóse in his dorm itory room an d was taken to a local hospital where he m ade a quick recovery afte r em ergency m edical treatm en t. His school counselor recom m ended he leave school and hospitalize him self for psychiatric treat­ m ent. He re tu rn e d hom e an d received th e sam e advice from a form er th e r­ apist w hom he h ad consulted previously re g a rd in g his compulsive gam bling. H e ag reed to the hospitalization and his form er th erapist arra n g e d his adm ission. O n adm ission, Mr. A stated th a t he was seeking hospitalization because “I ’m depressed an d not fu nctioning and I overdosed on sleeping pills.” A lthough he described his m ood as depressed, his affect was o f full range an d norm al intensity. T h e re were no disturbances noted in his th inking; no p erceptual disturbances were revealed on exam ination. His speech was n orm al in rate an d flow, b u t was rem arkable in its content in th a t he con­ tinually rem arked on how o th e r’s acts related to him w ithout any seem ing awareness o f his own role in b rin g in g a b o u t his difficulties. His attitu d e at such times indicated th a t fie expected o th ers to feel sym pathetic with his plight an d acknow ledge the special n a tu re o f his problem s. For exam ple, the im pact o f his accomplice’s a rrest on his “hopelessness” an d on his p oor academ ic perfo rm an ce were presented as obvious an d he felt the overdose was actually the physician’s fault for n ot adequately in fo rm in g him o f the d an gerous potential o f overusing the d ru g . He rep o rted th at at the tim e he had overdosed, he had n ot felt suicidal an d he rep o rte d no present sui­ cidal feelings.

DSM-III-R Diagnosis Axis I: Axis II: Axis IV’: Axis V:

D ysthym ic d iso rd er Narcissistic personality d iso rd er (P rim ary diagnosis) Rule o ut A ntisocial personality d iso rd er M ild— new school year Fair— some im p airm en t in b o th social an d occupational functioning

Treatment and Hospital Course Mr. A quickly adjusted to the routine o f the un it an d seem ed to fit in easily w ith the o th e r patients. He d em o n strated no difficulties in sleeping an d always a p p e a re d to be in good spirits. He continued to com plain o f feeling depressed despite any objective evidence o f abnorm al m ood or changes in neurovegetative functioning. T h e lack o f objective evidence to

460 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning su p p o rt Mr. As com plaints o f depression led his psychiatrist to consider a diagnosis o f a personality diso rd er as Mr. A’s prim ary diagnosis. Mr. A had no family history o f affective disorders. His father abused alcohol and his b rother abused drugs, b u t neither o f them had ever been treated for these substance abuse problems. He adm itted to using m arijuana and alcohol on m any occasions, b u t was convinced his substance use had never presented a problem for him . His parents were concerned about his difficulties, but were also angry at him and found it difficult to un d erstan d how the hos­ pitalization could be helpful.

Psychological Assessment In o rd er to help in establishing Mr. A’s personality d isorder diagnosis, he was referred for psychological testing. T he psychiatrist requested infor­ mation reg ard in g his intellectual abilities and the n atu re and degree o f his depression. In light o f his history o f academic underachievem ent, the psy­ chiatrist also requested th at he be evaluated for any learning disabilities or o th er neuropsychological difficulties. He received a neuropsychological screening exam , an MMPI, a WAIS-R, Rorschach, TAT, Sentence Com ple­ tion Test, and B ender Gestalt. A review o f the results from his screening exam revealed no significant neuropsychological findings. His academic difficulties seem ed more likely to be related to motivational and o th er psychological difficulties th an to neuropsychological ones. He achieved a full-scale IQ o f 108, which reflected the average o f markedly discrepant verbal and perform ance IQs o f 124 and 86, respectively. His subscale scores ranged from the B orderline and Low Average levels (Picture Completion, Block Design and Picture Arrangement) to the Very Superior levels (Similarities and Comprehension). A m ong the verbal subtests, his relatively poor perform ance on the Digit Span and Arithmetic subscales was partially a reflection o f anxiety and diminished concentration. His perform ance subtests were lowered by his tendency to work quickly and to settle on the first approximate solution to be achieved without giving pro p er attention to a final check o f the details. For exam ple, he com pleted the eighth item o f the Block Design in 100 seconds, but inverted the red tri­ angle in the lower left-hand corner o f the design. This deficit was partic­ ularly noticeable on the Picture Completion subtest, which assesses discriminative judgm ent, where he gave his weakest performance. His rela­ tive strengths were ap p a re n t on those subtests requiring the exercise o f abstract reasoning, knowledge o f social conventions, and the application o f some modicum o f social judgm ent. Mr. A did well on these subtests despite some mild intrusions o f his own idiosyncratic concerns.

Personality Disorders I 461 B earin g in m ind th a t the WAIS-R is a highly stru c tu re d evaluation d u r­ ing which the exam inee is required to produce responses with a high degree o f factual o r consensual validity, Mr. A’s m ild intrusions take on diagnostic im portance. For exam ple, on th e Comprehension subscale, which elicited his second best perform ance on the WAIS-R, elements o f grandiosity and enti­ tlem ent were woven into his generally quite adequate answers. In explaining how one should act if one is the first person to see smoke and fire in a movie theater, he th o u g h t it best to inform the usher an d call the fire d e p a rtm e n t and then “get th e people o u t calmly.” Interestingly, d espite his clear rec­ ognition th a t those in a position to take responsibility for clearing th e th e ­ a te r an d controlling the fire should be notified, he felt th a t he m ust be directly involved him self in o rd e r to insure an adequate outcome. Likewise, w hen asked to explain the m ean in g o f the proverb “Strike while the iron is hot,” he focused on the p rep ared n ess o f th e ag en t (“Strike w hen you’re ready, not later o r before”) ra th e r than, as is more usually the case, the avail­ ability o f the opportunity. His responses to those Comprehension items involv­ ing relationships betw een individuals an d agencies also reveal the sam e egocentric focus. B orrow ing money from banks ra th e r th a n from friends was seen as advantageous because “friends aren’t always there, banks a re ”; people should pay taxes in o rd e r “to get services from the state.” W hile Mr. A clearly recognizes his own needs, he feels th a t some d eg ree o f guile and duplicity is necessary in o rd e r to m eet them . His first p ercep t on the Rorschach is o f “a fox,” an anim al associated in mythic lore with craft and wiliness in the p u rsu it o f his own needs. But also like the fox o f Aesop’s fable who contem ptuously disparages the grap es he can n o t reach, Mr. A m ust find some way to protect him self from the hum iliation o f failure. C on­ stan t praise is req u ired to m aintain his self-esteem (e.g. when someone looks at me, 1 “feel goo d ”; after he made love to her he “felt g o o d ”). In seeking it in the aren a o f social relationships, however, the th re a t o f n ot receiving it an d the hum iliation en g en d ered by openly d esirin g it are the risks. O n the Sentence Completion Test, Mr. A acknowledges th a t he felt proud that he “was sm art,” b u t also notes th a t he can be m ade to “feel stupid” if he is criticized o r if he fails an exam ination. H is p referred a ttitu d e to such situations is to hold him self back from any gratifying em otional engagem ent with others. In his very constricted Rorschach, he m anages only 13 responses, a level o f productivity th a t is inconsistent with his intellectual abilities. O f note, b oth o f his h u m a n responses are “two females staring at each o th er” (cards 111 an d VII). He generally limits him self to the obvious and m undane. Almost one-half o f his responses are p o p u lar responses (P% = 46), an equal proportion are based solely on perception o f form (F% = 46), and with few exceptions they are lim ited to easily perceived anim als (A% = 85). His B ender also

