In order to better illustrate the features of the most commonly diagnosed mental illnesses, the below case studies are presented.


Major Depressive Disorder


Name: Eeyore
Source: Winnie the Pooh (TV Show, 1966)
Background Information
Eeyore is an older gray donkey. There are no documents indicating the exact age or specified background information, and he chooses not to share this information. Eeyore does not have an occupation. His health compared to other donkeys is slightly underweight, but slender. He chooses not to share his family background. One main difficulty Eeyore has elaborated on is his detachable tail, which seems to cause him several problems. He has indicated that his goals are to remain strong for his friends despite his lack of confidence within himself, and as a result he often feels lonely without support from others that he is close to. Some forms of coping mechanisms include trying to feel useful in the presence of others and also trying his best to find pleasure in life.
Description of the Problem
Eeyore constantly insists that his tail falls off rather frequently. Eeyore’s posture typically involves a slumped head, droopy eyes, and commonly says “thanks for noticing me.” Sluggish movement is also apparent, without any physical cause for movement delay. He seems to step on his tail often and fall down. Eeyore indicates that sometimes it seems that even his close friends do not need him. Around friends, he typically makes comments about his relative unimportance and travels near the back of the pack. He also stated that although he tries to force a smile, a real smile has not existed in a long time, even though others try to cheer him up. He often feels empty even when accompanied by friends. Eeyore also seems to experience a loss of energy throughout the day, although sleeping habits are not explicitly expressed.
Diagnosis
296.2x Major Depressive Disorder, Single Episode
Eeyore exhibits five symptoms of a major depressive episode, and has also experienced these for several years, therefore meeting full criteria. Criteria met include depressed mood most of the day, markedly diminished interest or pleasure in activities, fatigue or loss of energy nearly every day, feelings of worthlessness, and diminished ability to think or concentrate were indicated. Overall, Eeyore exhibits severe clinical major depression without psychotic features. Further diagnosis will be needed to determine catatonic, melancholic, or atypical features as details are limited at this point. Postpartum onset is not a factor.
Accuracy of Portrayal
Eeyore is a character that displays a relatively accurate example of major depressive disorder. One major issue with the character portrayed is his consistent involvement with a support group. A lack of interest in activities is common with this disorder, causing most persons with depression to not frequently spend time with others. This is in contrast to Eeyore, who seems to be surrounded by friends much of the time. Also, his support groups seems rather sarcastic at times, as well as exhibiting their own issues so it may be hard to diagnose if environmental factors may prolong the depression longer than it may otherwise last. Some would argue that this may be closer to a diagnosis of Dysthymia, but since Eeyore seems to exhibit more severe symptoms closer to major depression and each season of the show lasts less than two years, it is hard to fully identify a long term timespan of his disorder.
Treatment
Although various treatments exists, I would recommend cognitive behavioral therapy, and possibly electroconvulsive therapy if CBT does not work alone. Since donkeys have not been tested with medication normally given to persons suffering from depression, I would not advise any type of tricyclics, MAO inhibitors, or SSRIs be used. Regarding cognitive behavioral therapy, it is important that Eeyore first understands the relationship between events, emotions, and cognitions. As mentioned, he must first realize that if his tail falls off that he is not less of an individual. Furthermore, he must also realize that the need to be of worth can be self-induced and that he does not need to rely on others to find this feeling. Treatment would then be followed by instructing Eeyore on identifying, evaluating, and modifying automatic negative though patterns that exist. He acknowledges his feelings of worthlessness, but also having the tools to evaluate his negative thoughts as something he can control should enable him to eventually take control over his thoughts. Stress management, social skills, and activities training will then follow to give Eeyore a path to improve his well-being by being able to optimally connect with others and join in on activities that spark his interests.


Name: Anthony Soprano, Jr.

Source: The Sopranos (television series, 1999-2005)

Background Information
Anthony Soprano, Jr., referred to as A.J., is a male born on July 15, 1986 to Anthony and Carmela Soprano. The family is of Italian decent and they live in New Jersey. From a very young age, A. J. had disciplinary problems in school and a possible learning disability. After extensive testing and meeting with school counselors, he was deemed to be suffering from Attention-Deficit Hyperactivity Disorder.

It was very obvious throughout the various seasons that A. J. had a strong family history of multiple psychiatric disorders. His father was diagnosed with depression from the beginning of the series. He was on medication and would see a therapist regularly. In addition, his father had antisocial personality disorder and panic disorder without agoraphobia. His father was involved in organized crime, which caused strains on his parents’ relationship. Due to these marital issues between his parents, A. J. would often act out during their period of separation and possible divorce. As A. J. got older, his father insisted on him becoming more responsible and not a failure in life. As a way to make A. J. more productive, his father got him a job at a construction site. A. J. started the job and was doing well. He met a Puerto Rican girl named Blanca at the construction site and they started dating.

The two became really close, and A. J. eventually proposed to Blanca. After some reconsideration, she decided that A. J. was not right for her and broke up with him. This is when he became depressed. A. J. continued to work at the construction site for some time, but the site of Blanca talking to other men became too much for him, so he eventually quit. Just as things seemed like they would never improve, A. J. met some childhood friends whose fathers were also in the Mafia with his father.

He started hanging out with them and seemed to be improving. He also began seeing a therapist and was prescribed Prozac. He improved to the point that he even began to take some college courses. However, these new friends turned out to be a bad influence. They were running some illegal gambling on campus and would use violence to collect money. A. J. did not seem to be affected by this, but when they badly beat up an African American student, this sent A. J. spiraling down once again.

Description of the Problem
After the breakup with Blanca, A. J. started sleeping all the time and would not come out of his room. He had a decreased appetite and anhedonia. He seemed to lack energy for quite some time. There were no suicidal ideations initially. After the African-American student incident, he again confined himself to his room and developed similar symptoms to what he was displaying after his break up with Blanca. It progressed to the point that he attempted to kill himself by tying a plastic bag around his face, wrapping a cinder block around his leg, and jumping in the pool while his parents were out of the house. Luckily, his father came home and saved him prior to there being any significant damage. A. J. was admitted to an inpatient psychiatric facility and received the therapy he needed.

Diagnosis
The diagnosis for A. J. Soprano is Major Depressive Disorder (recurrent), 296.3x. According to the DSM-IV-TR, the following are eight of nine criteria that are met for the diagnosis:

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
A. J. exhibits a depressed mood consistently for at least two weeks in both of his major depression episodes.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
A. J.’s mother noticed that he quit attending his job at the pizza parlor, even though he used to enjoy working there.
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
A. J.’s mother would constantly cook different things that A. J. used to enjoy before his decrease in appetite, but none of the things she cooked seemed appealing to him.
4. Insomnia or hypersomnia nearly every day
A. J. could be seen sleeping throughout most of the day due to his depression.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
This is the only criterion that does not pertain to A. J.
6. Fatigue or loss of energy nearly every day
A. J. appeared to be tired at all times of the day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
After Blanca broke up with him, A. J. appeared to have feelings of worthlessness.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
A. J. stopped attending his college classes due to his inability to concentrate.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
A. J. actually attempts suicide, but failed to drown himself.
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
A. J. displays interepisode recovery between his two major depressive episodes, making his a case of major depressive disorder, recurrent.

Accuracy of Portrayal
The average person watching A. J. on the Sopranos would receive an accurate portrayal of Major Depressive Disorder (recurrent). He displays a majority of the symptoms for the disorder in both episodes he has had. These breaks of normalcy between the two episodes are crucial in understanding major depression episodes, especially when the depression is recurrent. Major Depressive Disorder is highly heritable, so watching A. J.’s father, who also displays signs of depression, helps to understand some of the genetic influence on depression.

Treatment
Proper treatment of A. J.’s Major Depressive Disorder would, given his severe symptom levels, include beginning with antidepressant medication. Psychotherapy might also be added in A. J. case in order to increase effectiveness of treatment. It does not seem that electroconvulsive therapy would be necessary in A. J.’s case since he does not exhibit psychotic symptoms or catatonia.



Alzheimer's Dementia

Name: Alice Howland

Source: Still Alice by Lisa Genova (book, 2007)

Background Information
Alice Howland is a Caucasian female who is 50 years old. She currently works as a cognitive psychology professor at Harvard University. Overall, Howland presents as a healthy 50-year-old woman. Howland is a petite woman, but not underweight. Howland remains active in her work and social life and other than leading a hectic life appears happy. Howland lives with her husband (John) and the two have three grown children, all of which live out of the home. Howland maintains many close friendships and is in a stable, long-term relationship. Howland does not have any reported drug or alcohol related history. Howland states that she may have a glass or two of wine with dinner, but the only medication she takes is a multivitamin. Howland has not had any head injuries or serious health issues. Howland’s mother and sister died in a car accident when she was 18 and her father died the previous year from Cirrhosis of the liver. Howland allowed that her father was an alcoholic and that they did not have much contact over the last several years before his death.

Description of the Problem
Howland frequently exhibits disorientation and gets lost when she is only a few blocks from her home. She recognizes the building and knows that she is supposed to know how to get home, but her mind is blank. Howland frequently misplaces items and is unable to find them. At times, she replaces items and later finds the lost item. She frequently loses her train of thought, or is unable to remember significant details of her life. As a professor, she often visited other universities as a guest speaker or would present at conferences, lately, she would lose track near the middle to end of her lecture and have to refer to her notes. This was not common for Howland as she used her speeches repeatedly only making small changes that were easy to remember. Howland reports forgetting words during a lecture, she states that it is not even on the tip of her tongue; the word is just completely gone from her memory. Howland recently missed a conference in Chicago, simply because she forgot about it. Howland also states that she has to write down a detailed schedule of what time and where her classes are or she will simply forget to go teach them.

Diagnosis
Dementia of the Alzheimer's Type (294.1x)
· Diagnostic criteria
o A. The development of multiple cognitive deficits manifested by both
§ (1) memory impairment (impaired ability to learn new information or to recall previously learned information)
§ (2) one (or more) of the following cognitive disturbances:
§ (a) aphasia (language disturbance)
§ (b) apraxia (impaired ability to carry out motor activities despite intact motor function)
§ (c) agnosia (failure to recognize or identify objects despite intact sensory function)
§ (d) disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting)
o B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
o C. The course is characterized by gradual onset and continuing cognitive decline.
o D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
§ (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
§ (2) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficeincy, hypercalcemia, ceurosyphilis, HIV infection)
§ (3) substance-induced conditions
o E. The deficits do not occur exclusively during the course of a delirium.
o F. The disturbance is not better accounted for by another Axis I disorder (e.g. Major Depressive Disorder, Schizophrenia).

Howland displays impairment in recalling previous learned material and has disturbances in executive functioning. Howland is not suffering from any central nervous system conditions, systemic conditions, or substance-induced conditions. She is having difficulties at work due to her memory loss unlike her previous performance in her job. Her memory loss and confusion began gradually and steadily worsened.

Code based on presence or absence of a clinically significant behavioral disturbance:
· 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
· 294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).

Howland does not present with any behavioral disturbances at this time.

· Specify subtype:
o With Early Onset: if onset is at age 65 years or below
o With Late Onset: if onset is after age 65 years
· Coding note: Also code 331.0 Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer's disease on Axis I (e.g., 293.83 Mood Disorder Due to Alzheimer's Disease, With Depressive Features, and 310.1 Personality Change Due to Alzheimer's Disease, Aggressive Type).

Howland’s diagnosis falls under the Early Onset subtype as she is only 50 years old.

· Epidemiology
o The prevalence rates of Dementia of Alzheimer's Type increases dramatically with increasing age, rising from .6% in males and .8% in females at age 65 to 11% in males and 14% in females by age 85. As age increases so do the prevalence rates; at age 90 the rates rise to 21% in males and 25% in females, and by age 95 the prevalence rates are as high as 36% in males and 41% in females. Unfortunately, 40%-60% are moderate to severe cases.

Howland was unaware of her extended families medical history because her mother passed at a young age and her father, to her knowledge, did not display any symptoms before his death.

Accuracy of Portrayal
Overall, the book accurately displays the course of Early Onset Alzheimer’s. The high and lows of mood as the disease progresses are genuine and show the true emotions that not only a person suffering from the disease deals with, but what family members and friends deal with. The book also shows how the disease progresses, somewhat slowly at first and then a continual decline in functioning, not only mentally but also physically. The rate at which each person declines is different, but overall the beginning is gradual and then the decline seems to speed up. It does seem as if the book may have sped up the disease a bit much. The confusion and slight memory loss that progresses into complete memory loss and description of living with strangers does seem to ring true. A person with this disease must frequently feel as if she is with strangers, even when she is with her own family. The book did not go into the very late stages of the disease, at which time those with Alzheimer’s physical decline is serious and require feeding tubes and most usually hospitalization or nursing home care, as they are no longer able to walk, feed themselves, or even speak.

Treatment
At this time, there are no medications available to cure Alzheimer’s, only medications that seem to slow the progression. For Alice Howland the best course of treatment would include cholinesterase inhibitors during the beginning stages and an N-methyl D-aspartate (NMDA) antagonist once symptoms become more severe in nature. These medications only slow the progression of the disease, although these medications have been effective in slowing the progression of Alzheimer’s in many patients. When the disease presents itself as a safety issue for Howland (forgetting that she is cooking, wandering off and getting lost or unable to take care of her personal daily needs) she needs either nursing home care or 24-hour home care. When Howland reaches the stage where she is no longer able to feed herself or walk, nursing home care is the best recourse for proper care. A healthy diet recommendation through all stages of the disease by limiting unhealthy food intake and eating healthy may help slow the progression of Alzheimer’s. However, this is in combination with proper medication. As long as she is able, exercise, reading, crossword puzzles, and other mentally and physically stimulating activities may help slow the progression of the disease, however, there is not adequate research into this area.

Name: Fiona Anderson
Source: Away From Her (movie, 2006)
Background Information
Fiona Anderson is a Caucasian female in her late 60’s/early 70’s. She is fit for her age, not overweight or underweight. Fiona’s family originates from Iceland, but she was raised in Canada. She is married to Grant Anderson (for 44 years) and they have no children. Fiona is currently unemployed; after Grant retired from his job as a professor, the couple moved to Brandt County, Ontario. The couple currently lives in the farmhouse that belonged to Fiona’s grandparents and have lived there for 20 years. Fiona lives an active lifestyle by going on cross country skiing trips around their property with her husband. The couple will occasionally see their other married friends, but most live far away. There is no known drug or alcohol problem. Fiona has the occasional drink at home with her husband, but in no way ever appears to have had too much. There is a subject matter that has remained unresolved between Fiona and her husband; while Grant was still teaching there was speculation and rumors that he had an affair with one of his students. Fiona, instead of enraged by Grant’s adultery was thankful that he did not leave her. In order to make a better life for themselves and they moved away from all the distractions. Fiona seems to have dealt with Grant’s unfaithfulness and her deteriorating memory with a great deal of acceptance and dignity.
Description of the Problem
Fiona exhibits the early signs of memory loss. When she is helping put away the dishes, she forgets, pauses, puts the frying pan in the freezer, and walks away. Her memory loss then progresses to where she has to put labels on all the cabinets and drawers of what belongs where. Fiona admits that at times she forgets what words mean, like the word yellow. Fiona forgets how to say “wine” while offering her guest another glass. During her evaluation she is asked a series of questions involving mail, she answers the majority of the questions correct but then forgets where a person would take the mail to send it. Fiona becomes even more disoriented as time goes by and loses her way home and wanders off. Her husband is constantly finding things that she has left undone or forgot about, such as when she put a pot of water on to boil, then left the house. The most recent development of Fiona’s memory degrading happened after she was admitted to Meadowlake, a care taking facility. After being separated from her husband for only 30 days she seemed to have lost all knowledge of their married life. She exhibited recognition of his face but not what they meant to each other or the life they shared. Fiona begins to form an attachment with a man who is in Meadowlake with her; when asked about him she states, “I like Aubrey because he doesn’t confuse me.”
Diagnosis
Dementia of the Alzheimer's Type (294.1x)
  • Diagnostic criteria
    • A. The development of multiple cognitive deficits manifested by both
      • (1) memory impairment (impaired ability to learn new information or to recall previously learned information)
      • (2) one (or more) of the following cognitive disturbances:
        • (a) aphasia (language disturbance)
        • (b) apraxia (impaired ability to carry out motor activities despite intact motor function)
        • (c) agnosia (failure to recognize or identify objects despite intact sensory function)
        • (d) disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting)
  • B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
  • C. The course is characterized by gradual onset and continuing cognitive decline.
  • D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
    • (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
    • (2) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, ceurosyphilis, HIV infection)
    • (3) substance-induced conditions
  • E. The deficits do not occur exclusively during the course of a delirium.
  • F. The disturbance is not better accounted for by another Axis I disorder (e.g. Major Depressive Disorder, Schizophrenia).
Fiona meets criteria for A1 and A2; the cognitive disturbances that she exhibits are aphasia, agnosia, and possible impaired ability to carry out particular motor abilities. The impairments from criteria A1 and A2 have affected her relationship with her spouse, friends, and how she interacts with others, as well as her daily activities. Fiona does not have any recorded nervous system, substance-induced, or systemic conditions that could impair her memory. Fiona’s memory loss has had a continuous decline and started gradually. She is not recorded to have any other Axis I disorders.
Code based on presence or absence of a clinically significant behavioral disturbance:
  • 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
  • 294.11 With Behavioral Disturbance:if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).
Fiona has presented some behavioral disturbances, such as wandering the street and woods.
Accuracy of Portrayal
Overall, the movie provides an accurate portrayal of the disease and the effects it has on the person suffering from it. A person not knowing anything about Alzheimer’s would learn from the movie that with time that short-term or working memory starts to diminish first. A person suffering from Alzheimer’s will gradually lose more of their memory abilities, eventually impairing their long-term memory and recall. They will also learn that people with Alzheimer’s can know someone one day but not know them the next. They may also repeat the same questions or statements, having no recollection of already saying them. In the movie they say Fiona is young for already having Alzheimer’s, which is not entirely accurate, as she is beyond the age of 65. This puts her in the Late Onset category, which is more common than Early Onset.
Treatment
There is no current cure for Alzheimer’s, but there are medications shown to help slow the progression of the disease. The Food and Drug Administration has approved two types of drugs that could help Fiona: cholinesterase inhibitors and mematine. A good diet and exercise will also help in creating a good environment for the medication to work and help Fiona stay mentally alert. It would also be beneficial to keep the mind working by taking part in any sort of puzzles that help exercise the brain. In the movie they admitted Fiona into a caretaking facility not too long after she was diagnosed with the disease. In my opinion, they could have waited longer to admit her. Her memory seemed to deteriorate faster after she was in the care of the home.



Tourette's Disorder


Name: Lionel Essrog

Source: Motherless Brooklyn by Jonathan Lethem (book, 1999)

Background Information
Lionel Essrog is a Caucasian male and presumably in his mid to late thirties. Lionel Essrog is an orphan and the whereabouts of his biological parents is unknown. Essrog spent his childhood and adolescence in the St. Vincent’s Home for Boys in Brooklyn, New York, which is a publicly funded boarding house for orphaned young males. The residents of St. Vincent’s are required to attend public school and Essrog acquired his high school diploma but has not received any further education. Essrog currently works for a man named Frank Minna with three other of his housemates from St. Vincent’s. The four of them call themselves “Minna Men” and they specialize in unconventional and frequently illegal types of jobs as provided by Frank Minna. Any familial mental health history is unknown. Essrog has no history of drug or alcohol abuse. He does not seem to have any long term goals, other than to continue working for Frank Minna. Beginning in early childhood, Essrog began experiencing compulsions which involved twitching and jerking his neck. These compulsions soon turned into various forms of motor tics, including incessant tapping of the metal-pipe legs of schoolroom desks and chairs as if in search of certain ringing tones, reaching for doorframes, and kneeling to grab at untied shoe laces of other classmates. One of his compulsions actually involved grabbing and kissing his fellow classmates and housemates at St. Vincent’s. Because of his behavior, Essrog did not have very much social interaction with peers his age and spent a lot of time alone. Around the time he was thirteen years old, the kissing compulsion ended but was replaced with others. He was prone to tapping, whistling, tongue-clicking, winking, rapid head turns, wall stroking, and other various tics. During this time, Essrog began experiencing rapid thoughts that were becoming more and more of a compulsion to speak out loud. Many of these thoughts were echoic variations to things he heard. For example, when Essrog heard “Alfred Hitchcock” he would silently rephrase it as “Altered Houseclock”. Essrog found it more and more difficult to withhold these compulsions and began exhibiting simple vocal tics by barking like a dog and chirping like a bird. While he still has the compulsion to do simple vocal tics, he also exhibits complex vocal tics as well.

Description of the Problem
Essrog currently displays simple and complex motor tics as well as simple and complex vocal tics. Examples of simple motor tics are eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, and abdominal tensing. Complex motor tics include hand gestures, jumping, touching, pressing, stomping, facial contortions, repeatedly smelling an object, squatting, deep knee bends, retracing steps, twirling when walking, and assuming and holding unusual postures (including dystonic tics, such as holding the neck in a particular tensed position). Simple vocal tics include meaningless sounds such as throat clearing, sniffing, grunting, snorting, and chirping. Complex vocal tics more clearly involve speech and language and include the sudden, spontaneous expression of single words or phrases; speech blocking; sudden and meaningless changes in pitch, emphasis, or volume of speech; palilalia (repeating one’s own sounds or words); and echolalia (repeating the last-heard sound, word, or phrase). Essrog also shows coproplalia, which is the sudden, inappropriate expression of a socially unacceptable word or phrase. Essrog describes his vocal tics as follows; “My words begin plucking at threads nervously, seeking purchase, a weak point, a vulnerable ear. It’s an itch at first. Inconsequential. But that itch is soon a torrent behind a straining dam. Once I’m able to scratch that itch, it let’s off the pressure in my head and I am able to concentrate”. Essrog’s tics cause him anxiety in social situations but the men with whom he works have learned to accept his behavior. Essrog also claims that his tics are more difficult to suppress when he is anxious or nervous.