462 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning reflects detachm ent in his minimally invested, perfunctory copies o f geo­ m etric designs. O n the TAT, he tells trite stories th at, like his Rorschach responses, avoid th e em otional nuances o f the interaction. For exam ple, his story to card 10 deals with the 15th anniversary o f “a m an and a w om an” who “h ope to live a good life the next 15 years. I t’s ju s t a nice family, the A m erican d re a m .” W hen actually caugh t u p in the em otional content o f the card , he offers endings involving suppression and denial of strong affects (cards 13MF, 3BM a n d 7BM) o r a retre a t into reluctant com pliance an d formalistic “d u ty ” (cards 1 and 6BM , respectively). Sham e is to be particu larly avoided, as Mr. A notes in his story to card 13MF. T h e card depicts a wom an with bare breasts lying on a low, narrow bed with h er face partially tu rn e d tow ards the wall. In the fo reground is a m an dressed in shoes, pants, sh irt an d tie who is holding his rig h t arm across his face and is stan d in g beside a small table contain in g books an d a lamp. He opened his story, after a long pause, with the com m ent th at “this is b rin g in g back lots o f bad m em ories.” He went on to state th at “this guy h ad picked up a hooker in a cheap hotel room . She’s a stone cold ju n k ie , flat on h er back. He’ll leave feeling lower th an before. He’ll w an d er the streets an d try to forget.” A m nesia seem s to be the only possible solution to “bad m em ories.” T h e possibility th a t em otional difficulties could be worked th ro u g h with th e help o f som eone is trea ted w ith contem pt. His story to card 12M involves a hypnotic treatm en t for cessation o f sm oking by a client who “doesn’t th in k it’s going to work, b u t $25.00 isn’t too m uch to pay.” T he hypnotist is, as predicted, unsuccessful in im mediately helping the client to deal m ore satisfactorily w ith his oral needs and the experience simply becom es “som ething to talk a b o u t with the guys at the office.” A lthough Mr. A’s dysphoria an d low self-esteem were quite real features o f his c u rre n t psychological state, he seem ed m ore prone to address these difficulties th ro u g h an action orientation designed to provide im m ediate relief. His MMPI profile showed its p eak elevations on scales 2 an d 4 (both > 80) w ith scales 3, 7 an d 8 also showing clinically significant elevations ( > 70). However, desp ite his awareness o f these difficulties, he showed little concern over them (e.g. F scale < 60). T he exam ining psychologist sum m arized these test findings as most con­ sistent w ith a narcissistic personality disorder, specifically h ig h lig h tin g his d etached view o f others, his insensitivity to th eir feelings, his own sense o f entitlem ent an d specialness, w ith som e evidence o f sociopathic ch arac­ teristics given his willingness to exploit others for his own needs. T hese latter feelings about him self were felt to be features o f his personality disturbance that would make it especially difficult to engage him in a psychotherapeutic treatm en t w here he could acknow ledge his m ore p ain fu l feelings o f d e p re ­

Personality Disorders / 463 d a te d self-worth and address the defensive purposes o f his entitlem ent and contem pt for others.

Treatment Planning and Outcome Mr. A was inform ed o f the results an d form ulation o f the psychological testing and responded by bein g quite pleased th a t his difficulties could be given a nam e. D espite his acceptance o f the diagnosis an d his agreem ent with the form ulation o f his difficulties, he continued to speak o f his p ro b ­ lems in term s o f the fault resting with others. In his individual psychother­ apy, this a ttitu d e was gently confronted an d he was encouraged to accept some responsibility for his problem s and his treatm en t. He paid lip service to the need for him to do so if he were to alter his situation in life, b u t invested no real effo rt in the task. T h e only ch ange recorded d u rin g his subsequent treatm en t was th a t he ceased com plaining o f his “depression.” As Mr. A began to feel less “depressed,” he began to push for a discharge from the hospital. T h e hospital staff, feeling th a t there was no longer any need for Mr. A to continue his treatm en t in the hospital, b egan to allow him passes from the hospital to arra n g e for his discharge. He used these passes to reacquaint him self with several recently disch arg ed , fem ale patients w ith whom he developed social, an d in some cases intim ate, rela­ tionships. W hen the hospital staff became aware o f these liaisons, they con­ fronted him with th eir im propriety. He was u nable to recognize o r accept that these activities were yet an o th er exam ple o f how he continually got him ­ self into trouble by acting out his difficulties rath er th an seeking alternative, and m ore constructive, solutions. He was d isch arg ed from the hospital with a referral for individual psy­ chotherapy an d w ith recom m endations th a t he enroll in a local college and live independently o f his family. In o rd er to help his family continue to work on th eir own difficulties in allowing the separation, they also were referred to a family therapist.

4 6 4 / Psychological Assessment, Psychiatric. Diagnosis, and Treatment P lanning

EXHIBIT

1

A rea of

C l in ic a l

P s y c h o l o g ic a l

A ssessm en t

E x a m in a t io n

E x a m in a t io n

Grandiosity

Emphasizes the special n ature o f his problems

Projects a view o f him self as unique

Preoccupation with fantasies

None

Preoccupied with proving his intellectual bril­ liance while having basically low self-esteem

Exhibitionism

Requires the adm iration o f others to maintain adequate self-esteem

Intensely focussed on his own needs and desires

Response to criti­ cism is rage, humiliation, or feelings o f inferiority

Poor academic perform ­ ance leaves him hope­ less; hum iliated and enraged by alleged theft

Avoids becoming affec­ tively involved with the examination

Entitlement

Surprised no one believes his innocence

Believes his own needs are always param ount

Exploitativeness

Readily exploits other patients for his sexual needs with complete disregard for rules

Some sociopathic tendencies

Lack o f em pathy

C annot understand how his parents, hospital staff or other patients feel

Indifferent or unable to recognize how others feel. Detached from others.

II. Personality Factors

Personality features con­ sistent with a narcissis­ tic personality disorder

Personality style consists o f alternating im pulse ridden periods and anhedonic despair

III. Cognitive Abilities

Possible learning disabil­ ity or neuropsychologi­ cal difficulties

No learning disabilities or neuropsychological dif­ ficulties; average or above average intellec­ tual ability but func­ tions very inefficiently

I.

Symptoms/Diagnosis Narcissistic personal­ ity disorder

Personality Disorders / 4 6 5

A rea of

C l in ic a l

A ssessm en t

E x a m in a t io n

IV. Psychodynam ics

V.

T herapeutic Enabling Factors

VI. Environm ental D em and and Social A djustm ent

P s y c h o l o g ic a l E x a m in a t io n

Poor frustration tolerance

Perform ance highly susceptible to d isru p ­ tion by anxiety

Feelings o f shame and hum iliation prevent acknow ledgem ent o f any responsibility for his problems

Use o f avoidance, denial and externalization to m aintain self-esteem

Provisional acceptance o f recom m endation for treatm ent

Accepts recom m endation but is not motivated to change and expects failure

Above average verbal skills

Above average verbal skills

Chronic history o f poor academ ic perform ance with recent academic probation

Consistently achieves below abilities unless assured o f ultim ate success

Active social life with no close friends

Sees others largely in term s o f th eir ability to fulfill his own needs

466 ! Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT WAIS-R

2

Sum m ary

Scaled Score

Verbal Subtests Inform ation Digit Span Vocabulary A rithm etic Com prehension Similarities Verbal Score

12 9 13 9 14 16 73

Performance Subtests Picture Completion Picture A rrangem ent Block Design Object Assembly Digit Symbol Perform ance Score

6 8 7 10 9 40

Verbal IQ Performance IQ Full Scale

124 86 108

MMPI Summary FKL/ 24"7853'6-901/ Rorschach Summary N um ber o f Responses Rejections Populars O riginals Average R/T Chrom atic Average R/T Achromatic F% F+ % A% H%

13 1 (C ard IX) 6 0 12" 8" 46 77 85 15

Personality Disorders I 467

R orsch a ch Sum

W :M M :S um C m :c V III-X % FK + F + Fc (H + A ):(H d + A d ) A p p e rce p tio n w

m ary

69% D 31% d 0% Dd + S 0%

9:2 2:1 4:0 31 46 12:1

4 6 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment P la n n in g

EXHIBIT

3

R o rschach Sum m ary

Response

Inquiry

Scoring

I . 10"

1. A fox.

T h e whole thing; you know, spaces were eyes, ears were at the top. Just the shape.

W(s)FAd

(More') 2. T h e whole thing. Looks like wings on the side, b u t­ terfly body in the m iddle.

WFAP

It was the black parts on the sides. Just short, stum py little anim als laying on th eir sides. (?) You know, laying down, like facing each other.

DFMA

1. T h e black p a rt is two females staring at each other, p u ttin g th eir hands on a table.

T he black parts on the side. Looks like females because o f shape, breasts, female form.

WMHP

2. T h e red p a rt is a butterfly.

2. T h at was red p a rt in the m iddle. Just looked like a butterfly.

2. A butterfly.

II. 21" 1. 1 see groundhogs in the black p a rt . . . th a t’s all 1 see.

I I I.

9"

DFAP

IV. 11" 1. T his looks like a butterfly this way.

T h e whole thing. T h e sides look like wings, top p art was the head. Just the shape.

WF-A

V. 5" 1. T his looks like a butterfly, too.

1. T he whole thing. Just the shape, wings, antennae, head.

WFAP

Personality Disorders / 4 6 9

R orschach Sum mary

Response

Inquiry

Scoring

VI. 4" 1. T his looks like a m ashed pussy cat (laughs).

1. T he whole thing. Looks like som ebody ran over it and m ashed it. Top p a rt is head with whiskers, rest is shaped like a m ashed cat.

WFA

1. T he whole thing. Top parts was the heads, and rest looks like bodies. (Staring}) Yeah, they were facing each other.

WMHP

1. T he bears are two figures over the sides; the green p a rt is shaped like a tree and the rest is p a rt o f the tree or rocks. (?) It was the shape.

W FM A.Nat.P

VII. 8 " 1. T his looks like two females staring at each other.

V III.

7"

1. T his is two bears clim bing a tree.

IX. 17" I don't see anyth in g in this one. I t ju s t looks like an inkblot.

Rejection

X. 8 " 1. T he whole thing. It was the colors . . . and the shapes (points to different figures.) It looks like differen t things sw im m ing around.

W FM.FCA

2. T h e blue is angel fish.

2. Itju st looked like a colorful fish to me, like an angel fish swimming.

DFM-A

3. T he red in the m iddle is shrim p, ju s t the colors. T hey’re sw im m ing around.

3. It looked like a shrim p swim ming a ro u n d in the water, not the cooked kind.

DFM-A

1.

T his looks like Sea World.

470 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning

EXHIBIT

4

T h e m a t ic A p p e r c e p t io n T e s t

CARD 1 Well. H is paren ts w anted him to take violin lessons, b u t he doesn’t like it. He doesn’t w ant to be p u t th ro u g h th a t to rtu re. (What will happen}) He’ll get used to it, learn to like it o r he’ll give up. CARD 3BM She’s ju s t d esp airin g . I don’t know a b o u t w hat. Life’s gotten to be too m uch for her. (W/iat’s she despairing about}) I don’t know. (W hat will h ap p en ?) She won’t kill herself. H opefully she’ll get over w hatever it is. CARD 4 A scene o u t o f a movie . . . He’s going o ff to some g reat ad v en ­ tu re, som ething very, very dangerous. She could give him h appiness b ut he has to d o som ething to prove his m achism o. (What will happen}) He’ll probaby end u p g ettin g killed o r som ething. CARD 5 M other h e ard a noise . . . she o p en s th e d o o r an d sees n o th in g ’s w rong. (What’s she thinking}) She’s w orried a b o u t a child. She h e a rd som e­ th in g fall on a table b u t she found o ut it was ju s t a cat fooling aro u n d . CARD 6BM Just a m other and son at a funeral. Someone som ewhat close to them has died but not all th at close. T hey’re w aiting a ro u n d to pay th eir respects. T h en they’ll go hom e. Ju st a family d uty one has to p erform . CARD 7BM Just two businessm en talk in g at a b a r about everything. T hey’re d rin k in g a little too m uch an d they’re a little bored. T hey’re do in g som ething m ore pleasurable th a n going hom e to th e ir wives. T hey’ll get in th e ir cars, go hom e, an d hopefully n ot kill anybody on the way. CARD 10 Ju st a m an an d a w om an on th e ir 15 th anniversary. T hey hope to live a good life the next 15 years. It’s ju s t a nice family . . . the A m erican dream . CARD 12M T his m an is bein g h y pnotized to quit sm oking. H e doesn’t th in k it’s going to work, b u t $25 isn’t too m uch to pay. He won’t succeed but it’ll be som ething to talk about with th e guys at the office. CARD 13MF (longpause) T his is b ringing back lots of bad memories. This guy has picked u p a hooker in a ch eap hotel room ; she’s a stone cold ju n k ie flat on h er back. He’ll leave feeling lower th an before; he’ll w ander the streets an d try to forget. CARD 14 Just a m an looking o u t a window . . . overlooking a sidewalk on a hot su m m er day; people are going by. He’s plan n in g to go out tonight. He’s d o in g a healthy form o f contem plation.

Personality Disorders / 471 T

h e m a t ic

A

p p e r c e p t io n

T

est

CARD 15 (Laughs) I never saw this one . . . H m m m . . . (Longpause) This looks like som ething out o f a h o rro r movie . . . (frowns) . . . T h e person is at a grave, som eone has died, there’s em ptiness in this picture. C an’t even tell if it’s a male o r a female. Almost som ething like visiting a graveyard after W WI . . . like those im ages o f people going to see th eir d ead sons who are never com ing back. Som ebody who was 18 years old, went o ff to war and was blasted to bits an d this person outlived th e ir own ch ild ren an d they’ll die a lonelier d eath . T his p icture could alm ost be used for p ropaganda. (How io?) You know, war, d eath , its waste. (Sighs) I ’ve read so m uch about it. (And}) Well, you know, some wars are useful b ut nothing was gained after W W I. So m any people had sons th a t never cam e back. O f course, she’s lucky in a way, lucky enough he cam e back to h er to be buried.

472 ! Psychological Assessment, Psychiatrie Diagnosis, and Treatment Planning

EXHIBIT Sen ten ce C

o m p l e t io n

5 T

est

3.

It looked impossible, so he “sto p p e d .”

7.

He felt proud that he “was sm a rt.”

8.

As a child my greatest fear was “b ein g alone.”

18.

Usually he felt that sex “was n e e d e d .”

29.

/ used to daydream about “bein g successful.”

32. Love is “n eed ed .” 38. When someone looks at me, 1 “feel g o o d .” 40.

After he made love to her, he “felt g o o d .”

42.

When I am criticized, I “feel stu p id .”

48.

When he found he luid failed the examination, he “felt stu p id .”

63.

Whenever he does below average work, he “feels stu p id .”

Personality Disorders / 473

DISCUSSION T h e two patients we have chosen to illustrate this personality d iso rd er are both young m en. Both o f these young m en were hospitalized n ot for in ter­ personal behavior characterized by narcissism , b u t for situational depres­ sion and behaviors th a t were illegal (stealing, using cocaine) an d could be conceptualized as in a p p ro p ria te attem pts to han d le anxiety and o th e r d if­ ficulties. Both Mr. A an d Mr. C m anifest difficulties in relating to others, not exclusively related to o r c a p tu re d by the narcissistic label. Mr. A seems quite shallow and m anipulative in his relationships, and his behavior has antisocial characteristics. Mr. C seems to have a m ore salient and m eaningful connection with his m other, at least, b u t rem ains superficial in m any o f his contacts. A nd, m ost crucial for tre a tm e n t p lanning, both o f these young m en manifest personal attitudes and interpersonal behavior th a t are threats to the form ation o f a viable treatm en t alliance. Both are inclined to blam e th eir troubles on extern al factors and want little assistance beyond im m e­ diate sym ptom relief. Psychological testing is called for in both cases to p in­ po in t these threats to th e treatm en t alliance, and to use the d a ta in o rd e r to confront the patients with th e ir p articu lar deficits. Mr. A was a 19-year-old college sophom ore who cam e to the attention o f the m ental health com m unity because o f a series o f behaviors th a t led to a d ru g overdose (possibly suicidal in nature). A resolve m ade to his fath er to achieve in school was followed by his stu d y in g only w hat pleased him . T his was followed by possible theft and trouble with the authorities, which led to depression and fu rth e r dysfunction. T hus, after a series o f behaviors involving acting out an d , m ost probably, lack o f honesty ab o u t his own behavior, he was hospitalized with depression th at seem ed situational, with the overriding issue o f his personality traits th a t chronically got him into trouble. T he projective m aterials were noteworthy for their content th at was obvi­ ous, m undane and trite. T h e general picture em erged o f a young m an who solved difficulties by action designed to give im m ediate relief, built on a basic a ttitu d e o f insensitivity to o th ers and a sense o f his own specialness and entitlem ent. T h e testing results portrayed in clear detail the serious pro b ­ lems in beginning a therapeutic approach with such an individual. T he dif­ ficulty o f establishing a therapeutic alliance in which the patient recognizes, at least to som e degree, his own difficulties, his contrib u tio n to these d if­ ficulties, and his need for assistance to ch an g e is greatly am plified by this m an’s basic ch aracter traits involving acting out, d isreg ard for others, and a false sense o f his own specialness. At best, the testing assisted the therapist