Diagnosis
The diagnosis that seems to fit appropriately for Essrog is Tourette’s Disorder (307.23)

Diagnostic Criteria for Tourette’s Disorder (DSM-IV-TR)
A. Both multiple motor tics and one or more vocal tics must be present at the same time, although not necessarily concurrently

Essrog exhibits multiple motor and vocal tics.

B. The tics must occur many times a day nearly every day(usually in bouts) nearly everyday or intermittently over more than one year, and during this period there must not have been a tic-free period of more than three consecutive months.

Essrog’s experiences tics everyday and has not shown any evidence of a tic-free period.

C. The onset is before age 18 years.

Essrog’s symptoms began in early childhood. Motor tics normally develop at about 6 – 7 years of age and vocal tics normally occur at after the onset of motor tics. Essrog’s onset fits this criteria.

D. The disturbance must not be due to the direct physiological effects of a substance (e.g., stimulants) or general medical condition (e.g., Huntington's disease or positive encephalitis).

Essrog shows no signs of substance abuse or any symptoms of medical conditions.

Accuracy of Portrayal
Jonathan Lethem’s characterization of Lionel Essrog was very accurate in the portrayal of a person diagnosed with Tourette’s Disorder. The age of onset was the same as listed in the DSM-IV-TR and the description of the compulsions and tics the character exuded were also accurately portrayed when compared to the diagnostic criteria of Tourette’s Disorder.

Treatment
Treatment for Essrog should include a specific kind of psychotherapy. The primary supported therapy for Tourette’s Disorder is habit reversal training (HRT), commonly known now as Cognitive-Behavior Intervention for Tics (CBITS). In HRT, a person first learns to know when and where he/she is going to have a tic, followed by development of competing responses that prevent you from physically being able to perform the tic. These responses are held until the urge to tic dissipates. Over time, particularly with motor tics, the client learns that they do not need to tic to feel the release and relaxation. In many cases, Tourette’s Disorder can be effectively managed. If the Tourette’s Disorder is severe enough, antipsychotic medications can be helpful. These include but are not limited to Chlorpromazine, Haloperidol, and Pimozide. The severity of the tics may be exacerbated by administration of central nervous system stimulants, such as those used in the treatment for Attention-Deficit/Hyperactivity Disorder. Alternative treatments for treating Tourette’s Disorder have proven to be helpful for some patients. These treatments are herbal medicines, nutritional, vitamin, and mineral supplements and behavioral therapies. It should be known that these treatments should be used as complementary and never as a substitute.




Antisocial Personality Disorder


Name: The Grinch

Source: How the Grinch Stole Christmas! (Movie, 2000)

Background Information
The Grinch, who is bitter and cave-dwelling creature, lives on the snowy Mount Crumpits, a 10,000 foot high mountain that is north of Whoville. His age is undisclosed but he looks to be in his 40’s and does not have a job. He normally spends a lot of his time being alone in his cave. The patient appears to be suffering from antisocial personality disorder with depressed mood. There was no background history on his family, as he was abandoned as a child. The Grinch was taken in by two ladies who treated him like he was their own like every other Who children with love for Christmas. He does not have any social relationship with his friends and family. The only social companion the Grinch has is his dog Max. There was no history of drug or alcohol use. The Grinch did have some life difficulties when he was a little boy being made fun of the way he looks at his school. The Grinch had no goal in his life except to stop Christmas from happening. The coping skills and weakness was to run away from his problems and leave the town, rather than facing problems.

Description of the Problem
The Grinch displays a number of problems. The Grinch was not a very happy man with life. He hated Christmas and wanted to stop it from happening. When he was little, he got irritated and aggressive at the school because he was being made fun of by the fat boy who now is the mayor of the town. The Grinch threw a fit and picked up the Christmas tree and threw it to the other side of the classroom. After that he no longer liked Christmas. Years and years later the Grinch decided that he was going to stop Christmas from happening. He decided to dress as Santa Claus and take away all the Christmas trees and presents from the people of Whoville. He failed to plan ahead to know what the consequences would be. As he went to Cindy Lou Who’s house to steal their tree and present, Cindy Lou asked him why he was taking the Christmas tree. He told her that he going take the tree to his place and fix the light bulb. The Grinch did not show any remorse of what he did. He wanted Christmas to be over. He also did not care for the safety of other including his dog. His dog had to be the reindeer. The Grinch was irresponsible and thinking recklessly. He wanted everyone miserable and thought that would make him feel better.

Diagnosis
The diagnosis that seems appropriate for the Grinch is Antisocial Personality Disorder (301.7).

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are groups for arrest
He would have gotten big trouble for stealing all the trees and presents. Also he got in trouble by getting peoples mails in the wrong box. The Grinch did not realize there are consequences.

2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
The Grinch lied to the little girl why he was stealing her Christmas tree and that he pretend to be a Santa.

3. impulsive behavior or failure to plan ahead
He failed to plan ahead thinking he would not run into someone while stealing Christmas tree and present. The Grinch did not think what would happen if he did this.

4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
The Grinch was irritated by being made fun of the fat boy. He got aggressive and picked up the Christmas tree and threw it across the room.
5. reckless disregard for safety of self or others
He did care for other people safety especially his dog max. He made his dog do something big than his dog can really do and that it could hurt him.
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
He was being irresponsible for what he did. He wanted to make people made and not care about anyone. He was irresponsible with his dog and didn’t care if his dog got hurt or not.
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

The Grinch had no regrets in what he had done. He didn’t regret what he did to those people. The Grinch was happy to make people unhappy and more.

B. The individual is at least age 18 years.
The Grinch is around in his 40’s.

C. There is evidence of Conduct Disorder with onset before age 15 years.
The Grinch shows evidence of having conduct disorder with the onset before age 15. He first started showing symptoms around when he was 8-10 years old.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.
During observation, the Grinch did not meet any signs showing schizophrenia but he was showing some of the signs of having a manic episode such as increased in goal-direct activities. The Grinch was very into making everyone’s Christmas miserable.

Accuracy of Portrayal
The average person watching this movie would learn quite a bit about antisocial personality disorder. They would also learn about bullying and depression. The movie did make it into fairy tale where they have happy ending for a person who has antisocial personality disorder. This is not the case in the real world with people who have that type of disorder. It does not cure them that quick. It takes time, efforts, and counseling. Though it is rare for someone who has antisocial personality disorder to seek help and get counseling. It does confuse the audience that makes them think you can cure the disorder quick when you can’t. This is a movie somehow helps show people what the antisocial personality is.

Treatment
Antisocial personality disorder is one of the most difficult personality disorders to treat because people who have it tend to think there is nothing wrong with them and do not want help. It is rare for people who have antisocial personality disorder to get help. First to treat the Grinch, he needs a full medical examination to see what symptoms would come up beside antisocial personality disorder. After the full evolution, the Grinch should seek counseling to talk about his past, learn to cope what he went through, and do some social skills training. Social skilling training would help him a lot to learn how to socialize with other people. There a few medication that could help the Grinch such as with his depression he could take antidepressant medication to help improve his depressed mood, anger, impulsivity, or irritability. However, these medication do not directly treat the behavior that characterize antisocial personality disorder, they can be useful in addressing conditions that co-occur with this condition.





Name: The Joker

Source: The Dark Knight (movie, 2008)

Background Information
The Joker is a disturbed and malicious villain who is the archenemy of Batman. His age is unknown but he looks to be in his late 40’s to early 50’s. His gender is obviously male with brown eyes, and sandy, light green hair. He does not have a “real” job, but some consider running the streets with thugs to be one of them. He spends majority of his time plotting to corrupt and destroy Batman along with bringing the city of Gotham to the ground. His overall health status is unknown, but to the naked eye, he physically looks ill along with the deep razor cuts to both sides of the mouth representing a permanent smile. Psychologically he appears to suffer from antisocial personality disorder, which is evident by his hasty behavior and lack of disregard to others. He does not have a relationship with his parents or relatives. The only social relationships he does have are those with thugs and delinquents. There is no evidence of drugs or alcohol use, although he reports that his father was an extremely abusive alcoholic, who attacked he and his mother with a blade, cutting him along the corner of his lips. The only goal in The Joker’s life was to destroy Batman and everything in his path. His only coping skill and weaknesses were to see someone other than himself get hurt along with Batman. He would then vanish from sight seemingly as if he had run away from his problems, not wanting to face the consequences.

Description of the Problem
The problems The Joker displays are tremendous. To begin, he absolutely hates Batman and everything to do with justice and peace. He seems to hate everything about himself as well, considering he has to hurt others around him to feel better. His only purpose in life is to destroy Gotham for no apparent reason and to destroy Batman considering he is constantly in The Joker’s way to destruction. The Joker wanted humans to understand that they were “bad” and destroyers when all the while he was the one committing crimes. The Joker expressed absolutely no empathy for his ruthless actions along with being extremely sadistic. He blatantly disregarded laws and socials norms of society as a whole, all of which are related to antisocial personality disorder.

Diagnosis
According to DSM-IV-TR criteria, the appropriate diagnosis would be Antisocial Personality Disorder (301.7)
  1. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
  2. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are groups for arrest.
The Joker was constantly being arrested and reprimanded by law enforcements due to his ruthless behaviors. At times it was difficult to catch The Joker committing a crime, but once he was he was punished (for a short amount of time) he would later escape to commit more crimes.

  1. Deceitfulness, as indicated by repeated lying, use of aliases, or conning other for personal profit or pleasure.
At one time, The Joker dressed as Bozo the clown while robbing the Gotham National City Bank. He manipulated his whole crew into robbing the bank and told them they would all split the money. However, The Joker ends up killing his crew and getting away with the money.

  1. Impulsive behavior or failure to plan ahead.
The Joker planned seemingly impossible tasks without thinking about the consequences afterward. At one time, he tried to blow up the Gotham General Hospital. Hitting his detonator, the majority of the bombs failed to blow therefore causing him to steal a nearby city bus as a quick getaway.

  1. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Without a doubt The Joker was constantly fighting, assaulting, torturing, or murdering another individual. One in particular would be Batman. Batman would fight The Joker, throwing him from wall to wall and all while The Joker would be laughing hysterically.

  1. Reckless disregard for safety of self or others.
He cared very little about his own safety considering he told Batman to run him over with his Batpod. This seemed to also be an attempted sign of sucide. Also, blowing up a hospital, violently blowing up a prison inmate, and using innocent people as police officer targets are all ways he disregarded the safety for others.

  1. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
The Joker was never considered to have a job. However, he would steal to receive cash payments and money to support himself.

  1. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
The Joker never apologized for his behavior nor having any remorse for killing innocent people. He enjoyed chaos and hurting people along with himself. He still didn’t feel remorse for being in jail considering that he brutally killed an inmate while there.

  1. The individual is at least age 18 years.
The Joker is in his late 40’s to early 50’s.

  1. There is evidence of Conduct Disorder with onset before age 15 years.
It may have taken place with his abusive father when he was younger which caused the scarring on his face. It is not known how old he was when this occurred.

  1. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.
The Joker’s behavior was constantly out of the norm. His ruthless behavior was continual for long durations of time so the presence of a Manic Episode would not be unlikely.

Accuracy of Portrayal
The average person watching the film would see that The Joker is a typical psychopath. The average person would learn the basics of antisocial personality disorder and character qualities an individual must hold in order to be classified as a psychopath. However, with antisocial personality disorder, it seems to remit by age 40 and is known to be higher among young adults than older adults. The Joker seemed to peek in his violent streaks at this age. Another inaccurate portrayal of antisocial personality disorder being used in the film was that majority of individuals suffering from antisocial personality disorders have high amounts of drug use and abuse. Drug use causes individuals to perform dysfunctional and out of the norm types of behavior. They seem to not care about the risk involved. The Joker was never seen using any types of drugs in the film. He would constantly cause harm to others on his own will without the use of mind alternating drugs. However, there were strong accuracies of portrayal. For instance, he was a male, came from an abusive childhood, had zero empathy, and performed extremely risky and ruthless behaviors. The film helped show the most extreme form of antisocial personality disorder.

Treatment
Antisocial Personality Disorder is difficult to treat, considering the fact that individuals do not believe they are in need of treatment. If a patient is taken into to counseling, there is usually a lack of improvement as the patient is usually uncooperative. The treatment that would most likely work for The Joker would be treatment in long-term structured residential settings to which he would be placed in an environment in which he cannot hurt others. If he modifies his behavior appropriately he will be able to earn privileges such as performing a non- threatening hobby of his. Since The Joker has not developed any healthy relationships in his lifetime, using psychotherapy along with behavior modification would help. Developing a relationship with a therapist would probably be beneficial for him as well. Since The Joker expressed a few signs of suicide attempts, it may be that he is suffering from depression as well. An antidepressant may help his depression and irritability. Even though antidepressants do not actually treat an individual with antisocial personality disorder, they can help with these types of comorbid conditions.






Social Phobia (Social Anxiety Disorder)

Name: Barry Egan

Source: Punch-Drunk Love (movie, 2002)

Background Information
Barry Egan is a Caucasian male in his early to mid-forties who lives alone in an apartment in Los Angeles, California. He is the owner of a small business that sells novelty items. Barry is not suffering from any known medical conditions or other health problems, but appears to have some mental health concerns. He is easily provoked into violent tantrums in which he punches walls, breaks windows, or destroys others personal property. He does not appear to have any alcohol or drug dependencies; in fact, he appears to drink alcohol very minimally. Barry has seven sisters, all of whom are very domineering and verbally abusive to him. Barry’s sisters have tormented and ridiculed him since childhood. As an adult, his sisters are still very controlling of his life and continue to torment him with embarrassing stories from his childhood. Barry has difficulty with personal relationships and appears to be lonely. His goals include growing his business. His hobbies include finding unbelievably good deals and repairing and learning to play the harmonium. Barry can be rather naïve and trusting of others, which leads to being taken advantage of and making poor financial decisions.

Description of the Problem
Barry is currently seeking help because he feels something might be wrong and states that he “doesn’t like himself,” but is unsure if this is abnormal since he is uncertain how other people are. He states that he “cries a lot.” Barry can be described as a socially awkward individual who does not seek out or actively engage in social activity with others. It appears that Barry has little to no family support system and that his relationship with his seven sisters relates to his low self-esteem. He constantly apologizes for things even when he did not do anything wrong, and stumbles with his speech by merging words together. Barry becomes very anxious in social situations. He endures these situations with intense anxiety and distress, which sometimes can lead to a panic attack following the interaction. Barry has a tendency to become violent when provoked with embarrassing stories from his childhood. He is known to lie and deny his actions when confronted. Barry is currently in a relationship with a woman he recently met. The relationship appears to be a positive factor in Barry’s life.

Diagnosis
The diagnosis for Barry Egan is Social Phobia (300.23). According to the DSM-IV-TR the following criteria are met:

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. NOTE: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

Barry shows fear in meeting new people or encountering people in unexpected situations. He showed this in several situations; for example, when he met Lena for the first time he was obviously uncomfortable and showing signs of fear and while at his sister’s house he also showed a marked fear of scrutiny from his sisters.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. NOTE: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

Barry’s reaction to his sisters demoralizing remarks about him from the other room was a panic attack that took the form of Barry kicking out the glass at his sister’s house.

C. The person recognizes that the fear is excessive or unreasonable. NOTE: In children, this feature may be absent.

Barry did not know exactly what was wrong with himself, but his attempt to reach out to his brother-in-law showed that he knew that something was unreasonable and that he needed help.

D. The feared social or performance situations are avoided or else endured with intense anxiety or distress.

Barry avoided meeting Lena at his sister’s house as best he could. When his sister brought Lena to his work to introduce the two, he was extremely anxious and distressed. He started fumbling all over the place, unable to perform his job and having a hard time communicating with Lena and his sister.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

Barry lived his life without much interaction with others before meeting Lena. Although he was lonely, he did not have the ability to initiate healthy interaction with others. He made a call to a 900 number as a way to engage in conversation with a woman.

F. In individuals under age 18 years, the duration is at least 6 months.

Even though Barry is in his forties, he has evidence of symptoms beyond 6 months. According to his sisters stories of Barry as a child, he might have been diagnosable before 18 years of age.

G. The fear or avoidance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.

Barry appears not to be on any medications or illegal drugs, nor does he appear to have another diagnosable mental disorder.

Specify if:
Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)
It appears that Barry works well with the other men in his company although Barry’s interaction with the men is limited and somewhat awkward.

Accuracy of Portrayal
There are few portrayals of a main character with social phobia in movies and television. Barry’s character in the movie gave an excellent portrayal of someone suffering from social phobia and the struggles they must face on a daily basis. The portrayal of his seven sisters gave a good indication that his upbringing was a humiliating and traumatic experience and gave insight into reasons why Barry might suffer from the disorder. Barry’s relationship with Lena is less accurate to the “real-life” relationship someone with social phobia might experience. His awkward demeanor, inability to maintain eye contact, and lack of conversation skills were accurately portrayed. The manner in which the two met was also likely since Lena pursued Barry and made most of the first moves in the relationship. The inaccuracy is in the fact that Barry and Lena found love and appeared to “live happily ever after,” which unfortunately does not happen for many individuals diagnosed with social phobia. In addition, Barry’s love for Lena seemed to give him the courage to confront the criminals that were taking advantage of him; however, it is unlikely for someone with social phobia to be assertive or confrontational. These two factors do not exclude social phobia as a diagnosis for Barry, they are just not the norm for what one might expect for someone diagnosed with social phobia.

Treatment
Cognitive behavioral therapy is likely the most effective treatment for Barry. This treatment will help change Barry’s pattern of thought about certain events by helping Barry better understand the reality of the situation and help Barry focus less on the idea that he will be embarrassed or humiliated. He will learn to identify and change his automatic negative thoughts. He will learn that everybody makes mistakes and that sometimes being embarrassed is going to happen but it will be okay. Therapy will also help give him coping strategies to change his behavior in anxiety provoking situations, as well as, giving him the skills to help manage his emotions and violent temper. Exposure therapy will help Barry learn that he can handle social situations without anxiety. Family therapy would likely not benefit Barry greatly but may help enlighten his sisters on the cause and effect their actions have on others lives. It would likely be most beneficial to meet with each sister one at a time with Barry as opposed to as a whole group.




Name: Charlie Kaufman

Source: Adaptation (movie, 2002)

Background Information

Charlie Kaufman is a Caucasian male in his mid-forties who lives with his twin brother Donald in an apartment they share together. He is a screenwriter who has been tasked with producing an adaptation of the book The Orchid Thief by Susan Orlean. Charlie appears to be suffering from some form of depression because he is constantly in doubt of his abilities to adapt the novel into a formidable screenplay, which affects his daily routines and interactions with his brother. There is no evidence of substance abuse (either drugs or alcohol), and he does not appear to be predisposed to partaking in consumption of dangerous substances. Charlie’s brother Donald constantly agitates him because he is embarking on a career in screenwriting and Charlie does not approve of his methods; he is baffled when Donald sells his work for a large amount of money. Charlie appears to have trouble with starting and maintaining close personal relationships, as evidenced by his awkwardness with a former girlfriend and a waitress at a local diner he frequents. He is able to start conversations but does not know how to keep them going and is not particularly skilled at inviting other people to join him in activities.

Description of the Problem

Charlie is a socially awkward person and although he is able to start minimal conversations with strangers and acquaintances, he is very nervous and cannot seem to keep his thoughts in one particular order that would benefit the situation. His family support system seems to only come from his twin brother, who is almost completely opposite in terms of personality, social interactivity, and general comfort with life. Since a lot of his thoughts are narrated for the audience, it is apparent that he craves relationships and people to share life experiences with but cannot bring up the courage to engage anyone past initial conversations. Charlie suffers from a severe case of writer’s block and takes his anger out on his brother, who is subsequently flourishing in his screenwriting endeavors. Much to the chagrin of Charlie, Donald seems to have picked up screenwriting and ran away with it and that bothers Charlie because he deems Donald an inferior screenwriter and too cliché to produce anything worthwhile. Charlie’s anxiety in social situations is profound and is outlined by a fantasy he indulges in regarding the diner waitress.

Diagnosis

The diagnosis for Charlie Kaufman is Social Phobia (300.23). According to the DSM-IV-TR the following criteria are met:

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. NOTE: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

Charlie shows a marked level of anxiety and fear when introduced to new people, especially in social situations. Excellent examples of these situations are when he meets a former girlfriend’s new “friend,” and when he is served by the waitress at the diner.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound situationally predisposed panic attack. NOTE: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

When Charlie meets the ex-girlfriend’s “friend”, it is obvious that he is speechless and cannot speak to him or the ex-girlfriend about his current situation. The waitress at the diner also causes Charlie to suffer through anxiety that freezes his conversation and makes the interaction very awkward.

C. The person recognizes that the fear is excessive or unreasonable.

Charlie knows that he is a socially awkward person and his continued interactions with his twin brother as well as his trip to New York to talk to Susan Orlean highlight his need to express himself in a socially acceptable way.