474 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning in articulating and confronting the patient with these difficulties quite early in treatm ent. Mr. C, a 28-year-old, u n m arrie d male, cam e to the attention o f the m ental health field, as d id Mr. A, not because o f his personality d iso rd e r perse b u t in an organic state d u e to cocaine abuse in the context o f depression an d g rie f following the d ea th o f his m other. Following his hospitalization, the organic delusional syndrom e cleared quickly an d th e tre atm e n t team was faced with assessing his personality stren g th s an d weaknesses. In fact, the treatm en t team was struck by his public ap p ea ra n c e o f norm ality, which was in sh a rp contrast with his profound sense o f loss an d g rie f over his m o th e r’s d eath as revealed in psychotherapy sessions. His testing results in some ways m irrored this dichotomy. For exam ple, his MMPI was in the nor­ m al ran g e on all scaled scores. W hile it does h a p p e n th a t psychiatric in p a ­ tients yield a norm al M M PI, this is a relatively rare event. W hile Mr. A’s Rorschach was significant for its banality, th at produced by Mr. C was exten­ sive, with very few p o p u lars and an em phasis on u n u su al details. T hem es o f dangerousness, countered by u n d o in g and with a focus on percep ts th a t were harm less, were noted in the Rorschach. It was in the TAT, however, th a t Mr. C revealed his preoccupation with fantasies o f success an d epic triu m p h .

References

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4 7 6 / Psychological Assessment, Psychiatric Diagnosis, a n d Treatment P la n n in g C ronbach, L.J. (1949). Essentials of Psychological Testing. New York: H a rp e r & Brothers. D ahlstrom , W.G., Welsh, G.S., & D ahlstrom , L.F.. (1972). An MMPI handbook. Vol. I. Clinical interpretation. M inneapolis: University o f M innesota Press. Dollin, A., & Phillips, W. (1976). Diagnostic referral questions in psychological test­ ing: C hanging practices in the fifties, sixties and seventies. Psychological Reports, 39, 850. Dollin, A., & Reznikoff, M. (1966). Diagnostic referral questions in psychological testing: C hang in g concepts. Psychological Reports, 19, 610. Elwood, D.J. (1969). A utom ation o f psychological testing. American Psychologist, 24, 2 8 7 -2 8 9 . Eron, 1..D. (1950). A norm ative study o f the T hem atic A pperception Test. Psycho­ logical Monographs, 64 (9, Whole No. 315). Eron, L.D. (1953). Responses o f women to the Them atic A pperception Test .Journal of Consulting Psychology 17, 2 6 9 - 282. Exner, J .E., Jr. (1974). The Rorschach: A Comprehensive System, Vol. 1. New York: Wiley. Fairbank, J.A., Keane, T.M., 8c Malloy, P.P. (1983). Some prelim inary d a ta on the psychological characteristics o f Vietnam veterans with post-traum atic stress dis­ order. Journal of Consulting and Clinical Psychology, 51, 912—919. Fowler, R.D. (1985). Landm arks in computer-assisted psychological assessment. Jour­ nal of Consulting and Clinical Psychology 53, 748—759. G arfield, S.L. (1983). The Study of Personality and Behavior (2nd ed.). New York: Aldine. G arfield, S.L., & K urtz, R. (197(5). Clinical psychology in the 1970s. American Psy­ chologist, 31, 1 -9 . G olden, C.J. (1979). Clinical Interpretation of Objective Psychological Tests. Newr York: G ru n e & Stratton. Goldstein, G., & Hersen, M. (Eds.) (1984). Handbook of Psychological Assessment. New York: Pergam on Press. G oldstein, K. (1939). The Organism: A Holistic Approach to Biology Derived from Path­ ological Data in Man. New' York: A m erican Book Co. G oldstein, K., & Scheerer, M. (1941). A bstract and concrete behavior: An e x p e r­ imental study with special tests. Psychological Monographs 53 (2, Whole No. 230). G oodenough, F.L. (1926). Measurement of Intelligence by Drawings. Yonkers, N.Y.: World Book Co. Hammer, E.F. (Ed.) (1958). The Clinical Application of Projective Drawings. Springfield, 111.: C harles C. Thom as. H arris, D.B. (1963). Childrens Drawings as Measures of Intellectual Maturity: A Revision and Extension of the Goodenough Draw-A-Man Test. New York: H arc o u rt Brace Jovanovich. Hathaway, S.R., & McKinley, J.C. (1942). A multiphasic personality schedule: T he m easurem ent o f sym ptom atic depression. Journal of Psychology, 14, 73—84. Hathaway, S.R., & Meehl, P.E. (1951). An Atlas for the Clinical Use of the MMPI. M in­ neapolis: University o f M innesota Press.

References / 4 7 7 Hevern, VW. (1980). Recent validity studies o f the Halstead-Reitan approach to clin­ ical neuropsychological assessment: A critical review. Clinical Neuropsychology 2, 4 9 -6 1 . Holt, R.R. (1967). Diagnostic testing: Present status and fu tu re prospects. Journal of Nervous and Mental Disease, 144, 4 4 4 - 465. Holtzman, W.H. (1968). Holtzman Inkblot Technique. In A.I. Rabin (Ed.), Projective Techniques in Personality Assessment (pp. 1 3 6 - 170). New York: Springer. Hulse, W.C. (1952). Childhood conflict expressed through family drawings, Journal of Projective Techniques, 16, 6 6 -7 9 . Hyer, L., O ’Leary, WC., Saucer, R.T., Blount, J., H arrison, W.R., 8c Boudewyns, P.A. (1986). Inpatient diagnosis o f post-traumatic stress disorder. Journal of Consult­ ing and Clinical Psychology, 54, 6 9 8 -7 0 2 Ju n g , C.G. (1910). T h e association m ethod. American Journal of Psychology, 21, 2 1 9 -2 6 9 . Klopfer, B., & Kelly, D.M. (1942). The Rorschach Technique. Yonkers, N.Y.: World Book Co. Koppitz, E.M. (1964). The Bender-Gestalt Test for Young Children. New York: G rune 8c Stratton. Koppitz, E.M. (1975). The Bender-Gestalt Test for Young Children: Research and Appli­ cation, 1963—¡973. New York: G rune & Stratton. K orchin, S.J. (1976). Modern Clinical Psychology New York: Basic Books. Lachar, D., 8c Alexander, R.S. (1978). Veridicality o f self-report: Replicated correlates o f the Wiggins MMPI content scales .Journal of Consulting and Clinical Psychology 46, 1349-1356. L ubin, B., L arsen, R.M., 8c Matarazzo, J.D. (1984). Patterns o f psychological test usage in the U nited States: 1935—1982. American Psychologist, 39, 4 5 1 -4 5 3 . L ubin, B„ Larsen, R.M., M atarazzo, J .D., 8c Seever, M. (1985). Psychological test usage patterns in five professional settings. American Psychologist, 40, 857—861. L uria, A.R. (1973). The Working Brain. New York: Basic Books. MacAndrews, C. (1965). T he differentiation o f male alcoholic outpatients from non­ alcoholic psychiatric patients by means o f the MMPI. Quarterly Journal of Studies in Alcohol, 26, 238— 246. Machover, K. (1949). Personality Projection in the Drawing of the Human Figure: A Method of Personality Investigation. S pringfield, 111.: C harles C. Thom as. Marks, P.A., Seem an, W., & Haller, D.L. (1974). The Actuarial Use of the MMPI with Adolescents and Adults. Baltimore: Williams & Wilkins. M atarazzo, J.D. (1972). Wechslers Measurement and Appraisal of Adult Intelligence (5th ed.). Baltimore: Williams 8c Wilkin. M eehl, P.E. (1954). Clinical versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence. M inneapolis: University o f M innesota Press. M organ, C.D., 8c Murray, H .A . (1935). A m ethod for investigating fantasies: T he Them atic A pperception Test. Archives of Neurology and Psychiatry 34, 289—300. Murray, H.A., et al. (1938). Explorations in Personality New York: O xford University Press.

4 7 8 / Psychological Assessment, Psychiatric Diagnosis, and Treatment Planning National Computer Systems (1984). 1984 catalog [Professional Assessment Services Division]. Minneapolis: Author. Pascal, G.R., 8c Suttell, B.J. (1951). The Bender-Gestalt Test: Quantification and Validity for Adults. New York: Grune & Stratton. Pfohl, B., & Andreasen, N.C. (1986). Schizophrenia: Diagnosis and classification. In A.J. Frances 8c R.E. Hales (Eds.), American Psychiatric Association, Annual Review, Volume 5 (pp. 7 -2 4 ). Washington DC: American Psychiatric Press. Pitrowski, Z.A. (1964). A digital computer administration o f inkblot test data. Psy­ chiatric Quarterly, 38, 1-2 6 . Rapaport, D., Gill, M-, 8c Schafer, R. (1945—1946). Diagnostic Psychological Testing (Vols. 1-2). Chicago: Year Book Publishers. Rapaport, D., Gill, M., & Schafer, R. (1968). Diagnostic Psychological Testing (rev. ed. edited by R.R. Holt). New York: International Universities Press. Reitan, R.M., 8c Davison, L.A. (Eds.) (1974). Clinical Neuropsychology: Current Status and Applications. New York: Halsted. Rohde, A.R. (1946). Explorations in personality by the sentence completion method. Journal of Applied Psychology, 30, 1 6 9 - 181. Rorschach, H. (1942). Psychodiagnostics: A Diagnostic Test Based on Perception (P. Limkau 8c B. Kronenburg, Trans.). Berne: Huber. (Original work published, 1921: U.S. distributor, Grune 8c Stratton). Rotter, J.B., & Rafferty, J.E. (1950). Manual for the Rotter Incomplete Sentences Blank, College Form. New York: T he Psychological Corporation. Schacht, R., 8c Nathan, P.E. (1977). But is it good for psychologists? Appraisal and status o f DSM-III. American Psychologist, 32, 1017—1025. Schafer, R. (1948). The Clinical Application of Psychological Tests. New York: Interna­ tional Universities Press. Schafer, R. (1954). Psychoanalytic Interpretation in Rorschach testing. New York: Grune 8c Stratton. Schmidt, H.O., & Fonda, C.P. (1956). The reliability o f psychiatric diagnosis: A new look. Journal of Abnormal and Social Psychology, 52, 2 62—267. Spitzer, R.L. (1980). An in-depth look at DSM-III (interviewed by J. Talbot). Hospital (si Community Psychiatry, 3 1, 25—32. Spitzer, R.L., 8c Fleiss.J.L. (1974). A reanalysis o f the reliability o f psychiatric diag­ noses. British Journal of Psychiatry, 125, 3 4 1 -3 4 7 . Spitzer, R.L., Forman, J.B., 8c Nee, J. (1979). DSM-III field trials: Initial diagnostic reliability. American Journal of Psychiatry, ¡36, 8 1 5 -8 1 7 . Spitzer, R.L., Williams, J.B., & Skodol, A.E. (1980). DSM-III: The major achieve­ ments and an overview. American Journal of Psychiatry, ¡37, 15 1 -164. Tendier, A.D. (1930). A preliminary report on a test for emotional insight. Journal of Applied Psychology, 14, 123—136. Wechsler, D. (1939). The Measurement of Adult Intelligence. Baltimore: Williams 8c Wilkins. Wiggins, J.S. (1973). Personality and Prediction Principles of Personality Assessment. Read­ ing, Ma.: Addison-Wesley Publishing Co.

References, / 4 7 9 Wolk, R.L., 8c Wolk, R.B. (1971). Manual Gerontological Apperception Test. New York: H um an Sciences Press. Zubin, J. (1967). Classification o f behavior disorders. Annual Rei’iew of Psychology, 18, 373-406.

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Name Index

Adams, K.M., 13 American Psychiatric Association, 1, 14, 15, 17, 20 A nastasi, A nne, 1, 2

Holtzm an, W.H., 5 Ju n g , Carl, 5 Keller, L.S., 1 3 -14 Kerner, J., 5 Klopfer, B., 5 Koppitz, E.M., 7 K raeplin, E., 3, 9

Bacon, S.F., 13-14 Bender, L.A., 6 - 7 Butcher, J.N ., 13-14 Cam eron, N., 8 C ronbach, L.J., 2

Levy, David, 5

Exner, J .E., Jr., 5, 13, 101

McKinley, J.C., 8 Machover, K., 7 Meehl, P.E., 11 Meyer, Adolph, 14 M organ, C.D., 6 Murray, H.A., 6

Ferrari, B., 3 Form an, J.B., 24 Freud, Sigm und, 4 G alton, Francis, Sir, 2—3 Gill, M., 11 G oldstein, K urt, 12 G oodenough, F.L., 7

N athan, P.E., 19 Nee, J., 24 O berholzer, E., 5

H arris, D.B., 7 Hathaway, S.R., 8 H eaton, R., 13 H enri, V.,3 Holt, R.R., 11

Piotrowski, Z.A., 5, 13 R apaport, D., 5, 11 Rohde, A.R., 8

481

4 8 2 / N am e Index Rorschach, H erm an n , 5, 1 1

Spitzer, R obert L., 17, 20, 24 T erm an, L.M., 4

Schacht, R„ 19 Schafer, R., 11 Simon, 3

W ertheimer, M., 6 W undt, W.M., 2

Subject Index

A bstract thinking, brain d am age an d , 12

A djustm ent disorder with depressed m ood, 3 5 0 -3 6 3 clinical and psychological exam ination results, 3 5 5 -3 5 6 t D SM -III-R diagnosis, 351 profile o f Mr. T, 3 5 0 -3 5 1 , 364 psychological assessm ent, 3 5 2 -3 5 3 Rorschach sum m ary, 3 5 7 -3 5 8 t, 3 5 9 - 3 6 It treatm ent and hospital course, 3 5 1 -3 5 2 treatm ent planning and outcom e, 3 5 3 -3 5 4 WAIS-R sum m ary, 357t A djustm ent d isord er with mixed disturbance o f em otions and conduct, 3 3 0 -3 4 9 clinical and psychological exam ination results, 3 3 6 -3 3 7 t profile o f Ms. K, 3 3 0 -3 3 2 , 3 6 4 -3 6 5 psychological assessm ent, 3 3 3 -3 3 4 Rorschach sum m ary, 3 3 8 -3 3 9 t, 3 4 0 -3 4 6 t Sentence C om pletion Test, 349t

T hem atic A pperception Test, 3 4 7 -3 4 8 t treatm ent and hospital course, 332 treatm ent p lanning and outcom e, 335 WAIS-R sum m ary, 338t Adolescents, depression in, 98 Affective disorders, in D SM -III-R , 22 Alcohol abuse. See Post-traum atic stress disorder, delayed with alcohol abuse, episodic A m erican Psychiatric Association, diagnostic nom enclature of, ix Anorexia nervosa, 29—45 clinical and psychological exam ination results, 35t D SM -III-R diagnosis, 30 -3 1 MMPI sum m ary, 36t profile of, 63, 64 psychological assessm ent, 3 1 -3 3 Rorschach sum m ary, 3 6 -3 7 t Sentence C om pletion Test, 4 4 -4 5 t T hem atic A pperception Test, 4 2 -4 3 t treatm en t an d hospital course, 3 1 treatm ent p lanning and outcom e, 3 3 -3 4

48 3

4 8 4 / Subject Index WAIS-R sum m ary, 36t A rm y A lpha and Beta test, 4 Avoidant Personality Disorder, 21 Axis I an d Axis II conditions, 25 Bender-G estalt Test (B ender Visual M otor Gestalt Test), 6 - 7 Binet s intelligence tests, 3 -4 B ipolar disorder, 214 B ipolar disorder, manic, with psychotic features, 2 3 4 -2 5 6 clinical and psychological exam ination results, 2 4 0 - 2 4 It D SM -III-R diagnosis, 235 profile o f Mr. M, 2 3 4 -2 3 5 , 255 psychological assessment, 2 3 6 -2 3 9 Rorschach sum m ary, 242—243t, 2 4 4 -2 5 It Sentence Com pletion Test, 254t T hem atic A pperception Test, 2 5 2 -2 5 3 t treatm ent and hospital course, 2 3 5 -2 3 6 treatm ent planning and outcom e, 239 WAIS-R sum m ary, 242t B ipolar m ania, w ithout psychotic features, 2 1 4 -2 3 3 clinical and psychological exam ination results, 222t D SM -III-R diagnosis, 216 profile o f Ms. G, 2 1 4 -2 1 6 , 2 5 5 -2 5 6 psychological assessm ent, 2 1 7 -2 2 0 R orschach sum m ary, 2 2 3 -2 3 4 t, 2 2 5 -2 3 3 t treatm en t and hospital course, 2 1 6 -2 1 7 treatm ent planning and outcom e, 2 20-2 2 1 WAIS-R sum m ary, 223t B orderline mental retard atio n , as DSM classification, 18 B orderline personality disorder, in D SM -III-R , 21