D. The feared social or performance situations are avoided or else endured with intense anxiety or distress.

On the trip to New York, Charlie ultimately avoids speaking with Susan Orlean and instead attends Robert McKee’s seminars. He then has Donald imitate him and interview Susan so he does not have to face her.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

Charlie’s avoidance behaviors and awkward social interactions severely hinder him from completing the screenplay and even render his trip to New York a waste of time and ultimate threat to his life as he is not able to talk to Susan Orlean in person.

F. In individuals under age 18 years, the duration is at least 6 months.

Charlie is well above the age of 18, but the film seems to suggest that his problems have persisted well beyond 6 months.

G. The fear or avoidance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder.)

Charlie’s social awkwardness and anxiety due to the social situations is not accounted for with any other condition or disorder. He seems to be genuinely suffering from a social phobia and no drugs or alcohol influence his behaviors.

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.

Charlie is not under the influence of any substances (legal or illegal), and his condition seems to be independent of any other diagnoses.

Specify if:

Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder.)

Charlie is able to maintain a steady job, do excellent work, and keep relationships with coworkers and everyday acquaintances, though to a minimal extent and not without awkward social interaction.

Accuracy of Portrayal

Charlie Kaufman is an adequate representation of a person suffering from a social phobia. It is not a perfect rendition, but it covers the base areas well enough to establish a passing resemblance. The character is not completely socially awkward, as he is able to strike up a conversation a few times (which do not lead to any sort of reliable, close relationship.) Charlie’s brother Donald plays a nice juxtaposition to his social anxiety and awkwardness, as evidenced by Donald’s general openness and lack of social anxiety. This suggests that, as children, Charlie probably suffered greatly from witnessing his brother’s easiness with social situations. A huge inaccuracy is the fact that Charlie becomes assertive and decides to fly to New York on a whim to meet with Susan Orlean. Also, his sudden insistence to check out what is going on between Susan and John Laroche is not typical of someone suffering from social phobia in any context. Although nothing good comes of these actions, the sheer fact that he pushed his social anxieties aside for those particular instances does not accurately portray someone with full blown social phobia. These are the only flaws portrayed by Charlie and the depiction is a passable example of social phobia.


Treatment

The most effective route to take with a person suffering from social phobia would be a treatment centered on cognitive behavioral therapy. This type of therapy could alter Charlie’s thought processes to allow him to acclimate himself to social situations in a socially acceptable manner. Through cognitive behavioral therapy, Charlie could slowly eliminate negative thoughts attached to social situations and therefore be comfortable enough to pursue relationships outside of the scope he has become accustomed to developing his entire life. He would be able to cope with social stressors such as the inevitable times when meeting new people will not go over very well and the situations in which established relationships start to deteriorate for numerous reasons. Slowly integrating real-life situations into the therapy (exposure) would then help Charlie come to terms with the changes that would come in his life and set him on the path to being a socially normal person. If the therapy was effective, Charlie would not become a new man overnight; rather, it would probably take years and consistent dedication to the changes to see him become adaptive to social situations.





Borderline Personality Disorder

Name: Mad Hatter

Source: Alice in Wonderland (movies, 1951 & 2010)

Background Information
In the 1951 film
Mad Hatter appears to be Caucasian male is in his late thirties, although his age is never disclosed. He is a fictional character in Alice’s dream. In the movie there are not any known physical or mental illness to be associated with the Mad Hatter, although there are visible traits to be noted for. He appears to be eccentric in his behavior and also in his appearance. He is dressed in a olive green blazer, with a green vest, aqua bow tie, beige button down shirt in which the collar is up, green pants and a large green top hat where on the side there is a 10/6 paper. He has white hair sticking out from the hat, and is rather pink in complexation throughout the movie. Prior to Alice stumbling upon them, the Mad Hatter and the Hare can be seen having a party celebrating non-birthdays (a celebration of all the other days in the year that are not one’s birthday). Currently the Mad Hatter lives in the forest that is a figmentation of Alice’s dream. It is unknown if the Mad Hatter has any family, although he can be seen quite often with the Hare and a little mouse. The Hare can be seen has having similar traits as the Mad Hatter; not being able to sit in one spot, interrupting others, speaking rather fast, constantly moving and appears to break teacups.

In the 2010 version
The Mad Hatter appears to be living in a forest that is part of Alice’s dream, in which he lives with Mally and the Hare. He appears to be in his mid-thirties, although his age is never disclosed. He is Caucasian and dresses vibrant. He has on a rather large top hat on, which has random objects stick out of it. Under the hat can be seen his is orange hair that is rather wild. His face is painted, in which his eyes are painted an array of colors; such as blue on, orange, and brown on one eye and the other pink and orange and purple on the other eye. His whole face is painted white. He can be seen wearing a brown tattered suit that is randomly put together, in which it matches his personality perfectly. Throughout the movie, his parents and other family members are never disclosed. Although he is rather fond of the White Queen and he remains loyal to her. The Mad Hatter lost his enjoyment and became “crazy” due to the Queen of Hearts overtaking the White Queen. This happened when the Jabberwocky came and destroyed the White Queen’s area and caused massive damage to her property. After that the Mad Hatter was never the same, he was no longer happy.

Description of the Problem
In the 1951 film
The Mad Hatter can be seen singing and dancing with the Hare. They are drinking tea and while dancing they continue to pour each other tea. Once they discover Alice has been watching them, they stop their dancing and signing. They run to Alice to tell her " it's very very rude to sit down without being invited”, but quickly overcome this once she compliments them on their singing. While the Mad Hatter is talking to Alice, he has his elbow in a cup of tea, and at one point he even pours tea from the kettle down his shirt and makes the tea go into a cup. They ask Alice where she came from but never give her a chance to answer, because they become distracted by clean cups they stubble upon. While dancing with the Hare to teach Alice about what non-birthday celebration is, the Mad Hatter makes a cake appear in place of where his top hat was. At one point he dips his plate into his tea and takes a bite out of the plate. He never stays with one thing, while talking to Alice about birthdays, he insists that she drinks some tea, but as she starts to drink her tea he starts to sing “clean cup clean cup!!” Before Alice can even take a sip of her tea he has dragged her off to the other end of the table and proceeds to ask her if she would like more tea. He can hardly sit still, every few minutes; he is compelled to move down the table and has Alice and the Hare to move down with him. It is clear that the character has difficulty focusing their attention to one aspect and also has difficulty remaining in one spot. The Hatter asks her “Why is a raven like a writing desk?” but never gives Alice the chance to answer. He quickly becomes angry when she attempts to answer the question, but his attention is diverted when the White Rabbit comes exclaiming he is late. The Mad Hatter tells the White Rabbit that his watch his two days old and proceeds to destroy the White Rabbit’s watch by dipping it in tea and adding an assortment of food to the watch. After placing all the food into the watch the Hare smashes the watch with his sledgehammer and the Mad Hatter and he kick out the White Rabbit.
When called to Alice’s trial as a witness, it he decides to throw the Queen of Hearts a unbirthday party, but this makes the Queen happy and does not last long due to Alice seeing Chester the Cat on top of the Queen’s head and the Mad Hatter running on top of the Queen to obtain Chester the Cat.

In the 2010 film
Upon seeing Alice approach him, he climbs on the table and walks across it, as he breaks plates and teacups along the way. Mally tells him that it is the wrong Alice, the Mad Hatter is positive that it is not the wrong Alice, and this is the correct one. While Alice is having tea with the Mad Hatter, the Hare and Dormouse, Chester the cat appears. While Chester is having tea, he brings up a topic that is sore for the Mad Hatter, who instantly becomes enraged in which Dormouse has to remind the Mad Hatter he needs to calm down. He is rather protective of Alice; when the guards of the Queen of Hearts come he hides her in a tea kettle. Upon making sure that Alice is safe, Mad Hatter puts her on his hat, after he had shrunk her, and takes her for a walk. While walking he starts to talk about the Jabberwocky and becomes enraged when Alice tells him that she will not slay the Jabberwocky. Talking to Alice about why she needs to slay the Jabberwocky, Mad Hatter becomes emotional, and tells Alice she has changed. He continues to go to lengths to protect Alice; he throws his hat with her on it across the field, so the Queen of Heart’s guards do not capture her, instead they capture him. He lies to the Queen and tells he has not seen Alice; when she is clearly sitting next to the Queen. Instead of answering the Queen’s question, he tells her that he is thinking of things that start with M: moron, mutiny, murder and malice. He decides to charm the Queen, by tell her that he wants to make her a hat for her rather large head. Once the White Queen regained her land again, the Mad Hatter is happy. To show his happiness he does The Futterwacken Dance, which he was not able to do when the White Queen was not in power.

Diagnosis
The diagnosis the Mad Hatter seems to fit best is Borderline Personality Disorder (301.83).
  1. Borderline Personality disorder is consider a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. This is indicated by having 5 or more of the following characteristics:
  2. Being frantic to avoid abandonment, either real or imagined
  3. A pattern of intense, unstable interpersonal relationships characterized by alternating between extreme variances of idealization and devaluation
    1. He displays this among Mally and the Hare. He is constantly changing his mood and one minute is harsh to them, and the next minute he thinks they have the greatest idea ever. Also, he instantly he is drawn to Alice once he sees her. He goes out of his way to protect Alice from the Queen of Hearts.
  4. Identity disturbance: markedly and persistently unstable self-image or sense of self
Although he knows he is the Mad Hatter, he does not seem like he knows this all the time. In the 2010 version the Mad Hatter saw himself as being with the White Queen, but after the Queen of Heart took over, he no longer knew who he was. He was one minute was having tea with Mally and the Hare, the next minute protecting Alice from the Queen of Hearts, and also he was someone that made hats.
  1. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
The Mad Hatter in the 2010 version fits this better, in that he is willing to himself at risk constantly for Alice. He takes on the Queen of Hearts’ guards, he repeatedly insults them and challenges them. Although it is never disclosed, he displays a several symptoms of someone that may have substance abuse, he is quick to change his behavior, his moods are hardly stable; they vary greatly from sadness, happiness, and anger, his behavior is eccentric; he talks in riddles and is constantly moving.
  1. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
  2. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
He displays this GREATLY. He varies through multiple emotions, one minute he is happy then the next minute he is angry. Upon seeing Alice he drops what he is doing and decides to walk across the table to get to her. He is happy to see her because she is the right Alice and is the one that can slay the Jabberwocky. While Chester pops in for tea and brings up the topic of the Queen of Hearts taking over, Mad Hatter becomes angry instantly and cannot control his anger until Mally reminds of where he is. He displays symptoms of Attention Deficit Hyperactivity Disorder, one minute he is talking about something and his attention becomes drifted to something else. The Mad Hatter in the 1951 could qualify of Attention Deficit Hyperactivity Disorder due to his lack of being able to focus on one thing. One minute he is telling Alice to have tea but then makes everyone move down because he saw a clean cup. He is constantly over talking the Hare and Alice. His emotions are unstable; he can easy become angry but can be pacified quickly. Both of the Mad Hatters are impulsive in the sense they do something without thinking about it. For instance in the 2010 version, the Mad Hatter is quick to insult the Queen of Hearts, but is quickly able to get himself out of being killed by telling the Queen he wants to make her a hat for her big head. In the 1951 version, the Mad Hatter throws the Queen of Hearts a unbirthday party when he is on trial for Alice.
  1. Chronic feelings of emptiness
Personally I feel like he has these feelings, and hides them by being eccentric. Reasoning for why he would have feelings of emptiness is that when the Queen of Hearts took over, he could no longer do what he loved; being with the White Queen. He is now living in a forest and displays multitudes of emotions rather rapidly. You can sense he is hiding his true feelings; depression of the White Queen no longer in charge.
  1. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
He becomes angry instantly when Chester brings up the day of when the Queen of Hearts took over. Mally has to remind him of where he is and to control his anger.
  1. Transient, stress-related paranoid ideation or severe dissociative symptoms

Accuracy of Portrayal
In a sense both Mad Hatters portray this disorder but the 2010 version does a better job of doing so. The 2010 version shows more emotion and you can see what caused him to become eccentric. His mood varies rapidly; he is quick to be impulsive and has a short attention span. He displays having other mental illness, such as depression and attention deficit hyperactivity disorder. His attention is constantly shifted between topics and is always moving. He has a hard time sitting still; he is never in one spot. The depression would be due to the Queen of Heart coming to power. She destroyed the property that he lived on, it was the end of the world that he knew. Even though the White Queen lost her power, he still remained loyal to her. In losing the property that he lived on, and the White Queen no longer being in power, caused the Mad Hatter to be even more eccentric, psychotic.

Treatment
To treat the Mad Hatter a Diagnostic Interview for Borderline Patients would first be given. The interview looks at areas of functioning that are associated with borderline personality disorder. The four areas of functioning include Affect (chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, emptiness), Cognition (odd thinking, unusual perceptions, nondelusional paranoia, quasipsychosis), Impulse action patterns (substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors), and Interpersonal relationships (intolerance of aloneness, abandonment, engulfment, annihilation fears, counterdependency, stormy relationships, manipulativeness, dependency, devaluation, masochism/sadism, demandingness, entitlement). The best treatment for Borderline Personality Disorder is dialectical behavior therapy; this treatment focuses on the patient building a life that balances changes and handle situations that occur in their life. Patients with Borderline Personality Disorder respond best to psychotherapy. Establishing trust between the patient and therapist is difficult to create and also maintain once established. Types of psychotherapy that can be used are cognitive-behavioral therapy, transference-focused therapy, dialectical- behavioral therapy, schema-focused therapy, and metallization-based therapy. Also it would best to place the Mad Hatter in a stable environment, and around people that have stable moods.





Name: Ernie “Chip” Douglas “Aka” Larry Tate/Ricky Ricardo/ the Cable Guy.

Source: Cable Guy (Movie, 1996)

Background Information

From his reminisces, Chip grew up in a neglected home. His father was out of the picture, and his mother seemed to be some sort of cocktail waitress, or prostitute which is concluded from Chip watching a family scene on the television and saying to his mom” When am I going to get a brother to play with?,” while his mother replies,” Honey, that’s why mommy is going to happy hour,” as she leaves the house. Now in his early thirties, Chip works an eccentric cable guy who has a distinct lisp. The scene opens as Steven Kovacs waits on Chip to arrive to install his cable. It appears that Steven has waited all day on Chip. Finally, when Steven is in the shower, Chip arrives and starts banging on the door saying, “Cable guy,” multiple times, and with each time getting louder and more annoyed. Finally, Steven comes to the door, upset that he was late, and Chip also becomes upset and states that he will just leave instead. After Steven asks Chip to come inside, Chip starts looking around the living room for a spot to put the cable wires. He starts talking to the walls in a sexual manner, and even displaying gestures to the walls that makes Steven uncomfortable.

Once Chip installs the cable, Steven asks him for free cable since his friend told him all he had to do was slip the cable guy a fifty-dollar bill. Chip then asks Steven to hang out with him later on yet Steven was “busy” so Chip asked again, “Well, what are you doing tomorrow?” Steven agreed and Chip exited saying “See you tomorrow pal.” While hanging out, Chip takes Steven to the large satellite receiver where Chip becomes overly emotional about how people’s satellite usage will expand and how you will one-day play video games with your friends in Vietnam. Afterwards, Steven asked what his name was, and Chip becomes highly emotional and explains with a dramatic monologue how it amazes him at the thought that Steven wanted to know his name, and goes on to say that his name is Ernie Douglas, but everyone calls him Chip.

After Chip incentivizes his friendship with Steven by giving gifts such as a new home theater system while having no regard for personal space or privacy, although Steven asks Chip to return it, Chip becomes upset and says that he has given him friendship and that is greater than that stuff. Chip insists on awkward social activities, including dinner at Medieval Times where Chip becomes overwhelmingly aggression by competing in jousting, and sword fighting with Steven. The next day, Chip ignorantly stumbles upon Steven and his friends playing basketball, invited himself to join them, and ruined the game by breaking the goal. The next day, Chip leaves Steven thirteen messages on his machine, and undoes his cable, so that Steven will call him. Chip arrives furious that he only calls when he needs something.

To make Steven feel better about his girlfriend problems, Chip hosts a karaoke party with all the equipment he gave to Steven and without his knowledge, hires Steven a prostitute whom he slept with that night. Outraged, Steven throws Chip out, and Chip promises he will fix it. By fixing it, Chip goes stalks Steven’s girlfriend Robin with her date, and waits for him incognito in the bathroom and severely assaults her date then shows up at Robin’s house and installs her free cable. After Steven tells Chip he does not want to be friends anymore, Chip calls Robin to make her paranoid about how Steven is supposedly acting and then informs the police that Steven has stolen property. Once Steven is out on bail, Chip invites himself over to Steven’s parents where he instigates a game of porno password and insinuating that he slept with Robin. Infuriated, Steven punches Chip and Chip leaves. The next day, Chip kidnaps Robin, takes her to the huge satellite dish, and holds her hostage with a staple gun. Steven chases Chip and Robin up to the very top of the satellite. When the helicopter shines a light on Chip, he hallucinates that it is his mother telling him to jump. So, right as the world is waiting to hear the verdict on a huge case, Chip jumps and lands on the receiver, which knocks out the city’s cable. However, Chip survives the fall and makes a mends with Steven and Robin, and as the helicopter pilot airlifts Chip away, he calls Chip pal, which starts the whole cycle over again.

Description of the Problem

Chip shows instability with personal relationships such as friendships. He becomes frantic if he believes if his friend(s) are abandoning him. He has no job, He had been fired from several cable companies in which he used different television names as his own such as Larry Tate, which is known from “I dream of Jeannie.” Chip has feelings of abandonment, which stems from his neglectful childhood, where the television raised him instead of his parents. Chip has intense emotional problems such as erratic acts of aggression, violence, revenge, and dramatic emotions in terms of sobbing. Within moments, Chip can show signs that he absolutely loves his friends and then despise or hate the same friends. Chip shows signs of self-harming impulsivity such as reckless behavior including frequent trips to the large satellite dish, drinking, and hiring prostitutes. His risk of suicide behavior increased when he assumed he no longer had any friends and attempted, but failed at a suicide attempt.

Diagnosis

301.83 Borderline Personality Disorder

DSM-IV-TR criteria

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. This is indicated by having 5 or more of the following characteristics:

1) Being frantic to avoid abandonment, either real or imagined

Chip shows this throughout the entire movie at his multiple attempts to keep Steven as his friend, and then included Robin into the mix, and lastly the helicopter pilot.

2) A pattern of intense, unstable interpersonal relationships characterized by alternating between extreme variances of idealization and devaluation

Chip exhibits extreme highs and lows on how he feels about himself as a good and bad friend to Steven. Chip does this when he cooks Steven breakfast after a party the next morning (high) then feels incredibly bad at the fact that he hired a prostitute that Steven slept during the night (low). To fix the friendship, Chip goes out to make things right with Steven and Robin (high).

3) Identity disturbance: markedly and persistently unstable self-image or sense of self

Until Steven’s friend did a background check, it was unaware. However, Chip was terminated from multiple cable companies where he had different alias from television shows such as Ricky Ricardo, and Larry Tate. Even though that Chip believes he is a great friend, he has broken into Steven’s house and disrupted his privacy by wiring cameras in Steven’s home and using them as blackmail.

4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

It is not real clear, however, there were scenes of him drinking alcohol and what seems to him being either drunk or drugged. In addition, by hiring the prostitute for Steven, Chip knows how to get women, whether it is through giving free cable or something else.

5) Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior

Chip displays few suicidal behaviors. However, Chip did imply that he should end his life when the police shined the light on him, and then plunged to what he thought would be his death. Chip survived the fall.

6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

When Chip first met Steven to install his cable, he was very annoyed that Steven took a moment to answer the door, and then switched his mood to friendly when he asked Steven to hang out with him. Another instance occurred when Steven did not reply to Chip’s 13 messages on the machine, until Steven’s cable went out and then was upset at the fact that Steven only called when he needed something. Chip displayed signs of depression or dysphoria when he was telling Steven that no one ever asked his name until then.

7) Chronic feelings of emptiness

Chip appears to feel empty from an early age as he lives in a neglectful home. There is no father present and a mother who goes out to happy hour in search of a man. In his adult age, Chip feels empty because no one takes the time to ask for his name let alone befriend him.

8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

Frequent temper outbursts and anger along with fights are seen throughout Chip’s behavior towards Steven. Chip has temper tantrums when Steven does not want to be his friend. Chip becomes angry and vengeful when Steven says he does not want to be his friend anymore. Chip shows erratic when he plays basketball with the guys and begins to name call and play “street ball” after someone runs into him. Chip has two physical fights, one with Steven at the Medieval Times where he comes at Steven with a sword, a joust, and a mace. The second occurrence is where he waits for Robin’s date in the bathroom and assaults him until he has to be rushed to the hospital.

9) Transient, stress-related paranoid ideation or severe dissociative symptoms


Accuracy of Portrayal.

I believe that Chip matches most of the criteria of this disorder unquestionably if not perfectly. His uncontrollable anger issues, feelings of emptiness, unstable interpersonal relationships, and his abandonment issues seem to make him fit the criterion of this disorder. Some things that need to be addressed is the few instances of self-mutilation to himself, including impulsivity, and suicide behaviors. More examples of suicidal tendencies needed to be seen in order to accurately diagnose him with Borderline Personality Disorder. In the movie, Chip only has the one instance of self-harm, which was the attempted suicide, and although Chip portrays himself to know the prostitute, he never mentions that he himself has had personal encounter with her, nor does it ever show that Chip was sexual impulsive. With some of the criteria still uncertain, Chip does fit eight out of the nine characteristics.