B orderline personality disorder: Ms. I, 4 0 2 -4 1 8 clinical and psychological exam ination results, 4 1 0 -4 1 It D SM -III-R diagnosis, 403 profile o f Ms. J, 4 0 2 -4 0 3 , 438 psychological assessm ent, 4 0 5 -4 0 7 Rorschach sum m ary, 4 1 2 —413t, 4 1 4 -4 1 7t Sentence Com pletion Test, 418t treatm ent and hospital course, 4 0 4 -4 0 5 treatm ent planning and outcom e, 4 0 7 -4 0 9 WAIS-R sum m ary, 412t B orderline personality d isorder: Ms. W, 4 1 9 -4 3 7 clinical and psychological exam ination results, 425t D SM -III-R diagnosis, 420 profile o f Ms. W, 4 1 9 -4 2 0 , 438 psychological assessm ent, 4 2 1 -4 2 3 Rorschach sum m ary, 4 2 6 -4 2 7 t, 4 2 8 -4 3 3 t T hem atic A pperception Test, 4 3 4 -4 3 7 t treatm en t and hospital course, 42 0 -4 2 1 treatm ent p lanning and outcom e, 424 WAIS-R sum m ary, 426t Brain dam age, behavioral m anifestations of, 12 Bulimia nervosa, 4 6 -6 2 clinical and psychological exam ination results, 5 3 -5 4 t D SM -III-R diagnosis, 47 profile o f Ms. V, 6 3 -6 4 psychological assessm ent, 4 8 -5 1 treatm ent and hospital course, 4 7 -4 8 treatm ent p lanning and outcom e, 5 1 -5 2 Case studies, selection of, x

Subject Iudex / 4 8 5 CAT. See C hildren’s A pperception Test C attell’s intelligence tests, 3 C B T I. See C om puter-based test interpretation C hildren’s A pperception Test (CAT), 6 C hinese civil service selection program , 2 C hronic brain syndrom es, 15 Clinical psychological testing, focus of,

1 Clinical psychologists, after World War II, 10 Clinical psychology, MMPI and growth o f field of, 9 C om puter-based test interpretation (CBTI), 12 ethical issues reg ard in g , 14 C om puterized tom ography (CT), 119, 120

C om puters, in psychological testing, 13-14 C onduct disorder, defining characteristic of, 64 C onduct disorder, group type and mixed substance abuse, 6 5 -8 0 clinical and psychological exam ination results, 7 0 - 7 It DSM-I I I-R diagnosis, 66 profile o f Mr. P, 65—66 psychological assessm ent, 6 7 -6 8 Rorschach sum m ary, 7 2 -7 3 t, 7 4 -7 8 t T hem atic A pperception Test, 7 9 -8 0 treatm ent an d hospital course, 66 treatm ent plannin g and outcom e, 69 WAIS-R sum m ary, 72 C onduct disorder, undifferentiated type, 8 1 -9 7 clinical and psychological exam ination, 8 6 -8 7 t D SM -III-R diagnosis, 81 MMPI sum m ary, 88t profile o f Ms. A, 8 1 ,9 8

psychological assessm ent, 8 2 -8 4 Rorschach sum m ary, 8 8 -8 9 t, 9 0 -9 3 t Sentence Com pletion Test, 97t T hem atic A pperception Test, 9 4 -9 6 t treatm en t and hospital course, 82 treatm ent p lanning and outcom e, 8 4 -8 5 WAIS-R sum m ary, 88t CT. See C om puterized tom ography DAP. See Draw-A-Person Test Depression, causes of, 25 Depressive disorders, 183 Diagnostic and statistical m anuals (DSM), 1, 14 -2 3 DSM-I, 1 4 -15 D SM -II, 1 5 -17 D SM -III, 1 7 -2 0 D SM -III-R , 2 0 -2 3 . See also D SM -III-R DSM-IV, 24 overall reliability o f data, 24 psychological testing and treatm ent planning, 2 3 -2 6 Diagnostic procedures, treatm ent p lanning developed from, ix “D isorder,” as term , 14-15 Draw-A-Man Test, 7 Draw-A-Person Test (DAP), 7—8 DSMs. See Diagnostic and Statistical M anuals DSM -III-R categories, x characteristics o f schizophrenia, 100 m ood disorders in, 183 schizoaffective disorders in, 1 3 7-138 subtypes o f schizophrenia in, 100 E ating disorders, behaviorally oriented treatm en t un it for, 63. See also A norexia nervosa, Bulimia nervosa

4 8 6 ! Subject Index Ego-dystonic homosexuality in D SM -III, 19 in D SM -III-R , 22 E xner Rorschach Com prehensive System, 13 Explorations in Personality, 6 Factitious disorder, in D SM -III, 19 G eneralized anxiety disorder, in D SM -III-R , 21 Gerontological A pperception Test, 6 G oodenough scale, 7 H alstead-R eitan Neuropsychological Battery, 12-1 3 H istrionic personality disorder, in D SM -III-R , 21 Homosexuality in D SM -III, 19 in D SM -III-R , 22 H um an figure draw ing, 7 ICD-6. See International Classification o f Diseases Intelligence Tests B inet’s work on, 3 -4 Flenri’s work on, 3 World War I and , 4 International Classification o f Diseases (ICD-6), 15 Kleksographien, 5 Late luteal phase dysphoric disorder, in DSM -II I-R, 23 L uria-N ebraska Neuropsychological Battery, 12, 13 MacAndrews Alcoholism Scale, 9 M ajor depression, recu rren t, with psychosis, 197-212 clinical and psychological exam ination results, 2 0 2 -2 0 3 t D SM -III-R diagnosis, 1 9 7-198

psychological assessm ent, 198-201 Rorschach sum m ary, 2 0 4 -2 0 5 t, 2 0 6 - 2 lOt Sentence Com pletion Test, 2 1 1 -2 1 2t treatm ent and hospital course, 198 treatm ent p lanning and outcom e, 201 WAIS-R sum m ary, 204t Major depression, single episode, with melancholia, 1 83-196 clinical and psychological exam ination results, 188—189t D SM -III-R diagnosis, 1 8 4-185 psychological assessm ent, 1 85-187 Rorschach sum m ary, 1 9 0 -1 9 It, 192—194t T hem atic A pperception Test, 195—196t treatm ent and hospital course, 185 treatm ent planning and outcom e, 187 WAIS-R sum m ary, 190t Major depressive syndrom e, 183 Manic episodes, characteristics of, 214 M ental deficiency, as term , 15 M ental illness, classification of, 3 M ental tests, 3 - 4 M innesota M ultiphasic Personality Inventory (MMPI), 8 - 9 in anorexia nervosa, 36t in bipolar disorder, manic, with psychotic features, 242t in bipolar m ania, w ithout psychotic features, 223t in borderline personality disorder: Ms. J, 412t in bulim ia nervosa, 55t co m p u ter program s for, 13 in conduct disorder, u n d ifferentiated type, 88t in narcissistic personality disorder, 466t in narcissistic personality diso rd er

Subject Index / 4 8 7 with organic delusional syndrom e, 448t in obsessive compulsive diso rd er with m ixed personality disorder, 282t in post-traum atic stress disorder, chronic, 306t in schizoaffective disorder, bipolar type, 147t MMPI. See M innesota Multiphasic Personality Inventory Mood disorders, in D SM -III-R , 183 Multiaxial evaluation system, 17