Treatment.

To accurately diagnose Chip with BPD, He would be given the Diagnostic Interview for Borderline Patients Test, the Structured Clinical Interview (SCID-II) and the Personality Disorder Beliefs Questionnaire (PDBQ). For treatment, the best thing available is the Dialectical behavior therapy. In this therapy, it is broken down into three focuses, which would help Chip survive and build a meaningful life by helping him to balance change and accepting his life’s situations. First, life-threatening or harmful situations are addressed in Chip’s life. This would include self- harm from self-mutilation or attempted suicide; each instance would be dealt with accordingly. Then, Chip would be gently pushed to experience emotions that are painful for him. Pushing Chip to experience intense emotions head-on is a type of exposure with response prevention therapy. As Chip faces his toughest emotional outbreaks with different situations, Chip’s anxiety levels will eventually decrease. The decreased anxiety will allow Chip to experience those situations again only without the emotional outbreaks and anxiety. Lastly, Part three addresses living problems. Although it is unclear in the movie of Chip’s living conditions, this portion of the DBT will help Chip feel complete as a person. By feeling complete, Chip would be able to deal with the feelings of “emptiness” and the imagined fears of being abandoned. Once Chip is able to cope with these feelings, he will be able to identify when these feelings are beginning and be able to recognize that they are not real. By being able to identify these feelings, Chip will be able to control his outbursts of anger and mood swings.






Intermittent Explosive Disorder

Name: Matt Foley

Source: Saturday Night Live (TV series, early 1990s)

Background Information
Matt Foley is a 35 year old, male motivational speaker. Physically he is severely overweight due to his steady diet of government cheese. This may lead to high blood pressure and other health complications. He also seems to have trouble breathing normally, not just during his “rage” episodes. He doesn’t speak of any interpersonal relationships, family or other, so family history and his childhood environment are unknown. Matt did admit openly that he is twice divorced and lives in a van down by the river, and he is very unsatisfied with these two facts. His social skills are very awkward. When he is around people he is loud and generally awkward, either not understanding social cues or (more likely) ignoring them. He becomes very physical with others, lifting them, invading “personal space” and so on. One episode he talked about began with shaking children to “drive his point home” that Santa wasn’t real (during this episode he was being paid to dress as Santa at The Mall. At time of evaluation he had been on a coffee binge, drinking it for four hours straight. With the exception of his coffee spree there is no evidence or admittance of harder drug use. He has little to no coping skills, often reverting to yelling to relieve tension. He generally frightens people with his behavior. And while his goal in life is to not live in a van by the river (and convincing young kids that they don’t want that, too) he seems unable to help himself in achieving that goal.

Description of the Problem
Matt Foley’s personality is off-setting. While he can seem overly enthusiastic, it is a façade to hide his short temper. His irritability is evidenced in all his mannerisms, from his constant fidgeting to the way his voice grows louder the more irritated he becomes. He constantly has to adjust his pants and shake out his arms to get rid of his temper “tingling” in his arms. He is very short with people who think differently than he does, choosing to be verbally demeaning instead of allowing them their own opinions. This is costing him his audience when he gives speeches and not allowing him to form connections. Not being able to make positive relationships is harming his work performance and not allowing him to advance on to higher positions. Higher positions would mean a pay increase and allow him to move into a more permanent habitation (such as an apartment or a house).

His explosive nature has also led him to destroy other individual’s property. While at a house for a job he annihilated a coffee table in the living room. He was sorry after the fact, but could not seem to say anything other than “whoopsie.” He also once forcefully suggested he move in with another person to set them on the right path. During another episode he yelled at a mother to “shut your cake hole!” and he promptly destroyed a Christmas scene set at The Mall. Yet another episode he discussed involved him interviewing a highly respected comedian/talk show host (Conon O’Brien). The interview included Matt yelling insults, such as threatening to use the studio’s curtains to “wipe (his) rear end with (them).” His episodes last about 6 minutes (specifically 5 minutes and 49 seconds) and occur sporadically.

Diagnosis
Diagnosis is Intermittent Explosive Disorder, DSM-IV 312.34. Matt clearly shows an inability to control his impulses. His episodes last less than a half hour at time and usually result in a physical altercation or destruction of property. They are also grossly uncalled for as Matt loses control “at the drop of a hat.” His actions are neither planned nor used for personal gain, other than to relieve his anger. Having no history of drug abuse or suggestion of family history of mental health, it can be safely assumed that Matt is not under the influence of anything other than his own unchecked rage. That is, his actions are not accounted for by any other mental disorder or substance abuse. Since Matt is divorced he may have some unresolved anger issues, or he may have had a tense marriage where it was not unusual for him to go into episodes. Matt also says he is remorseful for the destruction of property, proving he does have a sense of what he’s doing is wrong. Similar episodes have occurred before, one time involving public property at The Mall, the other involving verbal abuse during an interview with a well-known comedian Conan O’Brien.

Accuracy of Portrayal
Intermittent Explosive disorder is an impulse disorder that is specifically a lack of restraining anger and aggression. Statistically men are more likely to have IMED than women. The episodes are grossly out of proportion to the situation, be it a yelling match or breaking something. These episodes are also not accounted for by another mental disorder, drug use, or by any physiological condition (such as brain injury, dementia, Alzheimer’s, and so on.). Matts episodes are short in duration (generally no longer than 20 minutes), which is consistent with the diagnosis for IMED. The breaking of the table and Christmas scene could also be accidental rather than purposeful, but it’s still accounted for by his episode. His “drug use” (coffee and espresso binge) is atypical, but not unheard of. His aggressive tendencies are interfering with his life and relationships, and will continue to do so until he gets a handle on his behavior. In all these ways, Matt is a perfect example of an individual who suffers with IMED.

Treatment
As mental health professionals would agree, there are a few options for Matt Foley. Empirically supported treatment for Matt could include drug therapy such as β-Blockers, α(2)-agonists, anti-anxiety, anti-convulsion, ant-depressants, antipsychotics, and mood stabilizers. Drug therapy can be used with or separate from cognitive behavioral therapy. In cognitive behavior therapy individuals identify stressors that lead to episodes and how to cope or avoid them. Other forms of treatment include social skills training, in which the individual works on improving their interpersonal skills. Although social skill training is a form of treatment it is less effective than drug and/or cognitive behavioral therapy.
Matt Foley would benefit most from the combination of drug therapy and cognitive behavior therapy. Matt would be a good candidate for β-Blockers, because they specifically block the β 1 and 2 receptors that stimulate the body into “fight or flight” mode. They would also help to lower his blood pressure, which may further help to reduce his stress and anxiety by strengthening his health. In cognitive behavior therapy he and his therapist would work specifically on ways to control his anger or use it in more constructive ways. One strategy for controlling his anger would be to record specific instances that send him into episodes. Knowing these situations would allow him and his therapist to work on ways to reduce his rage should these situations ever occur again.

Intermittent Explosive Disorder
Name: James Howlett (Wolverine), Logan, formerly Weapon Ten, Death, Mutate #9601, Jim Logan, Patch, Canucklehead, Emilio Garra, Weapon Chi, Weapon X, Experiment X, Agent Ten, Canada, Wildboy, Peter Richards, many others, but primarily claiming Logan as his primary name.

Source:Marvel Comics (As Wolverine, cameo) Incredible Hulk #180 (1974), (as Wolverine, fully) Incredible Hulk #181 (1974), (as Patch) Marvel Comics Presents #1 (1988), (as Weapon X) Marvel Comics Presents #72 (1991), (as Death) Astonishing X-Men #1 (1999)

Background Information
Logan is more than one hundred years of age, although he has the appearance and health of a man roughly 35-40 years of age. Born James Howlett, he was a frail boy of poor health from Alberta, Canada during the late 19th Century. He was the second son of wealthy landowners John and Elizabeth Howlet. His mother, who was institutionalized for a time following the death of her first son, John Jr., in 1897, largely neglected James. Elizabeth later committed suicide. He spent most of his early years on the estate grounds and had two playmates that lived on the Howlett estate with him: Rose, a red-headed girl who was brought in from town to be a companion to young James, and a boy nicknamed "Dog" who was the son of the groundskeeper, Thomas Logan. James assumed the name “Logan” while living incognito following a violent incident involving his companion Rose, who was consequently wrongly accused of murder. Logan is a veteran of several conflicts and wars including World War II. He has served in covert government operations working under the title Weapon X as an assassin. Logan worked as a miner in British Columbia for a time and was highly regarded as being a hard worker. He has also worked as an adventurer, instructor, bartender, bouncer, spy, government operative, mercenary, soldier, and sailor. Logan has an almost immunity to the intoxicating effects of alcohol, but no evidence of use or abuse of any other substances is apparent. Logan tends to make friends easily enough, but due to his violent and tragic past has difficulties with trust. Logan’s romantic relationships are often complicated and tedious, frequently becoming situations where either his love cannot be displayed, or his love is for someone committed to someone else. Logan’s difficulty with interpersonal relationships as well as his propensity toward violent outbursts often causes him to withdraw and spend a lot of time alone. This isolation often serves as a means of coping.

Description of the Problem
Logan has a strong and often forceful demeanor. He often engages in aggressive competitive behaviors, as well as being somewhat of a bully when in certain company. He seems to be tender toward women, but sees other males as either competition, or subordinates. Logan shows a generally hostile disposition, as well as a tendency to engage in aggressive forms of humor in the limited instances in which he interacts with others. When engaged in conversation, he is often abrupt and bordering on rude.
Logan’s (Wolverine’s) skeleton includes six retractable one-foot long bone claws, three in each arm, that are housed beneath the skin and muscle of his forearms. Logan can, at will, release these slightly curved claws through his skin beneath the knuckles on each hand. This ability coupled with Logan’s short fuse and incredible physical ability often makes him dangerous.


Diagnosis
Diagnosis: Intermittent Explosive Disorder, DSM-IV 312.34. Logan displays a number of impulsively violent outbursts, many of which last only a short time, but are extremely severe and destructive. Logan often displays violent outburst of temper, threatening others, even peers with physical harm, as well as considerable destruction of property both with his claws as well as other means. Logan is quick to anger and aggress and is often severe in his reactions to perceived threats to his safety. During one of his altercations with another male from his past, Logan inadvertently killed his childhood companion, Rose, by impaling her with his claws. One form of aggression, known as amok, is characterized by acute, unrestrained violence, typically associated with amnesia. This is primarily seen southeastern Asia but has also been seen in Canada and the United States. Unlike IED, amok does not occur frequently but in a single episode. One reason for suspecting that Logan may be suffering from this is due to two factors:

A) Logan has extreme memory loss due to having had his memories “wiped” from his consciousness after his service as Weapon-X
B) Logan possesses memories of being a Samurai in Japan. Perhaps during his travels in the Far East, he found himself in southeastern Asia.

The only reason for mentioning this is due to Logan’s chronological age being much longer than that of a non-mutant human.

Accuracy of Portrayal
Being male, Logan is more at risk of having developed IED. IED is one of the impulse-control disorders that involve the inability to control impulses of anger, or rage and often results in violent physical outbursts or violent verbal attacks. Logan definitely displays these tendencies. Logan doesn’t seem to have any other mental disorders such as schizophrenia, bipolar, affecting him, however during the process of “wiping” his memory, a degree of brain injury may have occurred. Logan’s extremely reactive nature and his severity during his explosive episodes is often maladaptive and causes him to have to be transient in nature, drifting from location to location, rarely settling down into one specific location. His romantic relationships have been complicated by his angry outbursts as well. Enemies he has made in the past due to his mercenary work and covert government work have caused the death of at least one potential life mate.

Treatment
Since few controlled studies exist involving treatment of IED, Logan would probably benefit from cognitive behavioral therapy (CBT), helping him to identify triggers for his outbursts. Teaching him coping skills such as diaphragmic breathing, counting, and also the keeping of a stress and incident journals to help him identify what triggered specific incidents and what to do to avoid them or possibly handle them differently if a similar situation arises. Anger management and group therapy could also be effective as well. If these were unsuccessful, or only marginally effective, then the use of certain medications such as anti-convulsion, anti-anxiety, mood regulators, anti-depressants, antipsychotics, beta-blockers, alpha (2)-agonists, or phenytoin could be indicated.



Narcissistic Personality Disorder

Subject Name: Jenna Maroney

Source: 30 Rock (Television series, mid 2000s)

Background Information
Jenna Marony is a forty-three year old woman, who was born Ystrepa Grokovitz on February 24, 1969. She grew up in Bakersfield, CA. Her father, was a burger server in suburban Santa Barbara. He dumped Jenna's mother, a dental hygienist, for another woman. Jenna still says she will "always be his little girl." After being spurned, Jenna's mother made her sit on every mall Santa's lap in Bakersfield in an attempt to find him. Jenna has a sister who urinated in one of Jenna's eyes when she was little, which causes it to not open all the way. Another sister is deceased. She did not get along with her half-sister, Courtney, who is now deceased. Upon hearing of her sister's demise, Jenna showed no obvious signs of sorrow or grief. Jenna also has a niece, who draws pictures of her Auntie Jenna. Jenna finds the pictures to be offensive, when in fact they are just childlike renderings of Jenna.

During Jenna's teen years, her mother moved what family she had left from California to Florida. Jenna attended high school on a boat, which has subsequently sunk. At the age of 16, Jenna was engaged to a congressman. She has also reportedly dated O.J. Simpson, a music producer, a sniper, a mob boss, and hinted at having been in a three-way relationship with Rosanne and Tom Arnold. Jenna's started singing at a young age, as a distraction for her mom, who was busy shoplifting. Jenna went on to study voice at Northwestern University and also at the Royal Tampa Academy of Dramatic Tricks, where she majored in playing prom queens and murdered runaways. She has been in various films and commercial, and is currently employed as an actress on a television series.

There is no history of substance use, however, there is a history of binge eating, but the episode was brief, and Jenna's eating habits have since returned to normal. Jenna is in good health, with no reported concerns.

Jenna seems to have coped with her life difficulties by becoming the "center of attention," and the center of her own universe. Abandoned by her father and used by her mother as a decoy, Jenna possibly feels unloved and rejected. Jenna's inability to empathize with others and sustain lasting relationships with are major weaknesses. She is constantly battling with someone, whether it be a co-worker, a friend or a family member. Currently, Jenna is involved with a transvestite who dresses as Jenna. In fact, Jenna met her lover while participating in a Jenna Maroney Look-Alike Contest, in which Jenna herself only placed fourth. Her new lover won the contest, and they have been intimate since that time.

Description of the Problem
Jenna does not feel she has any problems, other than not receiving the attention and recognition she feels she deserves. Her achievements are not commensurate with her desire to be "worshipped," and adored. Jenna feels she is entitled to special treatment and when this fails to occur within her career or social life, she becomes explosive and stubborn. She has an excessive need for admiration, as evidenced by her choice of careers. She seems to have no empathy regarding others, and on the rare occasions empathy is displayed by Jenna, it is not genuine empathy, but a means to an end. In other words, she fakes empathy to manipulate others, or for personal gain. Jenna repeatedly poisoned a co-worker in the hopes of dating one of the "hot" EMT workers who came to the rescue. Jenna is severely jealous of her co-star in her current television series, and is constantly looking for ways to undermine him. She dreams of unparalleled success and believes she is the most beautiful, talented woman to grace this planet. While Jenna does not see this as a problem, the rest of society fails to agree with her assessment of herself, and this causes much frustration for Jenna. Jenna reacts very unfavorably to even the slightest criticism, as she believes herself to be perfect and unique. If she is criticized, she feels that the person doing the critique, "just doesn't understand her," because they are not as special and wonderful as she.
Diagnosis
Jenna best fits the diagnostic category of Narcissistic Personality Disorder (301.81)

· A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
o has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
o is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (perfect marriage to the perfect spouse)
o believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
o requires excessive admiration
o has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations ("You owe me because I'm that good")
o is inter-personally exploitative, i.e., takes advantage of others to achieve his or her own ends -
o lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
o is often envious of others or believes that others are envious of him or her
o shows arrogant, haughty behaviors or attitudes
· Other Symptoms:
o history of intense but short-term relationships with others; inability to make or sustain genuinely intimate relationships
o a tendency to be attracted to leadership or high-profile positions or occupations
o a pattern of alternating between unrealistic idealization of others and equally unrealistic devaluation of them
o assessment of others in terms of usefulness
o a need to be the center of attention or admiration in a working group or social situation
o hypersensitivity to criticism, however mild, or rejection from others
o an unstable view of the self that fluctuates between extremes of self-praise and self-contempt
o preoccupation with outward appearance, "image," or public opinion rather than inner reality
o painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one has done)

Jenna qualifies for almost every single diagnostic criteria, as outlined in the Description of the Problem and her Background information. There is some overlap with Histrionic Personality Disorder, as Jenna does frequently use her sexuality to gain her desires, however, she fits more of the Narcissistic criteria than the HPD criterion.

Accuracy of Portrayal
The portrayal of narcissism in this character is fairly accurate, although there is some overlap with Histrionic Personality Disorder. One of the deciding factors whether this was NPD or HPD was the fact that Jenna falls in love with a man who dresses as her. Narcissus was also in love with himself and was forever doomed to gaze upon his reflection in a pool of water, until he died. It is said as his boat crossed over into the afterlife, he leaned over to catch on last glimpse of himself in the water. This is the epitome of Jenna. While more males than females are diagnosed with NPD, (7% for males and 4 % for females), Jenna is a prime example of a female narcissist.

Treatment
Narcissists rarely seek treatment, as their perception is that they are "better" than everyone else. If a narcissist does enter treatment, psychotherapy is the recommended course of treatment, and perhaps some group therapy. If group therapy is utilized, clear boundaries should be set as to respecting other people in the group. Prognosis poor.





Anorexia Nervosa

Name: Giselle Vasco

Source: Skinny by Ibi Kaslik (book, 2004)

Background Information
Giselle Vasco is a twenty-one year old, Caucasian female of Hungarian decent. She was the first born of two daughters after her parents, Thomas and Vesla, immigrated to the United States in the early 1970’s to escape the communist repression of their country. Giselle’s younger sister Holly is eight years behind her in age but, much like her sister, has a very grounded and intellectual personality. They both stand approximately five feet, eleven inches tall and have a very close relationship. Giselle and Holly are both considered accomplished in their own rights, even at young ages with Giselle enrolled in medical school and Holly being acknowledged as a “stand-out athlete” at her high school. At the present time, Giselle is home from medical school, taking a leave of absence to clear her mind and regroup her life. She is working at a hospital in the mental health ward as a companion to many patients. It is described that, after her first love had left, Giselle became a callous lover who would frequently sleep around - trusting nobody with her heart. This stayed a constant until she met her current boyfriend, Solomon (Sol), who desperately loves Giselle.
Both sisters however, are plagued by the fact that their father had recently passed away due to a heart attack. In the midst of this tragic loss, both sisters struggle in the grieving and coping processes respectively. Giselle and her father always had a rocky relationship that stemmed from a time before she was even born. Thomas questioned the faithfulness of his wife in the frequent suggestions that Giselle may not be his biological daughter. This was an obstacle that was battled through from Giselle’s birth up until her father’s death-and even after. The relationship between the girls and their mother, however, seems to be solid.
Giselle acknowledges that when she was her sister’s age (approximately 14) one of her primary focuses was to discover ways to “be smaller.” It is presumed that Giselle, and the entire Vasco family for that matter, were a religious group. At one point, Giselle asks for God’s forgiveness after lying to her mother about her weight at the time. Giselle also acknowledges that she would masturbate in upwards of six times a day and would drink only lemon water. In lieu of her desire to “be smaller,” Vesla would frequently take Giselle to see the doctor regarding her weight, often against her wishes. There is no mention of a history of drug or alcohol use by Giselle.

Description of the Problem
As mentioned earlier, while in high school, Giselle’s mother would constantly bring her to the doctor to check up on her weight. Giselle would do things like put rocks or weights in her pockets to tip the scale at 120 pounds, as opposed to the 95 that she weighed. Her lack of a proper diet surrounds her potential diagnoses. Holly describes her sister’s systematical approach to the dinner table as Giselle would figure out ways to clear her plate without digesting a single bite of food (i.e. dropping food on the floor, pretending to use the restroom and flushing portions of her meal). Aside from a lack of food toward her diet, Giselle would only drink lemon water.
Sexually, Giselle is not what you would call repressed. She became very sexually ambiguous after the departure of her first love. Also, as discussed earlier, Giselle would spend much of her time locked in her room, masturbating up to six times per day.
On a relational level, Giselle and her father always struggled with the speculation the she may not be his biological daughter. We go on to discover that this is indeed true. This made it hard for them to ever truly salvage a meaningful father-daughter relationship.

Diagnosis
In my personal opinion, Giselle’s diagnosis would be as follows: Axis I, Anorexia Nervosa, Binge Eating/Purging Type (307.1) and Axis IV, Problems with Primary Support Group.

Criteria needing to be met for above Axis I diagnosis as follows (from DSM IV-TR):
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
-Over the course of years, Giselle would consume an insufficient diet consisting of little or no food and lemon water, putting her at a weight that was below 85 percent than expected for her height. She constantly resists the cautions of her mother and doctor in regard to her weight.
B. Intense fear of gaining weight or becoming fat, even though underweight.
-Giselle exhibits this behavior in her everyday way of thinking. Even though she is of above average height, she intensely pursues a body weight that is unhealthy for her to maintain. Also, she takes extreme measures to ensure that her body weight stays exceedingly low and, in turn, dangerous to her general well-being.
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
-Although she is what is considered underweight, Giselle is indifferent to this fact and yearns to continue to lose dangerous amounts of weight. She evaluates herself as being “too big” but seems to have a partial awareness that she is ill-she may not be in denial.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)
-Symptoms of this nature were not discussed; however details about her sexual history and excessive masturbation are mentioned.



Accuracy of Portrayal
Although it may not be glaringly clear, should the average person read this book, they would find a fairly accurate portrayal of the onset and manifestation of the eating disorder Anorexia Nervosa. I say that it may not be clear, in large part, due to the fact that this work is narrated by two individuals (both sisters) as almost two different stories. Not only is Giselle’s case of Anorexia a prevalent point in the novel, but so is the poor relationship between Giselle and her father as well as the family dynamic after their father’s death. There were, however, some very accurate descriptions of what behaviors would be exhibited from an individual with this disorder. Her constant dilemma on how to trick those around her into believing she was eating a healthy diet is quite common in individuals with Anorexia. Giselle also references her constant hunger, although she denies it to those around her. Her cold and clammy hands as well as constant fatigue are also associated features of Anorexia that allude to her problem. With that being said, I feel that the book does an exceptional job of portraying an individual with Anorexia Nervosa.

Treatment
In treating Giselle for her disorder, the treatment team would focus their attention around two main goals: (1) To help Giselle gain weight and (2) To address Giselle’s psychological and environmental issues. A major step in treatment, as in the treatment of any disorder, would be to make sure that Giselle is aware that she has a problem. The most widely used form of treatment for this disorder is family and group therapy, which cannot be utilized to its full potential should the patient not admit that he/she needs help. In Giselle’s case, her sister and mother would play a very significant role in treatment. As a clinician, you would like to see Giselle’s family encouraging her on a regular basis, reinforcing the fact that she looks fine the way she is (while eating a normal diet), and that it is not necessary for her to exhibit these unhealthy behaviors. More specifically, I believe that Giselle’s sister Holly should be utilized as best as possible during treatment as they have always had a very strong bond and friendship. If anyone would be able to aid in “breaking through” to Giselle about her disorder, I think it would be her little sister.
Self-help groups are also successful in the treatment of those with Anorexia. Treatment for Giselle should include regular group meetings with individuals who have experienced the same negative outcomes in their lives due to the disorder. The thought here is that by discussing the topic of Anorexia among those who have it, Giselle will be afforded the opportunity to become more educated on the subject and, eventually put herself in a position where she is aware of the harm she is causing her body. Over time, between family therapy and self-help group therapy, hopefully a certain sense of cognizance will begin to develop with Giselle in regard to the harm she is causing herself-this will hopefully lead to a change in attitude and eventually behavior.





Alcohol Abuse

Name: Lila Blewitt

Source: Lila: An Inquiry into Morals by Robert M. Pirsig (book,

Background Information
Lila Blewitt is a Caucasian female and presumed to be middle aged, although her actual age is unknown. She is currently riding on a sailboat with a man she met the previous night in a bar located along side a river on the East Coast. Lila does not have an occupation. In the past, Lila has been a prostitute as well as a waitress. Lila’s mother was critical of her. As a child, when Lila did something good, the mother said nothing; but when she did something bad, her mother mentioned the incident repeatedly. Lila was previously married to a trucker and had a daughter. Her husband and daughter are deceased. Lila’s daughter died by smothering in her blanket, and her husband died in a car accident. She likes to dress very provocatively, but with no originality.

Description of the Problem
Lila has very little direction in life, and her mental processes and conversations are very surface. She dresses overtly sexual, and believes that with enough alcohol, relations with men are reduced to pure biology where they belong. Lila does not moderate her intake of alcohol, and drinks often and to the point of complete intoxication. She takes medication called Empirin whenever she begins to sense a psychotic episode is coming on. These episodes appear to be induced by social stressors, such as disagreements or arguments. Lila also suffers from severe delusions, odd ideations, and catatonia. Lila’s medication was stolen from her purse; she ended up lost in New York City and thought that taking all of her clothes off would be a good idea because then somebody would “see” her and help her. Lila’s social life greatly suffers due to impulsively rapid shifts between seeing individuals as either a rescuing friend, or as an enemy out to get her. Also while she was lost in New York City, Lila ordered three rum and cokes, although she didn’t end up being able to pay for them, and then thought that her childhood pet and dead husband were giving her directions on how to get back to the sailboat she had been riding on. Once back at the sailboat, Lila saw a doll floating in the river and believed it to be a human baby. Also at times, Lila’s speech is highly disorganized, described by the author as “word salad.”

Diagnosis
The diagnosis for Lila that seems to fit appropriately is Schizophrenia, Disorganized Type (295.10) with a comorbidity of alcohol abuse (305.00).
A. To be diagnosed with schizophrenia, two or more of the following characteristics must be present:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia, or avolition

Lila displayed all of these characteristics throughout the book.

B. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.
Lila was unable to hold down a job, drifting through life without goals or direction. Her interpersonal relationships suffered drastically. Everywhere that she went, people would end up wanting to get and stay away from her. Lila was unable to maintain stability in her life, with no home or occupation. She had to rely on others to take care of her.

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal
or residual symptoms.
The author indicated from conversations with a childhood friend of Lila’s that she had suffered from the above stated symptoms throughout her adult life.

D. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out
because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently
with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to the duration of the active and residual
periods.

Lila did not seem to display symptoms of mood disorders. Other than during a psychotic episode, Lila’s mood remained relatively stable throughout the book. She did not display depression, but she did display catatonia. Any time that she displayed anxiety, it would be involving a break from reality.

E. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
Lila’s substance abuse involved heavy drinking, but her above symptoms were never consequences of being under the influence of alcohol at that time.

F. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the
additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month.

There is no history of either of the above listed disorders present in Lila.

To fit the Diagnostic Criteria for 295.10 Disorganized Type, the following criteria are met:

A. Disorganized speech.
The author would describe the way Lila conversated as being “word salad.” It would make sense to Lila, but not to the listener.

B. Disorganized behavior.
Lila got lost in New York City because she was not paying attention to the direction that she was walking in, nor the direction that she would need to later return. She also thought that it would be acceptable to take her clothes off in order to get somebody to “see” her. She often needs others to rescue her from situations that she got herself into.

C. Flat and inappropriate affect.

During a psychotic episode, Lila’s affect became completely flat. She would not speak or respond to any outside stimulus for an entire day.

To fit the diagnosis for Alcohol Abuse (305.00)

A. recurrent substance use in situations in which it is physically hazardous and continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
Lila would drink to the point of being intoxicated in public places where she did not know anybody, when she did not have the money to pay for the drinks, and did not even know her own whereabouts. As a result of her behavior while intoxicated, Lila would behave inappropriately and aggressively towards others. These behaviors would cause Lila to be an outcast in her social circle.

B. The symptoms have never met the criteria for Substance Dependence for this class of substance
Lila does not meet the criteria for Substance Dependence. Although drinking alcohol did cause Lila the above stated problems, Lila did not drink as frequently as is required to be considered dependent.

Accuracy of Portrayal
The average person reading this book would see an accurate portrayal of a person whose behavior qualifies for alcohol abuse. The author does not make Lila out to be dependent on alcohol, but he does show how Lila overconsumes alcohol to the point of causing her problems in her social life, as well as putting herself in hazardous situations. The comorbidity of her alcohol abuse with her schizophrenia is also an accurate portrayal for someone with less severe schizophrenia, occurring in episodes rather than ongoing. The book also illustrates for the reader accurately what may be going on inside the mind of a person during a schizophrenic episode as well as while abusing alcohol.

Treatment
To treat Lila’s alcohol abuse, the first step would be to provide treatment for her Schizophrenia. No long term success for treatment of her alcohol abuse could occur while Lila was suffering from a psychotic disorder without treatment. Once Lila was in treatment for Schizophrenia, you would then address her alcohol abuse. Lila would have to realize and admit that she was abusing alcohol. The fact that alcohol abuse was causing social problems for Lila as well as putting herself in dangerous situations could be presented to Lila so that she would correlate alcohol abuse with its negative consequences. While her treatment for schizophrenia could involve medication, it would be important to look at possible drug interactions before prescribing her any medication to help her stop drinking. Next, Lila could start cognitive behavioral therapy to explore her emotional reaction to events in her life and her ensuing behaviors and their further consequences, while emphasizing alcohol abuse throughout this process. Last, Lila could attend Alcoholics Anonymous to learn more about alcohol abuse and to have a social environment that is supportive of her while she is learning to change her behaviors involving alcohol abuse.



Panic Disorder without Agoraphobia

Name: Tony Soprano

Source: The Sopranos (Television series, 1999-2005)

Background Information
Tony was born of Italian descent on August 24, 1960 and is male. At time of symptoms Tony was 39 years of age. Tony Soprano declares himself to be in the “waste management” business but is actually involved in criminal activity. The Tony is the capo in the Dilteo crime family. The duties included with this occupation are collecting “loans” and “persuading” people to pay back money that was “loaned” to them. These “persuasions” include physical attacks as well as other forms of violence. Tony has the added responsibility to attempt to keep peace between him and other members of the organization. Tony is in relatively good health for a man his age, but is noticeably overweight. Tony’s family mental health is very stressful. Tony has stressful relationships with his wife and work associates. An especially stressful and dysfunctional relationship with the mother is also present. Tony has a history of alcohol and tobacco use. Major life difficulties include stress from work and problems from aging mother. Tony displays poor coping skills, often resorting to anger and aggression. The use of alcohol and promiscuous relationships are used as escaping behaviors.

Description of the Problem
Tony has had several episodes of fainting. The first paint attack was described by Tony as a feeling of “ginger ale in the skull”. The symptoms Tony experiences during his panic attack episodes include “racing” heart, feeling faint and dizzy, chest pains, and breathing difficulties. Specific problems these symptoms are causing are increased difficulty dealing with demands from his occupation, increased stress with family responsibilities (especially issues involving the future of the Tony’s aging mother). Tony is hesitant to admit he is experiencing depression but ultimately does state that he is depressed. Tony became deeply saddened by the departure of ducks he had been caring for. He came to the realization the departure of the ducks symbolized his fear of losing control of his family, job, and life in general.

Diagnosis
Diagnosis for the Tony meets criteria for Panic disorder without Agoraphobia, DSM-4 TR code 300.01. Tony has recurrent, unexpected panic attacks and shows worry about the implications of the attack (e.g. losing control). The Tony does not display characteristics of agoraphobia. The panic attacks do not appear to be due to the Tony’s use of alcohol, tobacco, or any other pre-existing physical conditions.

Accuracy of Portrayal
The average person watching the portrayal of the Tony would think that panic disorder is only caused by extreme life stress and that the disorder has minimal impact on other aspects of life functioning. The main point for accuracy of portrayal included with this character is he also displays major depressive disorder. This lends to the accuracy of portrayal due to the high comorbidity between panic disorder and major depressive disorder, which is between ten to 65 percent. Also, accuracy of the portrayal comes from the recurrent and unexpected nature of the panic attacks. The inaccuracies from the portrayal include the presentation that panic attacks are only associated with highly stressful life events. Other inaccuracies are the lack of behavioral change and lack of impact on Tony’s relationships and social life.

Treatment
The primary source of treatment would be cognitive behavioral therapy. CBT would focus on having Tony face behaviors and thinking patterns that sustain or trigger the panic attacks. This treatment would have Tony realistically ask themselves such questions as, “what is the worst thing that could happen?” For Tony, questions might include, “what is the worst that could happen to my business or family if something were to happen to me?” When Tony is forced to look at the worst outcome and realize that everything would go on if this outcome happened, he learns the source of his panic is less terrifying. Cognitive behavioral therapy might also be supplemented with anti-depressant medicationdue to his co-occuring depressive symptoms. The treatment that is displayed on the show for Tony is a psychoanalytic approach. The American Psychiatric Association does not acknowledge the role of intensive psychoanalytic therapies, including psychoanalysis, in the treatment of panic disorders. However, studies have shown significantly reduced panic symptoms from panic-focused psychodynamic psychotherapy (Barbara et al., 2007). More evidence must be gathered before the treatment presented in the show is recognized as a significant treatment for panic disorder.




Panic Disorder with Agoraphobia

Name: Dr. Helen Hudson

Source: Copycat (movie, 1995)

Background Information
Dr. Helen Hudson is a retired criminal psychologist. Her exact age is not given but she is estimated to be in her mid 40’s. She is a physically healthy female without a family of her own. No family background is provided in the film. Dr. Hudson is very renowned in her field and often lectures on the subject. She testifies against and profiles serial killers. Dr. Hudson was attacked by a killer she testified against and witnessed him kill one of her police bodyguards. After he was sentenced to jail, he threatened to kill her. This triggered a deep fear and extensive amount of anxiety in Dr. Hudson. Due to her fear and anxiety, Dr. Hudson confines herself to her home and puts in premium security systems to attempt to feel safe. Because Dr. Hudson does not leave her home, her social relationships are confined to her live-in assistant and anonymous online friends she communicates with through chat rooms and games. She is a heavy drinker and takes many pills for her condition. Upon becoming homebound, Dr. Hudson retired from clinical practice and writes books to generate an income.

Description of the Problem
Dr. Hudson was extremely traumatized by her attack and the violence and death she witnessed. After the attack, Dr. Hudson not only retired from her practice but also became totally homebound to avoid contact with anyone who might be a potential serial killer. She feels she is “the pin-up girl” for serial killers. She believes they all know her and want to either impress her with their killings or want to kill her. Dr. Hudson displays perceptions of imminent danger in even simple tasks such as retrieving the newspaper from the hallway in front of her apartment door. When she does attempt to leave the apartment, even in the face of another attack, it brings on such severe panic that she almost becomes unconscious and returns to her home, even though there is an intruder inside. She has nightmares, paranoia, hyperventilates, becomes dizzy, breaks out in sweat, and sometimes will pass out from her panic symptoms. She occasionally hallucinates that she is seeing her attacker. Her panic attacks happen often enough that she keeps anti-anxiety medications in several places in her house for easy access. She has a live-in assistant to aid her in case she passes out during her attacks. Because of her alcohol and pill use, she does not trust her own thoughts or actions from time to time. She is often agitated. In severe stress situations, Dr. Hudson will sometimes laugh inappropriately. Dr. Hudson does not verbally discuss the symptoms she is feeling but she does obviously sweat during her attacks and blurred vision is implied with camera use in the film. She has a deep distrust of others and views herself as superior to others much of the time, especially police officers.

Diagnosis
The diagnosis for Dr. Helen Hudson would be Panic Disorder with Agoraphobia (300.21) and is comorbid with Post-Traumatic Stress Disorder (309.81).
DSM –IV-TR Criteria
  1. Both 1 and 2:
    1. Recurrent, unexpected panic attacks
    2. At least one of the attacks has been followed by one month or more or one or more of the following:
  • A. Persistent concern about having additional attacks.
  • B. Worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, “going crazy”)
  • C. A significant change in behavior related to the attacks
Dr. Hudson does have recurrent, unexpected attacks and has shown a drastic change in behavior.
  1. The presence of agoraphobia

Dr. Hudson does not leave her home.
  1. The panic attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication ) or a general medical condition (e.g. hyperthyroidism)
Although Dr. Hudson drinks heavily, her panic is not brought on by alcohol. Instead, it is a coping mechanism that she uses to numb her thoughts or “kick in” her medications.
  1. The panic attacks are not better accounted for by another mental disorder such as social phobia (e.g. occurring on exposure to a feared social situation), specific phobia (e.g. on exposure to specific phobic situation), obsessive-compulsive disorder (e.g. on exposure to dirt in someone with an obsession about contamination), post-traumatic stress disorder (e.g. in response to stimuli associated with a severe stressor), or separation anxiety disorder (e.g. in response to being away from home or close relatives).
Dr. Hudson does display the symptoms of PTSD. It is comorbid to her panic and anxiety. She experienced a life-threatening situation and has recurrent thoughts and dreams about the experience.

Accuracy of Portrayal
The people viewing this film would get a very accurate portrayal of panic disorder with agoraphobia along with post-traumatic stress disorder. Dr. Hudson displays many of the symptoms of all three conditions. Her condition is discussed in the film so it would give the general public the appropriate labels for both panic attacks and agoraphobia. However, PTSD is not discussed and seems to be the root of her problems. It is hard to feel completely confident in this diagnosis without a discussion with the character/author. Many of the symptoms one would feel in a panic disorder need to be verbally expressed. Is she feeling the symptoms of a heart attack? Is she nauseous? Does she feel like she is choking? Do all of her thoughts stem back to her attack? Only the physical symptoms are apparent to the viewer. The agoraphobia is well displayed in the film. She very obviously suffers with the feeling she will be in a situation that will not allow her to escape and will suffer as she did when she was attacked by a killer. Post-traumatic stress disorder is comorbid in this diagnosis. Dr. Hudson’s symptoms were brought on by a horrific, life-threatening event. She does have continued thoughts about this situation along with sleep disturbances from the attack.

Treatment
Dr. Helen Hudson would probably be very difficult to treat since she is a psychologist and would have been trained in and practiced treatments for her disorder. By taking an anti-depressant medication, she could hopefully reduce her agoraphobic symptoms and with a benzodiazepine she could control her panic attacks. However, beginning other therapies would a healthier way for her to overcome her issues. Hopefully the medications would not need to be a long-term solution.

Teaching Dr. Hudson some relaxation techniques would help her avoid the thought processes that lead to her panic and agoraphobic symptoms. Practicing and using diaphragmatic breathing and positive meditation when panic symptoms present themselves would be a good coping skill for her. Keeping a thought record to help her recognize what situations or thought processes bring about her attacks would also be helpful. Recognition of detrimental thought processes and the relaxation techniques might help to reduce her panic symptoms and possibly help her avoid them altogether.

Discussing the statistical data of people killed by serial killers would be a starting point in cognitive therapy for Dr. Hudson. She probably has a higher than chance probability of being targeted because she is a famous criminal psychologist and killers might try to impress her by outwitting her, but generally speaking the chance of being killed by a serial killer is low. Next, having Dr. Hudson go through some low-level fear exposures would be necessary. This would include viewing photos of serial killers and viewing documentaries about them.

Next, developing and rehearsing coping responses could be done. Here, intense imagery would be used to help Dr. Hudson imagine her darkest fears and increase her anxiety so that realistic solutions to her fears could be developed. In this case, possibly watching films of people being attacked (fictionally) and what they could have done to prevent or escape the attack.

To begin dealing with her agoraphobia, baby steps could be taken to get here to a place where she feels comfortable leaving the home. First might be opening the door to her apartment and just standing in the doorway. Second, walking out of the door and standing in the hallway. Third standing in the hall with the door to the apartment closed. These steps would continue hopefully to the point where she might even return to the convention hall in which she was attacked.

Ending Dr. Hudson’s reliance on alcohol would also have to be dealt with in her therapy. She uses this as a numbing agent or as a kicker to her anti-anxiety drugs. In confronting her issues, it would be assumed she could become less reliant on these substances and live a much more normal life.





Obsessive-Compulsive Disorder

Character Name: Adrian Monk
Source: Monk (Television series, 2002-2009)

Background Information
Adrian is a 51 year old widowed male with no children. Adrian shows no signs of physical ailments or other health problems. He does not have a history of drug or alcohol abuse. He presently works for the San Francisco Police Department as a consultant in homicide cases. Adrian obsesses over high levels of order and neatness and, therefore, has trouble functioning in the outside world. He also self-reports an extensive list of phobias. These symptoms were evident in childhood, but seem to have been exacerbated by the death of his wife. His goals are to extinguish the many phobias he suffers from and to experience some level of happiness. Adrian’s social circle consists of a few co-workers who are familiar with his condition.
According to Adrian, his parents were highly strict and very over-protective when he was a child. Adrian’s mother has been deceased since 1994. His father abandoned the family when Adrian was 8 years old, and they have only recently begun communicating again. Mental history of the father and mother are unknown. Adrian’s brother, Ambrose, suffers from agoraphobia. Ambrose has little social contact and fears leaving his home. Relationships with both his father and brother are strained, but otherwise healthy. No other family mental illness is known.
Though not a family member, an important person in Adrian’s life is his assistant. This person assists Adrian in his professional life as well as his personal life. Adrian has had two consecutive assistants that have filled this role for him. This assistant is aware of Adrian’s many phobias and does her best to help him avoid stressful situations. For example, she is responsible for always having anti-bacterial hand wipes available to “protect” Adrian from the germs he fears.