Narcissistic personality disorder, 4 5 8 -4 7 2 clinical and psychological exam ination, 464—465t in DSM -III-R, 21, 459 MMPI in, 466t profile o f Mr. A, 4 5 8 -4 5 9 , 473 psychological assessm ent, 4 6 0 -4 6 3 Rorschach sum m ary, 4 6 8 -4 6 9 t Sentence Com pletion Test, 472t T hem atic A pperception Test, 4 7 0 -4 7 It treatm ent and hospital course, 4 5 9 -4 6 0 treatm ent planning and outcom e, 463 WAIS-R sum m ary, 466t Narcissistic personality d iso rd er with organic delusional syndrome, 4 3 9 -4 5 7 clinical and psychological exam ination results, 446—447t DSM-II I-R diagnosis, 440 profile o f Mr. C, 4 3 9 -4 4 0 , 473, 474 psychological assessment, 4 4 2 -4 4 5 Rorschach sum m ary, 4 4 8 -4 4 9 t, 4 5 0 -4 5 4 t Them atic A pperception 'lest, 4 5 5 -4 5 7 t treatm ent and hospital course, 441

treatm ent planning an d outcom e, 445 WAIS-R sum m ary, 448t Neuropsychological testing, 12 Obsessive compulsive disorder, 2 5 7 -2 7 3 clinical and psychological exam ination results, 263t D SM -III-R diagnosis, 259 essential features of, 257 profile o f Mrs. H, 2 5 7 -2 5 9 , 2 9 7 -2 9 8 psychological assessm ent, 2 6 0 -2 6 2 Rorschach sum m ary, 264-2651, 2 6 6 -2 7 0 t T hem atic A pperception Test, 2 7 1 -2 7 3 t treatm ent and hospital course, 259 treatm ent planning and outcom e, 262 WAIS-R sum m ary, 264t Obsessive compulsive d iso rd er with m ixed personality disorder, 2 7 4 -2 9 8 clinical an d psychological exam ination results, 2 8 0 - 2 8 It D SM -III-R diagnosis, 275 MMPI sum m ary, 282t profile o f Mr. J, 2 7 4 -2 7 5 , 297 psychological assessm ent, 275, 278 Rorschach sum m ary, 282—283t, 2 8 4 -2 9 It Sentence Com pletion Test, 196t T hem atic A pperception 'lest, 2 9 2 -2 9 5 t treatm en t and hospital course, 275 treatm ent plan n ing an d outcom e, 2 7 8 -2 7 9 WAIS-R sum m ary, 282t The Organism, 12 Panic disorder, in D SM -III-R , 21 Paranoid personality d isorder: Mr. H, 3 8 5 -4 0 0

4 8 8 I Subject Ind ex clinical an d psychological exam ination results, 3 9 I - 3 9 2 t D S M -III-R diagnosis, 386 profile o f Mr. H , 3 8 5 -3 8 6 , 401 psychological assessm ent, 3 8 7 -3 8 9 Rorschach sum m ary, 3 9 3 -3 9 4 t, 3 9 5 -3 9 8 t S entence C om pletion Test, 400t T h em atic A p p ercep tio n Test, 399t treatm en t and hospital course, 3 8 6 -3 8 7 treatm en t p lan n in g an d outcom e, 3 8 9 -3 9 0 WAIS-R sum m ary, 393t P aran o id personality d iso rd e r: Mr. R, 3 7 0 -3 8 4 clinical an d psychological ex am ination results, 3 7 5 -3 7 6 t D SM -III-R diagnosis, 371 profile o f Mr. R, 3 7 0 -3 7 1 , 401 psychological assessm ent, 3 7 2 -3 7 3 R orschach sum m ary, 377—378t, 3 7 9 -3 8 3 t T h em atic A p p ercep tio n Test, 384t treatm en t a n d hospital course, 371 treatm en t p lan n in g a n d outcom e, 374 WAIS-R sum m ary, 377t P aran o id schizophrenia, subchronic, 1 0 1 -1 1 7 clinical an d psychological ex am ination results, 107—108t D S M -III-R diagnosis, 102 profile o f Mr. S, 1 0 1 -1 0 2 , 136 psychological assessm ent, 1 0 3 -1 0 5 R orschach sum m ary, 10 9 -1 1 Ot, 111 —114t Sentence C om pletion Test, 1 17t T h em atic A ppercep tio n Test, 1 1 5 - 1 16t tre a tm e n t and hospital course, 1 0 2 -1 0 3 treatm en t p lan n in g a n d outcom e, 1 0 5 -1 0 6 WAIS-R sum m ary, 109t

P aranoid subtypes, 101 Pascall-Suttell scoring schem e, 7 Personality D iso rd er E xam ination (PDE), 25 Personality theory, o f M urray, 8 P ost-traum atic stress d iso rd e r (PTSD ) in D SM -III-R , 21 sym ptom s, 298 Post-traum atic stress disorder, chronic, 2 9 9 -3 1 4 clinical a n d psychological ex am in atio n results, 3 0 4 -3 0 5 t D S M -III-R diagnosis, 300 MM PI sum m ary, 3 06t profile o f Ms. B, 2 9 9 -3 0 0 , 328 psychological assessm ent, 3 0 0 -3 0 3 R orschach sum m ary, 3 0 6 -3 0 7 t, 3 0 8 -3 1 It Sentence C om pletion Test, 314t T h em atic A p p ercep tio n Test, 312—3 13t tre a tm e n t a n d hospital course, 300 tre a tm e n t p lan n in g a n d outcom e, 303 WAIS-R sum m ary, 306t P ost-traum atic stress d iso rd er, delayed w ith alcohol ab u se, episodic, 3 1 5 -3 2 9 clinical an d psychological ex am in atio n results, 3 2 0 - 3 2 It D S M -III-R diagnosis, 316 profile o f Mr. W, 3 1 5 -3 1 6 , 328 psychological assessm ent, 3 1 7 -3 1 8 Rorschach sum m ary, 3 2 2 -3 2 3 t, 3 2 4 -3 2 7 t trea tm e n t an d hospital course, 3 1 6 -3 1 7 trea tm e n t p lan n in g a n d outcom e, 3 1 8 -3 1 9 WAIS-R sum m ary, 3 22t Projective technique, p u rp o se an d m eth o d of, 4 Projective tests, 4 - 8 word association test, 5

Subject Index / 4 8 9 Psychoactive substance abuse disorders, in D SM -III-R, 2 0 -2 1 Psychoanalytic ego theory, 11 Psychodiagnostic testing m eaningfulness of, 1 in 1940s, 11 prem ise of, 23 Psychodiagnostik, 5 Psychological health, definition of, 19 Psychological testing com puters in, 13-14 c u rren t testing trends, 12-14 diagnosis, 1 -2 6 DSMs, 14-23 DSMs and treatm en t planning, 2 3 -2 6 early testing efforts, 2 -3 frequency o f requests for “diagnostic labels" in referrals for, 24 history of, 2 -1 4 m ental tests d u rin g first p a rt o f twentieth century, 3 -4 projective tests, 4 - 8 purp o se of, I W echsler Scales, 9 -1 0 Psychological Testing, 1 Psychological tests, developm ent and function of, 2 Psychopathology, taxonom y for classifying, 1 Reaction, as term , 14, 16 Rorschach test, 5 - 6 , 13 in adjustm ent d iso rd er with depressed m ood, 3 5 7 -3 5 8 t, 3 5 9 -3 6 It in adjustm ent diso rd er with mixed disturbance o f em otions and conflict, 3 3 8 -3 3 9 t, 3 4 0 -3 4 6 t in anorexia nervosa, 3 6 -3 7 t, 3 8 -4 It in bipolar disorder, manic, with psychotic features, 2 4 2 -2 4 3 t, 2 4 4 -2 5 It