Description of the Problem
The greatest catalyst of Monk’s behaviors seems to be the tragic death of his wife, Trudy, who was murdered in a car bombing. Adrian was previously employed by the SFPD as a homicide detective but received a psychiatric discharge after the murder of his wife. Following his wife’s death, Adrian retreated to his home and refused to leave for three years. With the help of his nurse/assistant, he has reluctantly entered out into the world again, but still suffers from extreme obsessions, compulsions, and fears. Adrian has been unable to solve his wife’s homicide, and this causes great emotional distress to him. He often re-visits and obsesses over the case.
Adrian self-reports that he has 312 phobias and continues to accumulate more as time goes on. These phobias range from common fears such as heights or germs to unordinary fears such as, milk or mushrooms. Adrian also suffers from phobias of dentists, sharp objects, vomiting, ladybugs, glaciers, death, snakes, crowds, fear and small spaces. These fears prohibit him from completing everyday tasks such as driving, shopping, and social interaction.
Adrian’s work as a consultant for the SFPD requires him to visit crime scenes and evaluate evidence. His photographic memory is especially helpful in his line of work. However, his anxiety often prevents him from being able to use his talents. For example, he arrived at a crime scene that had a burnt out bulb in a chandelier and was unable to work until the bulb had been changed. In another instance, he was unable to work because a police officer’s zipper was undone. Adrian is very intent on every aspect of his life being orderly, neat, and clean. He has a habit of cleaning household cleaning appliances, such as vacuums. Balance and symmetry are also important. While working undercover at a bank, he added his own money to every deposit so that the amounts would be whole dollars. He also declined to see a therapist with an amputated arm because he could not get over the asymmetry.
Adrian keeps a meticulous home, with everything in order at all times. He is obsessed with cleaning and cleaning products. He has established certain menus and ways of eating that he also finds organized and acceptable. For example, he will only drink a certain kind of water and cuts his pancakes into squares because he prefers the symmetry. If travel is absolutely necessary, he goes to extreme lengths to pack. Everything must be kept in sealed plastic bags and he will often pack brand new, individually wrapped bedding so he does not have to use something that someone else has used.

Diagnosis
The main diagnosis for Mr. Monk appears to be Obsessive Compulsive Disorder (300.3). This disorder is classified in the anxiety disorders. DMS criteria require that either obsessions or compulsions must be present in order to qualify for the disorder. Both do not have to be present. Adrian appears to have both obsessions and compulsions. To qualify for this disorder, the client must exhibit uncontrolled concern about specific ideas and feel compelled to repeat particular acts of series of acts. Adrian’s concern over harmless objects, such as milk, and his compulsion to touch things, such as poles, makes him a candidate for Obsessive Compulsive Disorder.
Other DSM criteria include:
1) The person has recognized that the obsessions or compulsions are excessive or unreasonable
2) If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it.
3) The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
4) The disturbance s not due to the direct physiological effects of a substance or general medical condition.

Adrian fits this criterion as well. He is intelligent and sees that his behaviors are unreasonable, but is comforted by them anyway. His grooming and cleaning habits often take excessive amounts of time and go beyond what would reasonably be considered clean. He has no other known physical or mental problems that would cause his behavior. There is no history of substance abuse.

Associated features of OCD that are present in Adrian’s behavior are avoidance of situations where the objects of obsessions are present, frequent doctor visits, and feelings of guilt/responsibility. Adrian also exhibits the associated features of compulsive acts in order to alleviate anxiety, excessive cleansing or grooming practices, and extreme need for symmetrical aligning of objects.

Accuracy of Portrayal
I think the portrayal of Adrian Monk is an accurate description of Obsessive Compulsive Disorder. Someone watching this series would be able to learn about the irrational fears and the difficulties that Adrian has in overcoming them despite how irrational they are. They would be able to see how his behaviors prohibit him from functioning at an optimal level. Another positive aspect of the show is that it shows Adrian as someone with a mental illness, but he is not vilified or seen as inferior. I think this helps promote the idea that having mental illness is not shameful. One possible problem with the show is how his behaviors are usually seen as quirky but still fuional. For someone suffering from OCD in real life, the consequences can be much more detrimental and debilitating. Also, although he is presented as a gloomy character, real OCD can lead to severe depression in the affected individual. Also, he seems to have more phobias than compulsions. Aside from touching poles, he does not exhibit the repetitive behaviors associated with OCD.

Treatment
Treatment for Adrian could include a prescription for an SSRI medication in order to increase his serotonin production. This could aid in the reduction of depression symptoms, anxiety symptoms, and obsessive-compulsive symptoms. In addition to medication, intense behavioral therapy, specifically exposure therapy with response prevention, is also recommended. This would involve exposing Adrian to the things he fears most (whenever practical and ethical) and compelling him to experience his anxiety until it comes down to a bearable or normal level. In Adrian’s case, however, this would be very time-consuming due to the number of phobias he possesses. Due to Adrian’s difficulty in establishing interpersonal relationships following his wife’s death, grief counseling may also be indicated. Also, his assistant could be included in much of the therapy so that she could be reinforcing appropriate behaviors in his daily life.





Bipolar II Disorder

Name: Casey Roberts

Source: Mad Love (Movie, 1995)

Background Information
Casey Roberts is a female high school student in her late teens. Upon arriving at a new high school, she appears to be fairly normal in behavior. However, it is apparent from early on that she has almost no social relationships, or even more, a desire to have any. Aside from a relationship with her parents, who appear supportive and loving, she only has one other relationship which consumes her throughout the movie: her relationship with her boyfriend Matt. This relationship is what drives many of her actions throughout the movie. Her parents say there is no past mental health history in their families. However, they are in denial of her having an actual mental illness and attribute it to her trying to get back at them for controlling her, so the real history may not be reported. No major drug or alcohol use is apparent although casual drinking is seen throughout the movie and nicotine use, especially while in her depressed episode, is also shown. There are no outward health problems visible in Casey. She is a very intelligent girl with a very strong willed personality. However, she does not seem to care too much about asserting that intelligence towards any goals. School is in no way important to her.

Description of the Problem
Although Casey is at some points able of living and functioning normally, she has a past of suicidal behavior. As stated in the Background Information, she has little to no social relationships. However, she does appear to be a fairly friendly person. Probably the largest hindrance on her functioning is her impulsivity. She seems to think that she should do and be able to do whatever she wants when she pleases. Towards the end she also has a tendency towards thoughts that are very sporadic in nature. Casey displays much risk taking behavior without seeing any important consequences that could occur from them. She is also temperamental and very easy to irritate. Delinquent behavior is also presented in her behaviors in the form of truancy and the case of her pulling a fire alarm in the school. She also has very strong thoughts of guilt and states that as punishment for the things she has done to Matt, he should leave her. When the onset of her illness begins to be very apparent, she shows much distractibility and tends to not behave correctly in social situations. Insomnia also is presented along with strange ideas. These ideas could possibly also be symptoms of Schizophrenia such as thinking people are always watching her and out to get her. She believes that she must put cut outs of eyes up around their apartment to protect them.

Diagnosis
The diagnosis for Casey is Bipolar II Disorder (296.89). To reach that diagnosis the following must be true:
A. Presence (or history) of one or more Major Depressive Episodes.
Within the movie there is a Major Depressive Episode. Her parents also referred back to the fact that Casey had experienced episodes before as well.
B. Presence (or history) of at least one Hypomanic Episode.
A Hypomanic Episode was also included in the movie. Evidence on whether or not she had been through more than one episode of this before was not provided.
C. There has never been a Manic Episode or a Mixed Episode.
Casey’s symptoms were not severe enough to classify as a Manic or Mixed Episode.
D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Although Casey had some odd behaviors that seemed almost similar to ones that would be presented in Schizophrenia or a very similar disorder, they would not be classified as actual delusions. The inconsistencies in her behaviors seem to classify more into Bipolar Disorder.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Casey’s ability to form relationships was greatly affected by her symptoms. Also, distress was definitely seen within social situations. Casey was found in a bathroom with her dress off and hitting the walls and crying.

A diagnosis of a Major Depressive Episode was found by the following:
A. Must include five or more of the following over a 2-week period:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Casey presented symptoms 1, 4, 7, and 9.
B. The symptoms do not meet criteria for a Mixed Episode.
Her symptoms were not presented as both Manic and Depressive on a nearly daily basis.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Distress and impairment were definitely apparent in social situations. The example of the bathroom scene previously mentioned demonstrated this.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
No drugs were being used besides nicotine and no other stated medical condition was present.
F. The symptoms are not better accounted for by Bereavement, i.d., after the loss of a loved one; the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness suicidal ideation, psychotic symptoms, or psychomotor retardation.
No loved ones were lost; the symptoms had been reported for over 2 months and she had attempted suicide numerous times.

A diagnosis of a Hypomanic Episode was found according to the following:
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood. It is characterized as a period of increased energy that is not sufficient or severe enough to qualify as a Manic Episode.
Casey’s mood was elevated while they were traveling and she was in her Hypomanic Episode. The severity of it would not classify as a Manic Episode however.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Casey presents symptoms 2, 3, 5, and 7 within her Hypomanic Episode.
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
She seemed to function almost normally when the episode was not happening. When she started presenting symptoms, her level of functioning obviously decreased.
D. The disturbance in mood and the change in functioning are observable by others.
Like previously stated, her changes were observable.
G. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
Her Hypomanic Episode did not strike Matt as “scary” or needing help immediately like her Depressive Episode. No hospitalization was seen as necessary.
H. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
No drugs were being used besides nicotine and no other stated medical condition was present.
Accuracy of Portrayal
Watching the portrayal of Casey would give a person a fairly good look into Bipolar Disorder. Most people label someone as “bipolar” when really they are just having mood swings or maybe suffering from Cyclothymic Disorder. This idea of such rapid switching is not accurate. Although Casey did have her moments of sudden anger or happiness, that can be accounted for by simply an experience she had or something that was said. Simple reactions like this are very common. However, her episodes as portrayed were seen as changing over periods of time, not just in an instant, giving the watchers a pretty good insight on the disorder. In the film, Casey’s mother stated that Casey suffered from depression. This may have influenced watchers to disregard her Hypomanic symptoms. Overall, the audience would get a fairly good look into the actual life of a person with Bipolar Disorder.

Treatment
When Casey arrived for treatment, a medical work up would occur to make sure the disorder was accurately diagnosed. This would also allow knowledge of the current episode, suicidal thoughts, and hopefully more family history. Casey would probably then be prescribed lithium carbonate. Because of the potency of this drug, her dosage would need to be very closely monitored. Therapy would also be a very useful tool for Casey’s treatment. Cognitive behavioral therapy would be a good start to help her deal with her emotions and stress. Therapy would also help Casey to fully understand Bipolar Disorder and to know in the future when an episode may happen. Likewise, education would be essential for her parents. Helping them understand what exactly is happening with Casey and to recognize her episodes would be very beneficial.



Oppositional Defiant Disorder

Name: Stewie Griffin

Source: Family Guy (Television series, 1999 – Present)

Background Information
Stewie Griffin is a Caucasian male who is presumed to be one years old, although he may be four to five years old because in later episodes he attends preschool. Stewie is unemployed but shows a mastery level of physics and mechanical engineering. He has designed such things as mind control devices, weather control, fighter jets, and teleportation devices. Although there are not any known distinct physical illnesses, abnormalities, or disorders currently within Stewie Griffin, there are observable health concerns. The patient displays unprovoked hostility towards others, constant disobeying of parental rules, is extremely vengeful and vindictive, and easily loses his temper quite frequently. Stewie currently lives with his parents, Peter and Lois Griffin. Stewie’s father, Peter Griffin shows observable symptoms of mild mental retardation. This is evident when he took an IQ test in one of the episodes and scored a 70. It is also observed that Stewie’s parents exhibit a strong sense of control over his life, such as scheduling play dates for him to go on, toys he can/can not play with, and what/when, he can eat. Stewie exhibits strong introversion in social relationships. He does not have close relationships with anyone outside of his immediate family. This is due to the fact that Stewie sees his peers as obstacles in his path toward world domination. Because of this, he frequently kills off the lesser characters with tanks, guns, and other assorted weaponry. There have not been patterns of consistent alcohol usage by Stewie, but he has excessively used alcohol on occasion. This is particularly problematic, as any type of alcohol usage by a one year old can severely inhibit brain development. Stewie’s goal is to attain world domination by first killing his mother, who he fears will stand in his way. All of Stewie’s daily activities are designed to accomplish these two goals by creating weapons such as rocket launchers, engaging in violent criminal activities, carjacking, loan sharking, and forgery. Other weaknesses that Stewie displays are his stresses of infant life, such as teething and eating his vegetables.

Description of the Problem
Stewie Griffin currently displays a multitude of symptoms indicative of oppositional defiant disorder. He displays disobedient actions towards authority figures; however, Stewie believes that he is conducting himself in an appropriate manner for his own self-preservation. He also suffers from delusional behaviors such as having conversations with his stuffed teddy bear Rupert. He protects Rupert and will avenge any harm that comes Rupert’s way. Stewie deliberately annoys his peers by picking on them and continuously making rude remarks about their appearance or inabilities as a person. He also shows anger and resentfulness towards his mother because he feels that he is wrongly punished for activities he is supposed to carry out for the betterment of himself and world domination. As a result of this, he is also very spiteful and vindictive. For example, in one episodes Stewie loans Brian some money and they contractually agree that payment would be made on a certain date, but Brian does not repay on that date, so Stewie beats Brian with a bat daily until he receives payment. Stewie often uses a scapegoat for his own mistakes. When his attempts to kill his mother fail, he blames her for being unfair and bitchy.

Diagnosis
The diagnosis for Stewie Griffin that fits appropriately is Oppositional Defiant Disorder (313.81).
A. To be diagnosed with Oppositional Defiant Disorder a pattern of negativism, hostile, and defiant behavior lasting at least 6 months during which four (or more) of the following are present:
1. Often loses temper
2. Often argues with adults
3. Often actively defies complying with adults’ requests/rules
4. Often deliberately annoys people
5. Often blames others for his or her mistakes
6. Is often easily annoyed by others
7. Is often angry and resentful
8. Is often spiteful or vindictive

Stewie Griffin undoubtedly shows more than four symptoms of Oppositional Defiant Disorder, as described in the section “Description of the Problem.”

B. Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
Stewie possesses the ability to talk fluently at age one and interact with people at an intimate social level that is not yet observable in the one year old population. Typical one year olds rely heavily on parental care, where Stewie is significantly more independent than his peers (e.g. taking trips to San Francisco and Rhode Island).

C. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
Stewie is significantly impaired in social functioning because he does not develop and nurture his relationships, instead he sees his peers as obstacles towards his goal that he must defeat at all costs. Because of this, he does not have any significant social relationship with anyone outside his immediate family.

D. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
Characteristics of oppositional defiant disorder can be observed in the patient in all settings and instances throughout his daily activities.

E. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
The patient is between the ages of 1-4 years old.

F. There is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior towards authority figures.
Stewie is in constant confliction with how he is going to succeed in killing his mother and attaining world domination.

G. Occurs outside of normal developmental levels and leads to impairment in functioning.
Stewies behavior is clearly outside of normal development for a one year old, and this leads to impairment in functioning such as developing strategies to kill his mother and take over the world (e.g. making weapons with the purpose of carrying out these goals).

Accuracy of Portrayal
The typical person watching Family Guy would be able to reach the conclusion that the character Stewie Griffin is abnormally developing compared to his average peer. A person with an Abnormal Psychology background would be able to further determine that Stewie showed all the symptoms for Oppositional Defiant Disorder. This is a cartoon character created to break the boundaries of normal development for babies, even to represent the general helplessness of an infant through the eyes of an adult. This show helps illustrate Oppositional Defiant Disorder by successfully creating a character that exemplifies every characteristic of the disorder, and not wavering from season to season. Although Stewie is not an accurate portrayal of the average one year old, he still can be related to children suffering from this disorder. Therefore, Stewie Griffin is an accurate illustration of someone with Oppositional Defiant Disorder.

Treatment
To treat Stewie Griffin, after a full medical examination, it would be best to teach him problem-solving skills as well as parent management training. Problem solving skills would help Stewie learn to solve problems in a logical and predictable manner. The downfall with this strategy is that is time consuming and on average requires 20 sessions. Another effective way to treat Oppositional Defiant Disorder is parent management training. This allows the parents to develop and implement structured management programs at home. This is designed to improve interactions between child and parent. Parents implementing this strategy should positively reinforce good behaviors. A secondary methodology of treating Oppositional Defiant Disorder is to medicate the child using Ritalin. Research has shown children treated with Ritalin who have Oppositional Defiant Disorder, 75% of the children no longer showed symptoms of ODD.





Name: Walker Bobby and Texas Ranger “TR” Bobby

Source: Talladega Nights: The Ballad of Ricky Bobby (Movie, 2006)

Background Information
Walker and Texas Ranger Bobby are pre-pubescent males, with an estimated age of 11 and 7, respectively. Neither boy holds a job because of their young age. The Bobby brothers do not display any specific health issues. Walker and Texas Ranger live with both of their parents and their maternal grandfather, Chip. Their father, Ricky, is a famous racecar driver who displays some symptoms of Narcissistic personality disorder, claiming that he is “the best there is,” and that he “piss[es] excellence.” Their mother, Carley, does not show any observable symptoms of a mental disorder. However, she is very materialistic, markedly aggressive when provoked, and shows extreme devotion to her husband, at least until the promise of better prospect comes along (e.g., she leaves Ricky for Cal when Ricky can no longer race). In other words, their mother is a gold-digger. The family unit is still very much intact – they eat dinner together every night and attend all of Ricky’s races together. While the bonds between the family are obviously very strong, Walker and Texas Ranger display many types of defiant and hostile behaviors toward authority figures. Most likely due to their lack of shock and surprise, these behaviors are not typically directed towards their parents. Rather, the Bobby brothers act out to other close adults like both of their grandfathers, Chip and Reese, and their grandmother, Lucy. In fact, the boys’ mother and father seem to condone this behavior, claiming that they did not raise “sissies”. Walker and Texas Ranger were never portrayed as having done illicit drugs, although they did inquire about a comment that their grandfather Reese had made about possessing marijuana. Besides the problems that they have run into at school due to behavioral issues, the boys do not possess any real life difficulties. They do not have any deeply defined goals either as they are just kids looking to enjoy themselves while they can. Due to their inconsistent and overindulgent lifestyle, Walker and Texas Ranger’s coping skills are not very good. They handle less-than-perfect situations with immaturity and anger, often lashing out at whoever they believe will take it. Their weaknesses are handling new, unwanted situations (such as Sunday school) and being polite to adults.

Description of the Problem
Walker and Texas Ranger currently display a multitude of symptoms indicative of oppositional defiant disorder. They are consistently defiant and hostile, spouting out at whomever they believe deserves the criticism or hatred. These two display a constant need to argue and swear, especially to adults. They argue most often with their grandfathers, Chip and Reese, their grandmother, Lucy, and their teachers in school. There is nothing off limits for these boys. Their actions and criticisms are often unnecessary and cruel – usually just for the purpose of upsetting or annoying the adults around them.

Diagnosis
The diagnosis for the Bobby brothers that fits most appropriately is Oppositional Defiant Disorder (313.81). To be diagnosed with Oppositional Defiant Disorder the following criteria must be met:
  1. A pattern of negativism, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
    1. Often loses temper
    2. Often argues with adults
    3. Often actively defies or refuses to comply with adults’ requests or rules
    4. Often deliberately annoys people
    5. Often blames others for his or her mistakes or misbehavior
    6. Is often touchy or easily annoyed by others
    7. Is often angry or resentful
    8. Is often spiteful or vindictive

*Note – Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
Walker and Texas Ranger meet all criteria for oppositional defiant disorder except for number 5, blaming others for mistakes or misbehavior. They constantly insulted and swore at adults, threw Chip’s war medals off of a bridge to make him mad, argued with their teachers, and purposefully peed their pants and refused to take them off just to prove a point. These behaviors are more extreme than those of children at similar developmental levels. Where most children their age might only do these sorts of things once, Walker and Texas Ranger do them all of the time.
  1. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
The boys do not know how to function in a social setting, repulsing most adults who come into contact with them. The boys do not seem to care what other people think of them. They say mean things, causing adults to react negatively, creating a viscious cycle of disobedience. Academic functioning, although mentioned briefly, is most likely effected. Texas Ranger, specifically, flaunted his bad behavior in the classroom.
  1. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
The characteristics previously described are displayed in many contexts over a lasting period of time. They are not a result of a psychotic or mood disorder.
  1. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
Walker and Texas Ranger are approximately 11 and 7 years old, respectively. They did not physically aggress towards others and did not commit any serious crimes.
  1. Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior towards authority figures.
The symptoms are constant – they do not vary from day to day. Their disobedience is only in response to authority figures.
  1. Occurs outside of normal developmental levels and leads to impairment in functioning.
Most children their ages do not insult, swear, and act out this much. The quality of their interactions are severely inhibited and functioning is impaired.

Accuracy of Portrayal
The average person watching these boys would immediately recognize that there is a significant problem. Walker and Texas Ranger are on the extreme side of disobedience. Most parents would probably be able to relate the problems of these characters to those of their own children, only to a much lesser degree. They would learn that Oppositional Defiant Disorder is characterized by defiance, hostility, frequent outbursts of rage, swearing, and disobedience. The portrayal of this disorder is very accurate – the boys’ behavior was consistent throughout the movie and did not waiver. Their depiction, in particular, was very extreme as their behavior was observed both at home and in school. The inaccurate aspects of the boys’ portrayal would be their display of oppositional behaviors in unfamiliar territory, their lack of temper tantrums or clear frustration with difficult situations, and the ease and rapid pace of change in behavior once their grandmother decided it was time to start acting appropriately.

Treatment
In the movie, Walker and Texas Ranger’s grandmother, Lucy, took things into her own hands. She established what she called, “Granny Law,” and broke the boys like “wild horses” with community service, yoga, disposal of their weapons, and church attendance.

As a mental health professional, it would be best to first conduct a structured or semi-structured clinical interview to explore fully the family’s history, the symptoms that pertain to ODD, and the possible co-morbid problems that can occur as a result of the disorder. The first measure of treatment that should be implemented are Problem-Solving – Skills-Training programs, which involve teaching children how to solve problems in a logical and predictable manner. The only setback of this training is that it is extremely time-consuming, requiring an average of twenty sessions. Another possible treatment is called Parent Management Training. This training teaches parents how to effectively implement contingency management programs at home, allowing both parent and child to better enjoy their interactions by learning how to praise positive behaviors, establishing schedules and sticking to them, and maintaining effective timeouts. This greatly increases awareness in the child as to what is expected of them as well as what will happen if they misbehave.





Autistic Disorder

Name: Arnie Grape

Source: What’s Eating Gilbert Grape? (movie, 1993)

Background Information
Arnie Grape is a Caucasian male who is 17 years old and is close to turning 18. He does not go to school and spends most of his time with his older brother, Gilbert. Arnie appears to be mentally disabled or developmentally disabled. When Arnie was born, the doctor said he would be lucky if he lived to the age of 10 and when he turned 10, the doctor said he could die at anytime. He has repetitive speech, which it seems as if he is listening but then turns around, and does the same things over again. He engages in very dangerous behaviors but is not aware of how dangerous his behaviors are. For example, he climbed up the water tower in the town and was dangling off the side of the ladder laughing the entire time not knowing how serious the situation was. Arnie lives with his mother, brother, and two sisters. He is very close to his older brother because Gilbert takes care of him. His mother, Bonnie, who has not left the house in seven years, became morbidly obese and depressed when her husband committed suicide. His two sisters, Amy and Ellen, take care of the chores and do all the cooking. Arnie is very friendly to other children in his town but it does not appear that he has very many friends because they do not understand his ways of communication, although there were many children at his eighteenth birthday party. There is an instance when Arnie will not go into the basement because he said “dad is down there” and then he does a hanging motion. Arnie does not appear to take any medication or see a regular physician or psychologist. His feelings are easily hurt because he does not fully understand what people are saying to him. Arnie does not appear to have any goals other than trying to survive.

Description of the Problem
Arnie kills a grasshopper by cutting its head off in the mailbox and a little while after he kills it he gets very upset at himself and is sad that the grasshopper died. He has certain hand movements that he constantly does. He puts his hand to his mouth a certain way when he is in an uncomfortable situation. He has eye twitches and he blinks quite often. Arnie is always running off and hiding from Gilbert or climbing the water tower. Gilbert knows where Arnie is hiding but plays a game and pretends that he does not know Arnie is up in the tree and he thinks Gilbert has no idea where he is. When other people get hurt or when Arnie says mean things to others he thinks that it is very funny and usually laughs hysterically. He is arrested for climbing the water tower and when they put him in the cop car, all he is worried about is the cops turning on the lights and sirens. He is not able to take care of himself. For example, Gilbert puts Arnie in the bath and tells him that he is a big boy and can wash himself. Gilbert leaves and comes back the next morning to find Arnie still in the bathtub. Arnie repeats everything that people tell him to do and what they say in general. After the bathtub incident, Arnie is afraid of any kind of body of water. He gets very upset and starts to hurt himself when he tries to wake his mother and she never wakes up.

Diagnosis
The diagnosis for Arnie Grape that fits most appropriately is Autistic Disorder (299.00). To be diagnosed with Autism Disorder criteria A, B, and C must be met:
  1. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements)

Arnie meets the criteria for deficits for three out of the four in section one, as described in the section of “Description of the Problem”. Arnie does not meet the criteria in (c) because he was always trying to talk to people and make friends with them. Arnie meets all the criteria for section two because he repeats every word a person says to him, he is not able to carry on a conversation with anyone, and he does not seem to have any imaginative friends. He does not meet the criteria in section three listed under (b) because he does not have any specific rituals. Arnie meets the criteria for (a) and (c) because he was obsessed with taking care of a cricket and kept it in a jar and he constantly made the same hand movements when he felt uncomfortable in a situation.
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

1. Social interaction

2. Language as used in social communication

3. Symbolic or imaginative play
Arnie’s history was not given prior to age three but one could conclude that he had delays in all three areas prior to age three.
C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.
Arnie was born with his disorder and has had it his whole life. The doctors did not expect him to live long but he did and everyone called him a miracle child.
Accuracy of Portrayal
The average person watching this movie would probably think this individual is mentally disabled. They would see that he needs a caretaker constantly, that he is not able to communicate well with others and that he is unaware of the outside world around him. These symptoms could be confused with mental retardation or a mental disability. To be specifically diagnosed with autism all the criteria above have to be met. Arnie met all the criteria so if an individual was familiar with or educated on autism they would be able to see an accurate portrayal of autism. This movie lets people see the different types of autism. The types of autism that are usually shown in the media are children who are quiet, reserved and do not talk to anyone, but Arnie was the complete opposite. He was loud, tried to speak to everyone, and was not afraid of most things. Throughout the entire movie, no one talked about Arnie’s disorder nor did they label what he had been diagnosed with at birth. What’s Eating Gilbert Grape? was an accurate portrayal of an individual with autism.

Treatment
First, a full medical and psychological evaluation would be given to Arnie. Arnie would need to be put in a stable setting. Currently he lives with his mother and siblings but his mother is unable to take care of him. He needs an individual to take care of him full time and that individual needs to be specialized in how to take care of his needs. He also needs an individual to work with him on his communication skills, yes, he is past the developmental stage of language, but having that daily practice could help him greatly with his language skills. Arnie also needs behavioral treatment therapy so that he is able to understand how to act in certain situations. He needs more support from his family, everyone needs to be interactive in his treatment and give a helping hand



Name: Mandy (Amanda)

Source: Fly Away (movie, 2011)

Background Information
Mandy is a 16-year-old Caucasian female who lives at home with her mother Jeanne. Jeanne makes sure Mandy has a consistent daily routine and tries to teach her day-to-day responsibilities. Mandy seems to be making slow progress and then other days she regresses, especially when her mother is not as attentive to her needs. Mandy’s mother is a single mother who works from home to be able to provide constant care for her daughter. Her father Peter comes to visit occasionally but is not consistently there. He loves his daughter and tries to interact with her, but cannot seem to without becoming overwhelmed and angry. Mandy goes to a school for the mentally disabled; however, she does not like the staff and is always acting out to be able to go home. She takes medication twice a day, and has doctor visits regularly. She has a difficult time coping with certain situations and does not know how to control her emotional impulses. Her mother has to hold her and tell her to breathe before she will calm down. Sometimes the outbursts are so bad there is nothing and no one that can control or sooth her. Jeanne also uses singing to calm and refocus her daughter. Mandy is very responsive to this technique and it gets her back down to a controllable level. This is the only form of positive coping shown. Mandy’s weaknesses are her short temper, and violent outbursts. This makes it almost impossible for her to be out in public or in a social setting.

Description of the Problem
When a situation arises that a normal 16 year old could handle, she seems to react like a young child. Mandy repeats anything said to her, displaying echolalia. Mandy also has outbursts of aggression. Her aggressive behaviors include biting, pushing, punching, yelling, and running away from her mother. She has overly dramatic emotional swings during these outbursts, where she is very enthusiastic or very upset. While Mandy is experiencing these fits, she becomes physically abusive with objects, throwing them at walls and other objects around her. After the outbursts Mandy encounters, she feels sympathetic only to her mother. She is the only person that she will apologize to for her behavior.
In addition to the above outbursts, almost every night while she is sleeping she yells out, “Mandy’s a bad girl, I hate myself!” Her mother will then have to comfort Mandy. When Mandy is in public, her emotions are erratic; she is very enthusiastic or extremely angry. She is not concerned with the reactions of people around her or how her behavior impacts others. She has no impulse control and immediately acts on how she feels. She begins to feel the need for some social interaction, but due to lack of knowledge on how to do so, she is angered by this emotion as well. Her interest in the opposite sex becomes more apparent and at one point in the film she asks her mother if she will ever get married. This shows her longing for human interaction and her capability to understand social interactions. Physically, Mandy’s hands are disfigured and are constantly curled. She walks on her toes primarily, and she rocks whenever she feels anxiety.

Diagnosis
Autistic Disorder (299.00) is the criteria that Mandy fits in the DSM-IV diagnostic system. The patient must meet criteria for category A, B, and C to be diagnosed with Autistic disorder.
  • A) A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
    • Qualitative impairment in social interaction, as manifested by at least two of the following:
      • Impairments in social interaction may include the following:
        • Pronounced deficits in non-verbal social behavior
          • Lack of eye contact
          • Facial expressions
          • Body posturing
          • Gesturing
        • Lack of age-appropriate peer relationships
          • Possibly interacting with parts of people
        • Absence of spontaneous attempts to share interests or pleasure with others
          • Not pointing to or showing things to others
        • Lack of social/emotional reciprocity
          • Lack joint attention
          • Fail to share actively with other's activities or interests
          • Act as if unaware of the presence of others
          • Select solitary activities
    • Qualitative impairments in communication including both verbal and nonverbal communication, as manifested by at least one of the following:
      • Delay or absence in spoken language
        • not compensated for by attempts to communicate nonverbally
      • Inability to converse appropriately with others regardless of the presence of speech
      • Odd, stereotyped, repetitive uses of language
      • Absence of imaginative or pretend play
      • There is also a great deal of variability in communication.
        • Ranging from the absence of expressive or receptive language to fluent speech with semantic/inappropriate social uses.
        • Echolalia is the repetition of a phrase heard in the present or the past.
          • Occurs in up to 75% of individuals with PDD who are verbal
            • This characteristic is a cardinal feature of autism.
        • Receptive language continues to impair social communication in that individuals have difficulties in understanding abstractions.
          • Echolalia and receptive language are not utilized in a functional communicative fashion by those with autism.
  • Restricted and stereotyped behavioral patterns require at least one of the following criterion:
    • Restricted interests that are abnormally intense
      • Can range from cars and trains to numbers and letters
      • Inappropriately intense or odd in their content
      • Rigid adherence to routines or rituals
      • Repetitive motor mannerisms
        • Opening and closing doors
      • Preoccupation with parts of objects
        • May become overly interested in moving parts of objects
      • Compulsive behaviors
        • Lining up objects in a specific way
        • Slight alterations in routines can cause behavioral outbursts
      • Motor stereotypes
        • Hand or finger-flapping
        • Rocking
        • Spinning
      • Non-specific motor abnormalities
        • Toe walking
        • Unusual hand movements or body postures
      • Continuous course for those with autism however, school-aged children may show improvements in social, play, and communicative functioning, which ultimately can improve further intervention
  • B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

    1. Social interaction

    2. Language as used in social communication

    3. Symbolic or imaginative play



  • C. The disturbance is not better accounted for by Rhett’s Disorder or Childhood Disintegrative Disorder.

There would be no difficulties in diagnosis for Mandy as being autistic. She meets criteria in A, B, and C. Pertaining to the previously stated problems, Mandy is clearly autistic.

Accuracy of Portrayal
Most people who watch the film would label Mandy as having a mental disability. The average person would not know the criterion that depicts autism. Mandy clearly can be labeled as autistic because she meets all of the above criteria. Most films that portray individuals with autism show them as quiet and socially distant. This movie shows an individual with an extreme case of autism and does a very good job showing how hard it is to live with this disorder. The movie did a good job showing the daily hassles for the family members and how it affects the individuals self esteem. People watching this film got a truthful insight on the life of an individual with autism and would learn about the disorder through the film and Mandy’s character. Fly Away was an accurate portrayal of an individual with autism.

Treatment
First, Mandy would undergo a full medical and psychological evaluation. She would need to be put in a stable environment and be able to express some sort of responsibility and self support. Mandy lives with her mom and has a good support system but at her age Mandy needs to be able to do things on her own without some supervision and her mother is not trained properly to be able to provide that. Currently she lives with her mother. She needs to have a specialized worker that can help her but not treat her like a child. Developing her self sufficient skills will help her be able to control more of her emotional responses and better understand social interactions. She also needs an individual to work with her on her communication skills. Even though Mandy is past the developmental stage of language, but having that daily practice could help her greatly with her language skills. Mandy will also need behavioral treatment therapy so that she is able to understand how to act in certain situations and control her violent outbursts. With behavioral therapy, more developed communication skills, family support and more accountability Mandy will be able to better cope and function with her disorder.



Dysthymic Disorder

Name: Bill Dauterive, born Gillaume Fontaine de la Tour D'Haute Rive

Source: King of the Hill (Television series, 1997-2010)

Background Information
Bill Dauterive is a Caucasian male around the age of 42. This age estimate is based on his friends, including Hank Hill, who has been stated to be 42 years old, and that he was in the same school grade as his friends. Bill is from an upper-class family in Louisiana, around New Orleans. His family is not present very often and the only remaining relative he has is a male cousin. His self-reports of childhood hardships caused by his father could be fictitious because there is no way to verify this. He has almost no family so genetic factors are hard to account for. His cousin is in good shape and healthy. Bill is the opposite. He was told by a doctor that he would become diabetic if he did not change his lifestyle.

He was a high school athlete, nicknamed the “Billdozer”. He was very popular, had many friends and even held the school touchdown record. He was drafted into the military his senior year of high school and never graduated. He has remained in the Army and is now a Sergeant barber. He is not particularly poor or wealthy. He is a simple person and does not have any extravagant tastes or interests that he has reported.

He met his wife, Lenore, at a concert. She cheated on him and subsequently they divorced. This is reportedly when the depressive symptoms began appearing. He could not heal from the divorce and claims he still loves her. He became overweight and started losing his hair. His friends Dale Gribble, Jeff Boomhauer, and Hank Hill constantly comment on his depression and try to help him. He has had this core group of friends from a young age. They all live on the same street and get together in the alley to have a beer often. Bill is obsessed with Hank’s wife and believes she is the perfect picture of a woman. She is the complete opposite of Bill’s ex-wife. Even though he has a core group of these 3 friends, they often make fun of him and sometimes exclude him. He has a very poor sense of hygiene and his house is often very dirty. His friends and their wives often make remarks about this.

He is in a depressive state most of the time. The only time he is out of a depressive state is when he is with a woman (who always later rejects him) or gets very involved in a project, such as an instance where he turned his home into a halfway house. He enjoyed the company and enjoyed being needed, but the occupants took advantage of him and he missed so many days at work the Army almost reported him Absent Without Leave, or AWOL. He clings to women he gets into relationships with very quickly. He will be overly dedicated to the women but they always end up taking advantage of him and ending the relationship. He perceives relationships to be more serious than they are in reality. This behavior inevitably drives them away.

Description of the Problem
Bill often states that he is depressed. This depression has lasted since his divorce, which is estimated to be 7-9 years ago. He is in a depressed state most of the time. Others describe him as very depressed and down. He has some periods of normality, but usually he is just depressed. He believes no one loves him or will love him and gets into relationships in which he is very likely to be rejected. He overeats and does not take care of himself very well. He has a very poor image of himself but does not seem to care enough to attempt to better himself.

He often speaks of his ex-wife and the divorce and of still loving her. If he is not working, he is at home eating and watching TV or in the alley having a beer with his friends. He does not do much else. His friends often remark on his bringing up of his divorce and try to set him up with women, but the women usually reject him. There have been a few relationships he has ended himself, but the majority are not his choice His friends attempt to tell him he is too good for his ex-wife and that she is not coming back.
Bill gets particularly depressed around the holidays. He usually spends Thanksgiving with Hank Hill’s family, which is very intrusive to them. He went through a period of suicidal actions and thoughts but never completed or repeated these behaviors. His friends were constantly watching him.

Diagnosis
The disorder Bill Dauterive most accurately can be diagnosed as having is Dysthymic Disorder (300.4).

A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.
Bill is self-described as being depressed a lot of the time. His friends also state that he is depressed all of the time and it has been going on for longer than 2 years. In fact, it is closer to 7 years.

B. Presence, while depressed, of two (or more) of the following:
  1. poor appetite or overeating
  2. insomnia or hypersomnia
  3. low energy or fatigue
  4. low self-esteem
  5. poor concentration or difficulty making decisions
  6. feelings of hopelessness
Bill experiences overeating, low energy and fatigue, low self-esteem, and feelings of hopelessness. Occasionally he experiences insomnia and poor concentration. Quite often his despair will lead him to overeat which leads to further low self-esteem. The symptoms seem to compound themselves. Bill’s friend Hank is usually the one who makes a lot of Bill’s decisions because he has difficulty doing so himself, whether everyday decisions or more meaningful decisions.

C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
Bill fits this and does not seem to reach the 2 month mark for absence of symptoms. Bill’s symptoms of depression seem to be chronic. He is never out of his depressed state for longer than a few days and this is usually because he has found someone to be in a relationship with for a short time.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
This is hard to account for because Bill is being seen 7 years after the onset. Since it has lasted so long, however, Dysthymic Disorder accounts for it very well.

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
There has been no evidence of a hypomanic episode. The closest period would be when Bill experiences some type of normalcy does not last very long. He does not have manic episodes or even hypomanic episodes. Sometimes he is obsessive but that does not last very long and he slips back into depression, no period of normalcy is seen. He does not qualify for Cyclothymic Disorder because he does not have periods of hypomanic or manic symptoms.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
Bill does not have symptoms of a Psychotic Disorder.

G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
Bill does not present with any substance abuse or other medical conditions. Before the onset of Dysthymic Disorder, he was happy, popular, and content with his life. He does drink a beer in the alley with his friends nearly everyday, but it is usually just one beer. If he is feeling extremely depressed, he will drink to excess, but this is a result of his depression, not a cause.

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This disorder impacts every portion of Bill’s life. He needs to be needed, and when he is, for short periods of time, it makes him miss work; he was almost listed as AWOL on more than one occasion. In his social life, his depression causes major impairment. All his friends state that he is depressed all the time. He does not take care of himself which leads to low self-esteem. This majorly impacts his attempts at finding a date. He does not make new friends, and he only has the core group of friends he grew up with. When he attempts to meet new people, he is usually rejected and thus, he does not try very often.

Regarding etiology, Bill’s Dysthymia seems to have been caused by his divorce, so the psychosocial causal factor fits. There is no way to determine if genetic factors are possible as his only living relative is a male cousin.

Accuracy of Portrayal
An average person watching Bill in King of the Hill would get a very good idea for what Dysthymic Disorder is. Bill expresses almost all of the symptoms, almost all of the time. The portrayal is accurate in that Bill exhibits almost all of the symptoms of Dysthymic Disorder, nearly all the time. Saying that Bill is depressed all of the time is not an exaggeration. In people with Major Depressive Disorder there are longer periods of normalcy, but in Dysthymic Disorder there are not long periods of normalcy. More often than not, Bill is depressed. Major Depressive Disorder is more about episodes of depression, but Dysthymic Disorder is depression nearly all of the time, and Bill exhibits this. The only inaccuracy was his period of suicidality, but this was a cry for help, not an actual wish of death. It was not repeated.

Treatment
Dysthymia has not been widely studied and this impacts research on treatment. Many findings from Major Depressive Disorder have been applied to Dysthymic Disorder, since it is often referred to as a milder form of Major Depressive Disorder.
One could begin by treating Bill with an antidepressant. After the appropriate dosage was found, he would begin psychotherapy. Bill needs to be taught about the disorder and recognize that he is not in a normal state of mind and begin to come out of it. Since he does not really have any family to speak of to attend therapy with him, his friends should accompany him because they are the individuals he sees most often. They could be shown that their comments to Bill are hurtful and need to end. If Bill’s core group of friends were taught about Dysthymic Disorder they could learn ways to help Bill when he was feeling down and make him feel better about himself and the situations he finds himself in.
A therapist could use cognitive therapy to help Bill change how he sees the world and to think more optimistically. This would show Bill that not every bad thing that happens is a crisis and which events to just let go of. He needs help getting over his divorce and gaining his self-esteem back. Other recommendations that he find a hobby he likes and recommend him to someone to help him with nutritional skills, such as what to eat and what to cook.




Name: Andrew Largeman

Source: Garden State (movie, 2004)

Background Information
Andrew is a 26 year old actor and waiter from New Jersey. He was living in Los Angeles when he got the news that his mother has passed away. Returning to New Jersey for his mother’s funeral, he has to face his psychiatrist father with whom he has no relationship. When Andrew was nine years old a terrible accident occurred where he pushed his mother over a dishwasher door that left her paralyzed. This left him in a depressed and distant state. His mother was a very depressed individual too. Andrew resented the fact that he could never make her happy and that he had pushed her out of anger, leaving her paralyzed.

He appears to be very lost and detached. Drugs such as marijuana and ecstasy have been used by Andrew. He has complaints of reoccurring headaches. Andrew seems to be isolating himself from his father and others. In Los Angeles in particular, he has no friends and no desire to attain any. His general lack of attention is established when he forgets to remove the gas pump from the car when finished getting gas.

Andrew feels like he does not have a problem and for the first time has stopped taking the medication that has been prescribed to him. After meeting a female friend, Andrew feels that he can relate to her and seems less depressed when he is with her. However, this is largely just taking his mind off his problems and his symptoms are still apparent.

Gideon Largeman is Andrew’s father who is a psychiatrist. After his wife’s accident involving Andrew, Gideon tries to suppress a deep loathing towards his son. He blames Andrew for the accident that left his wife paralyzed. To “curb the anger” that he holds towards his son, he heavily medicates him starting at a young age to “protect him from his own feelings”. He puts Andrew on Lithium that has left him in an emotionless haze for many years. He feels that when Andrew was younger he had an anger problem so he decided to place him in boarding school fallowing his mother’s accident. His mother was very depressed and abusing alcohol before her accident. She died while drowning in a bath tub. This was known to be an accident and not a suicide attempt, although it was very suspect.