in bipolar m ania, w ithout psychotic features, 2 2 3 -2 2 4 t, 2 2 5 -2 3 3 t in borderline personality disorder: Ms. J, 412—4 13t, 4 1 4 - 4 17t in borderline personality disorder: Ms. W, 4 2 6 -4 2 7 t, 4 2 8 -4 3 3 t in bulim ia nervosa, 5 5 -5 6 t, 5 7 -6 0 t in conduct disorder, group type and mixed substance abuse, 7 2 -7 3 t, 7 4 -7 8 t in conduct disorder, u n d ifferentiated type, 8 8 -8 9 t, 9 0 -9 3 t in m ajor depression, recu rren t, with psychosis, 2 0 4 -2 0 5 t, 2 0 6 -2 lOt in m ajor depression, single episode, with melancholia, 1 9 0 -1 9 It, 192—194t in narcissistic personality disorder, 4 6 6 -4 6 7 1, 4 6 8 -4 6 9 t ’ in narcissistic personality d isorder with organic delusional syndrom e, 4 4 8 -4 4 9 t, 4 5 0 -4 5 4 t in obsessive compulsive disorder, 2 6 4 -2 6 5 t, 2 6 6 -2 7 0 t in obsessive compulsive d isorder with m ixed personality disorder, 2 8 2 -2 8 3 t, 2 8 4 - 2 9 It in paranoid personality disorder: Mr. H, 393—394t, 3 9 5 -3 9 8 t in p aranoid personality disorder: Mr. R, 3 7 7 -3 7 8 t, 3 7 9 -3 8 3 t in p aranoid schizophrenia, subchronic, 109-1 lOt, I I I —II4 t in post-traum atic stress disorder, chronic, 3 0 6 -3 0 7 1, 3 0 8 -3 1 It in post-traum atic stress disorder, delayed with alcohol abuse, episodic, 3 2 2 -3 2 3 t, 3 2 4 -3 2 7 t in schizoaffective disorder, bipolar type, 1 4 7 -I4 8 t, 1 4 9 -1 6 U in schizoaffective disorder, depressive type, 172t, 173—178t in u n d ifferentiated schizophrenia, chronic, 125—126t

4 9 0 ! Subject Index R otter Incom plete Sentence Com pletion Blank, 6 Sadistic personality disorder, in DSMIII-R , 23 SAT. See Senior A pperception Technique Schizoaffective diso rd er as DSM classification, 18 as D SM -III-R classification, 137-138 Schizoaffective disorder, bipolar type, 138-163 clinical and psychological exam ination results, 145—146t D SM -III-R diagnosis, 140 MMPI sum m ary, 147 profile o f Ms. N, 140, 182 psychological assessment, 1 4 1-143 Rorschach sum m ary, 147—148t, 1 4 9 -1 6 U Sentence Com pletion Test, 163t T hem atic A pperception Test, 162 treatm ent and hospital course, 140 treatm en t planning and outcom e, 143-144 WAIS-R sum m ary, 147t Schizoaffective disorder, depressive type, 164-181 clinical and psychological exam ination results, 170—1711 DSM-II I-R diagnosis, 164-165 profile o f Ms. R, 164, 182 psychological assessm ent, 1 6 6-168 Rorschach sum m ary, I72t, 173—178t T hem atic A pperception Test, 179—180t treatm ent and hospital course, 165 treatm ent planning and outcom e, 168-169 WAIS-R sum m ary, 172t Schizophrenia, 100-182 diagnosis of, reliability of, 100 in D SM -III, 18

in D SM -III-R , 22 D SM -III and D SM -III-R criteria for, 100 latent type, 16 negative sym ptom s of, 136 paranoid, subchronic, 10 1 -1 1 8 paranoid subtypes of, 101 positive sym ptom s of, 136 u n differentiated, chronic, 1 1 8-135 Schizophrenic patients subsets of, 100 treatm ent planning for, 1 3 6-137 Schizophrenic reactions, 15 SCID. See S tru ctu red Clinical Interview for Diagnosis Self-defeating personality disorder, in DSM -III-R, 23 Senior A pperception Technique (SAT), 6 Sentence com pletion m ethod, 8 Sentence Com pletion Test in adjustm ent d iso rd er with mixed disturbance o f em otions and conflict, 349t in anorexia nervosa, 44—45t in bipolar disorder, manic, with psychotic features, 254t in borderline personality disorder: Ms. J, 418t in bulim ia nervosa, 50t in m ajor depression, recu rren t, with psychosis, 2 1 1 -2 1 2t in narcissistic personality disorder, 472t in obsessive compulsive diso rd er with mixed personality disorder, 296t in p aranoid personality disorder: Mr. H , 400t in p aranoid schizophrenia, subchronic, 117t post-traum atic stress disorder, chronic, 314t in schizoaffective disorder, bipolar type, 163t

Subject Index / 491 in schizoaffective disorder, depressive type, 181 1 in undifferentiated schizophrenia, chronic, 135t Sexual deviations, as classification in D SM -III, 19 Sleep and arousal disorders, 2 2 -2 3 Social Introversion Scale (Si), 9 Stanford-B inet test, 3 - 4 , 10 S tructured Clinical Interview for Diagnosis (SCID), 25 Superego, in conduct disorders, 6 FAT. See Them atic A pperception lest Thematic A pperception lest (TAT), 6 in adjustm ent d iso rd er with depressed m ood, 3 6 2 -3 6 3 in adjustm ent diso rd er with m ixed disturbance o f em otions and conflict, 3 4 7 -3 4 8 t in anorexia nervosa, 4 2 -4 3 t in bipolar disorder, manic, with psychotic features, 2 5 2 -2 5 3 t in borderline personality disorder: Ms. W, 4 3 4 -4 3 7 t in conduct disorder, group type and m ixed substance abuse, 7 9 -8 0 in conduct disorder, undifferentiated type, 9 4 -9 6 t in m ajor depression, single episode, with melancholia, 195—196t in narcissistic personality disorder, 4 7 0 - 4 7 It in narcissistic personality disorder with organic delusional syndrom e, 4 5 5 -4 5 7 1 in obsessive compulsive disorder, 271—273t in obsessive compulsive diso rd er with m ixed personality disorder, 2 9 2 -2 9 5 t in paranoid personality disorder: Mr. H, 399t in paranoid personality disorder: Mr. R, 384t

in p aranoid schizophrenia, subchronic, 11 5 -1 1 6t in post-traum atic stress disorder, chronic, 312—313t in schizoaffective disorder, bipolar type, 162 in schizoaffective disorder, depressive type, 179—180t in u n d ifferentiated schizophrenia, chronic, 133—134t T reatm ent p lanning process, generalizations about, x i-x ii U ndifferentiated schizophrenia, chronic, 118—135 clinical and psychological exam ination results, 124t D SM -III-R diagnosis, 119 profile o f Mr. L, 1 1 8 -119, 136, 137 psychological assessm ent, 1 2 0-123 Rorschach sum m ary in, 125—126t, 127—132t Sentence Completion Test, 135t T hem atic A pperception Test, 133—134t treatm ent and hospital course, 119-120 treatm ent planning and outcom e, 123 WAIS-R summary; 125t

V code category, 19 Veteran’s A dm inistration (VA) clinics and hospitals, 10 WAIS. See W echsler Adult Intelligence Scale W echsler Adult Intelligence Scale (WAIS), 13 in adjustm ent d iso rd er with depressed m ood, 357 in adjustm ent d iso rd er with mixed disturbance o f emotions and conflict, 338t in bipolar disorder, manic, with psychotic features, 2 4 0 - 2 4 It

4 9 2 / Subject Index in bipolar m ania, w ithout psychotic features, 223t in borderline personality d isorder: Ms. J, 412t in borderline personality disorder: Ms. W, 426t in bulim ia nervosa, 55t in conduct disorder, group type and m ixed substance abuse, 72t in conduct disorder, undifferentiated type, 88t in m ajor depression, recu rren t, with psychosis, 204t in m ajor depression, single episode, with melancholia, 190t in narcissistic personality disorder, 466t in narcissistic personality diso rd er with organic delusional syndrom e, 448t in obsessive compulsive disorder, 264t in obsessive compulsive d iso rd er with mixed personality disorder, 282t in paranoid personality disorder: Mr. H, 393t

in p aranoid personality d isorder: Mr. R, 377t in p aranoid schizophrenia, subchronic, 109t in post-traum atic stress disorder, chronic, 306t in post-traum atic stress disorder, delayed with alcohol abuse, episodic, 322t in schizoaffective disorder, bipolar type, 147t in schizoaffective disorder, depressive type, 172 in u n d ifferentiated schizophrenia, chronic, 125t W echsler Scales, 9 -1 0 Word Association Test, 5, 8 W oodw orths Personal Data Sheet, 4 World H ealth O rganization, In ternational Classification o f Diseases, (ICD-6), 15 World War 1, intelligence tests and, 4 World War II, postw ar testing and, 10-12