Description of the Problem
Andrew looks depressed and acts depressed. He zones out and lacks attention to certain important daily functions. There is not any color present in his bedroom, everything is white and sterile. He also experiences terrible dreams of being in a situation where the people around him and himself are about to die, yet he still does not or cannot show any emotion. He is just in a daze, without care of what is going on in the world around him. He has explained that he has not cried in many years. It is apparent that he isolates himself from his family and friends.

Diagnosis
The appropriate disorder after evaluating Andrew is Dysthymia Disorder (300.4)

A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.
Andrew has indicated that he has been depressed for as far as he can remember. Before the accident that left his mother paralyzed, Andrew felt depressed by the fact that he couldn’t make his mother happy. After causing his mother to be paralyzed he also become depressed and was sent to boarding school where he was isolated from his family. He shows a great amount of guilt for his mother’s accident and her recent death.

B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness

Andrew experiences low energy, low self-esteem, poor concentration, and feelings of hopelessness. He seems to have low energy by the way he carries himself. He is late to work, has no interest and lacks energy when talking to people. Not being to work on time seems to be a reoccurring event for Andrew, as his boss mentions his last warning before he is replaced. Andrew expresses low self-esteem by explaining that he has a “fucked up family”. He blames himself for his mother’s accident and remains in isolation most of the time. His concentration on important things is also lacking. He has driven away with the gas pump still attached to his car, and has occasionally not responded to his name being called. Andrew has a sense of hopelessness; he does not have hope in the fact that he can fix the relationship between his father and him.

C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
Andrew meets this by explaining that he has felt this way from at least the age of nine. Before his mother’s accident he felt like he could not make her happy when she was depressed. He is also to blame for his mother’s accident and has been in therapy for depression since the age of 9.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance i.e., the disturbance is not better accounted for by Chronic Major Depressive Disorder, Major Depressive Disorder or in Partial Remission.
The criteria of Dysthymia are met due to the amount of time that Andrew has experienced these depressed symptoms. It is estimated that he has had these symptoms for approximately 17 years. No major depressive episode has occurred. He has successfully carried a job, and has played a major role in a film.

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
It is not apparent that Andrew has had Manic, Mixed or Hypomanic Episodes. The depression seems to remain at a consistent level over the time period estimated to be depressed. He does not meet the criteria for Cyclothymic disorder because Andrew has not experienced or expressed levels of Hypomanic episodes. He also has not experienced as time period of 2 or more months were he has shown no symptoms of depression.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
Andrew shows no symptoms of a chronic Psychotic Disorder such as Schizophrenia or Delusional Disorder.

G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
Andrew shows no symptoms that occur from drug, or medication abuse. The lithium that Andrew has been taking is to help his depression and aggression and he shows no signs of abusing it. He has experienced some drug and alcohol use. However it appears that it is only in social situations and he expressed signs of hesitation and has refused drugs from peers.

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Andrew’s symptoms have significantly impaired his social relationship with peers, friends, co-workers and his father. He shows little interest in having friends around and has been isolating himself for a long period of time. He has no relationship with his father and other family members and has isolated himself from them as well. Andrew’s job as a waiter seems to be coming to an end. He is consistently late and is on his last warning before he job position is replaced.

Early Onset – Occurred before the age of 9 and has continued through his adulthood.

Accuracy of Portrayal
When the average person watches Andrew it is obvious that he is depressed. It is also obvious that this depression has lasted a significant amount of time and has been consistent. He shows that he is suffering with depression more often than not. However, there are times where it seems as if Andrew is not depressed, such as when he is with his newest female friend. Yet, Andrew still shows apparent symptoms of depression and guilt that would categorize him with Dysthymia Disorder. One may inaccurately portray Andrew as someone who has major depressive disorder but, this is not the case. Andrew’s depression has lasted more than two years and he is depressed for most of the time. They may also label him with drug abuse; however, drugs are not a consistent player in his life. He knows to refuse it and to my knowledge has done ecstasy once after pressure from peers.

Treatment
Pharmacotherapy would be the most effective treatment for Andrew’s dysthymia. Andrew has been on anti-depressants and involved in therapy since the age of nine. He has been heavily medicated with Lithium prescribed by his father. From a mental health professional perspective Andrew should not be on Lithium. It is obviously not helping him or eliminating the depression he is feeling. The Lithium dosage is too high and maybe triggering some of the depression he is experiencing. Trying another form of anti-depressants and finding the correct amount needed, with the addition to psychotherapy appears to be the most effective treatment for Andrew.
Psychotherapy should be incorporated with Andrew’s treatment plan once his pharmacotherapy has been correct and is showing significant results in decreasing his depression. Therapy involving his father in attempt to repair their relationship should also be in Andrew’s treatment plan. This could relieve a lot of the stress and guilt built up in the both of them. Talk therapy is shown to benefit those with dysthymia. It will give him an opportunity to talk about his problems and learn ways to deal with him in a healthy manner.
Cognitive behavior therapy could also be helpful in treating Andrew’s dysthymia disorder. Here he can go over and review that his behavior as a child needs to be put in the past. He needs help realizing that what has happened cannot be taken back but, instead needs to be moved on from.




Bulimia Nervosa

Name: Shelly Hunter

Source: Hunger Point (movie, 2003)

Background Information
Shelly Hunter is a Caucasian female currently in high school. Although her age is unknown, she is presumed to be a teenager. A first look at Hunter gives evidential proof that she is seriously underweight. This raises serious concerns about her health. Hunter lives at home with her domineering mother, Marsha, and David, her passive father. She is the younger sister of Frannie, who is away at college and also struggles with eating. Shelly has a very strenuous relationship with her mother. As a child Hunter was always very slender, but she grew up listening to her mother lecture Frannie, who was not as slender, on the importance’s of being slim. Mrs. Hunter’s obsessive belief that being slender is the most important thing has severely distorted Hunter’s views on eating. Hunter clearly seeks approval from her mother and puts great strains on her body to reach that approval. Hunter’s life is devoted to her weight. Her time is spent obsessing about being slender. She does not know how to cope with her eating disorder and her irrational views on being skinny. The eating disorder is also causing severe mental problems with Hunter. She is exhibiting signs of depression and distrust from her family.

Description of the Problem
Hunter displays the symptoms of an eating disorder. She is abnormally underweight for her age and is very unhealthy. She exhibits the characteristics of Bulimia Nervosa. She eats very little when she is in the presence of other people. Most undoubtedly when she is eating in front of her mother, she becomes very self conscious about what and how much she eats. After restraining from food intake for a period of time she then will over eat. She stuffs herself with large portions of food. After doing so she begins to feel shame and guilt for over eating. The way she deals with her guilt is to self- induce vomiting. This purging is a defense mechanism Hunter uses to cope with “disappointing” herself as well as her mother. Although it only lasts for a short while, she feels satisfied with her body after vomiting.

Diagnosis
The diagnosis for Hunter appropriately fits Bulimia Nervosa (307.51).
  1. To be diagnosed with Bulimia Nervosa one or more or a combination of the following characteristics must be present:

1. Eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; it is common for more than 10,000 calories to be consumed per binge.
2. An abnormal constant craving for food; a sense of a lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
3. Eating is usually done in secret.

Hunter displays the characteristics of 1 and 3. As described in the “Description of the Problem” she eats large portions of food alone.
B. Recurrent inappropriate, compensatory behavior in order to prevent weight gain. Such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

Hunter exhibits these compensatory behaviors in order to prevent weight gain. She fasts for a long period of time. She then will binge eat and self-induce vomiting.
C. The binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for three months.

Hunter began binge eating at a very young age and continues to binge eat into her high school years.
D. Self-evaluation is unduly influenced by body shape and weight.
Hunter has a very unhealthy view about her body. She is constantly concerned with gaining weight. Even though she looks too slender and unhealthy to others, she views herself as overweight.
E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Hunter will eat very little for a short period of time, and then she will binge eat to self-induce vomiting.

Accuracy of Portrayal
The average person watching this movie would see an accurate portrayal of the behavioral characteristics of Bulimia Nervosa. Hunter displays the onset characteristics of someone suffering from this disorder. Someone watching this movie would learn that having an eating disorder can cause many other problems. Hunter became very untrusting and displayed signs of depression. Bulimia Nervosa took control over Hunter’s life and began to affect her mentally. Therefore, the movie Hunger Point portrays an accurate depiction of Bulimia Nervosa.

Treatment
After fully examining Hunter it might be best to start her on some medications. To help with depression Tricyclic antidepressants or Selective Serotonin Re-Uptake Inhibitors (SSRI's) could be prescribed to elevate her mood. Vitamin and mineral supplements would be prescribed until signs of deficiency disappeared and normal eating patterns were reestablished. The vitamins would also help to treat acid reflux caused by bulimia. After Hunter’s weight becomes stabilized it would be a good idea to start a behavioral therapy program. This will help to change the mindset of Hunter and her negative views about her body. This will also help to control her binge eating habits. Not only does Hunter need individual therapy, but she and her mother need family therapy. Mrs. Hunter needs therapy in order to understand that her obsessive beliefs, about being slender, caused her daughter to become diagnosed with bulimia nervosa. Communication exercises will be exhibited to help resolve conflict and re-establishing boundaries. The treatments will better help Hunter to have control over Bulimia Nervosa and to gradually overcome the disorder.




Name: Blair Waldorf

Source: Gossip Girl (television series, 2007-present)

Background Information
Blair Waldorf is a 16 year old female who lives in Manhattan, New York. She is a full time student, and attends a private high school. She is in good health, and her family is in good mental health. Her parents are divorced, mother in Manhattan and father in Paris. She has a great relationship with her father, but he left his family for a male model, so Blair suffers slightly with separation anxiety and depression. Her mother has very high status in Manhattan, and would do anything to keep it that way. Blair and her mother get into arguments every now and then, but no more than a normal teen and her mother. Blair is an only child. Serena is Blair’s best friend and has been since they were little. Blair is snobbier of the two, and Serena keeps her grounded without going overboard. They often get into tiffs, but always end up making up. Blair’s ex-boyfriend is Nate. They dated from age 5 until 16. Dealing with the breakup of her longtime lover, Blair goes a little crazy and her separation anxiety and depression shows up again. Blair drinks often, and for some reason in the world that she lives in, adults do not seem to care. She could walk into a bar and drink martinis all night, and it would be completely normal. She does not do drugs, however. Her biggest life difficulty is staying queen bee at her high school. She goes through a lot throughout the show, but staying the most popular girl in school is always her top priority. Her number one goal is to attend Yale after she graduates, and later become a trophy wife just like her mother was. Blair copes with her problems by putting other people down. She loves the fact that she is at the top of the totem pole, and she is not afraid to let anyone and everyone know it. She also often uses alcohol to cope with her problems.

Description of the Problem
During the first season of Gossip Girl, the fact that Blair had been to treatment in her past comes up a few times. Blair’s eating habits are normal for the first few episodes, but after she experiences different stressors, her eating habits become abnormal again. She starts to pick at food most of the time, but binges at other times. Also, her best friend Serena and her mother started to bring up the fact that her symptoms were returning. She completely closed them off and ignored the fact that they were. Every time that she would get into a fight with Serena, her ex boyfriend, or her mother, her lack of control for eating would return. One incident that was shown on the show was that Blair had gotten into a huge fight with Serena on Thanksgiving, which caused Blair to be extremely snappy with her mother. She found out that her mother lied to her about her father coming into town for the holiday, which caused a fight with her mother as well. She was picking at her Thanksgiving meal during dinner, and when her mother told her to go pick out a dessert, she stormed off to the kitchen. She found an apple pie that she wanted to eat, but instead of just taking one piece, she stared at it for a few minutes, and binged and ate the entire pie. Immediately, she went into her bathroom and started to purposely vomit. She has always had an issue with her self-image, and the binging and purging was her solution to make herself feel better. After vomiting in her bathroom, she called Serena, and she quickly came over and let Blair cry on her shoulder. This is not the only incident that Blair had with binging and purging, but it was a very critical event to Blair’s illness.

Diagnosis
The diagnosis for Blair Waldorf fits most appropriately with Bulimia Nervosa (307.51).
To be diagnosed with Bulimia Nervosa, you must have the following characteristics:
  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by the following:
    1. Eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than most people would eat during a similar period of time and under similar circumstances.
    2. A sense of lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
Blair Waldorf displays both of these characteristics. When she has an episode, it is as if she cannot control what food she is putting into her body, or how much food she is putting into her body.
  1. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
Blair Waldorf will do whatever she thinks is necessary to prevent weight gain, and her methods of choice are self-induced vomiting and fasting.
  1. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
The television show does not state what age Blair Waldorf started binge eating, but while she was only 16 years old, her mother discussed Blair already having gone to treatment for her Bulimia. So this must have been a problem in her life for quite a few years.
  1. Self-evaluation is unduly influenced by body shape and weight.
Blair Waldorf is very self conscious of her body image and her weight. Her mother mentions a few times that she needs to watch her weight, so this may have helped lead to Blair’s body image issues.
  1. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Blair Waldorf will eat a very small amount and continue to pick at food at every meal, until another episode of binging and purging occurs.

Accuracy of Portrayal
The average person watching Gossip Girl and watching Blair with her eating disorder would learn the behavioral characteristics of Bulimia Nervosa. Someone watching this television show would understand that it is a disorder that a person cannot necessarily always control. There can be triggers that can lead to an episode, just like any other illness. This portrayal is accurate of Bulimia Nervosa. However, the show does not show the seriousness as much as it should of this disorder. It was mislabeled in this way because it has affected Blair’s mental health, so any issue in her life that leads to her showing any signs of depression will most likely lead to an episode. This is her way of dealing with problems in her life, and Gossip Girl does not show the severity of this.

Treatment
After evaluating Blair Waldorf’s condition, it would be best to start her with a behavioral therapy program. She was not taught the proper way to handle her emotions and deal with problems that arise in her life, and therapy would help approach these issues. Therapy could also approach her body image issues, and help her to devise an exercise program that would make her feel more in shape and healthy. Her mother and her friends would have to help monitor her eating habits, but after understanding her condition fully and seeing that there are other ways of dealing with issues, Blair would take on a better eating schedule. Also, putting Blair on a very low dosage antidepressant or Selective Serotonin Re-Uptake Inhibitors (SSRI’s) and monitoring her progress very closely while on this medication would help a great deal. Communication exercises will also be necessary between Blair and her mother to teach them how to discuss this illness in a healthier manner. These different treatments will, in time, help Blair overcome this disorder. She will be able to talk about her feelings and problems, rather than regressing to binging and purging.




Histrionic Personality Disorder

Name: Michael Scott

Source: The Office (American television show, 2005-2011)

Background Information
Michael Scott is a forty-six year old Caucasian male from Scranton, Pennsylvania. Scott is the regional manager at Dunder Mifflin Inc., a local paper and printer distribution company, where he has worked for the last fifteen years. There are no known medical conditions held by Scott, though his family history is unknown. He claims to be of English, Irish, German, Scottish, and Native American descent, though this is unconfirmed, and perhaps an exaggeration. The patient’s outward appearance is well put together, as he presents as a business professional, and there are no obvious health concerns. Despite his seemingly composed demeanor, Scott displays exaggerated emotions and reactions. In addition to this, romantic relationships have proven turbulent for Scott throughout his life, as he goes from one relationship to the next with the other person usually being the one to end it. He has few close friends or relatives, and tends to perceive new friendships as closer than they actually are. Scott believes his subordinates to be his family, and often times gets involved in their personal lives without their consent. His parents divorced when he was young (age unknown), and he displays clear resentment towards his stepfather and sister, whom he once didn’t talk to for fifteen years. Scott has a very close relationship with his mother now, though this was not case when he was a child. Though Scott seems to be lacking in managerial style, responsibility, and delegation, he demonstrates above average sales abilities due to his personable qualities. Scott does not have a history of drug or alcohol abuse, though he will drink in social situations and when pressured to do so by coworkers.

Description of the Problem
The patient demonstrates many personality traits that could be indicative of a variety of disorders. Scott seeks attention every opportunity he gets, and this often interferes with his ability to function in his job as manager. In addition to attention-seeking, Scott often interrupts his subordinates from working to discuss his personal life. This behavior not only affects his ability to work, but it interferes with the overall productivity of the office. It is Scott’s belief that he should not be seen as just a boss, but more of a close friend and even family member, to the dismay of his subordinates. This expectation of a close bond leads Scott to display rapidly shifting emotions, from exuberant and hopeful, to depressed and hopeless. There seems to be a lack of consistency in his behavior, rather a dramatic shift from extremely happy to irreversibly sad. In Scott’s depressed state, he feels as if the entire office should be focused on his problem and that others’ problems pale in comparison, such as his birthday being of more importance than a coworkers cancer scare. When he is happy, however, work at the office ceases to a halt, as his well-being is put before the needs of the company. In addition to his attention-seeking and rapidly shifting emotions, the patient is easily suggestible and is often the victim of pyramid schemes and persuasive coworkers. Scott also shows a pattern of theatric behavior, including different characters, voices, and personalities, in which he uses as distractions on a constant basis.

Diagnosis
The diagnosis that seems to fit most appropriately for Scott is Histrionic Personality Disorder (301.50).

To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (I.e., ways of perceiving and interpreting self, other people, and events)
2. Affectivity (I.e., the range, intensity, and appropriateness of emotional response)
3. Interpersonal functioning
4. Impulse Control
Mr. Scott displays dysfunctions in many, if not all, of the above categories. His thoughts are consumed by his thinking that he is a comedian, consistently referring to his improv classes and impersonations. The affectivity displayed by the patient is continuously out of proportion to the situation, such as halting the workday for an office meeting over a minor problem, oftentimes a non-work related problem. His interpersonal and relationship functioning is severely limited, demonstrated by his lack insight into the true feelings (I.e. distain) of the people in his life. His impulse control is lacking, if not nonexistent.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The displayed symptoms cause, and have caused, significant distress in the areas of work relationships, friendships, and romantic relationships. The observed behavior also has negative consequences in many aspects of his life, including resentment and distain from coworkers, as well as from his superiors and romantic partners.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The inflexible nature of his symptoms clearly affects his ability to function in his day-to-day tasks. His ability to function is severely impacted by his need for attention, as he demonstrates a lack of motivation and productiveness in his occupation and social life. This enduring pattern has also led to resentment from his subordinates, who believe he is incompetent due to his emotional outbursts.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
Scott’s symptoms have been present for at least six years, though they seem to have been present during his entire employment at Dunder Mifflin, and are pervasive in both his work and personal life. The symptoms can be traced back to his early adulthood, as demonstrated by his lack of friendships and romantic relationships in the past. The symptoms may also be a result of early childhood experiences, as he lacked a father-figure and his mother seemingly neglected him.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
Although the patient demonstrates some characteristics consistent with Narcissistic Personality Disorder, he is too suggestible to fit this criteria. As those with Narcissistic PD are interpersonally exploitative, Scott demonstrates a need for immediate attention as opposed to a need for future success. Neither mood, psychotic, nor anxiety disorders better account for his symptoms.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
The presenting symptoms are not the result of drugs, alcohol or head trauma.

To fit the Diagnostic Criteria for 301.50 Histrionic Type, at least five (or more) of the following criteria must be met:

1. Uncomfortable in situations in which they are not the center of attention
In many instances, such as making a coworkers wedding all about him, caring more about his superficial wound than an employee with a concussion, holding impromptu meetings to discuss his personal life, or dozens of other examples, Scott demands the attention be on him and only him. Typically in a situation in which he is not the center of attention, Scott is visibly uncomfortable and can barely sit still.
2. Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior
Although Scott does not demonstrate sexually seductive behavior, he exhibits provocative behavior on a regular basis by use of inappropriate jokes or sexual advances on coworkers.
3. Displays rapid shifting and shallow expressions of emotions
Scott goes from angry, to upset, to jealous, to happy, to ecstatic very rapidly, and displays a pattern of shallow emotions. For instance, after hitting a coworker with his car, the patient displayed little remorse or genuine emotion.
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
After a superficial wound, the patient exaggerated the symptoms for the entire day, demanding the focus of that workday be on his recovery. Scott also demonstrates theatricality through use of characters, voices, and impromptu presentations.
7. Is suggestible, I.e., easily influenced by others or circumstances
Scott is highly suggestible, and has been observed to lose substantial amounts of money in pyramid schemes due to his trusting nature and easily influenced personality. The patient is so suggestible that he has participated in highly risky behaviors, such as placing his face in drying cement, from pressure from those around him.
8. Considers relationships more intimate than they actually are
In many aspects of his life, the patient demonstrates a destructive attachment style, oftentimes believing those around him are closer to him than they actually are. Scott believes the office staff to be his family, and considers a temporary employee to be his best friend after only one day of knowing him. As with his friendships, Scott’s personal relationships suffer from the same overzealous attitude. While once dating a woman, Scott placed his own photo over the photo of her ex-husband, while also proposing to her after three dates.

Accuracy of portrayal
To those watching The Office, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is quite good, though those with the disorder are more often females than males. Those with Histrionic Personality Disorder are known to use their body as a seductive tool, and Scott’s portrayal lacks this important quality of the disorder. However, due to the differing presentation of Histrionic Personality Disorder between men and women, this trait may be unnecessary for the diagnosis. The sudden change of emotion is quite accurately portrayed, as well as the attention-seeking behavior patterns. As symptom expression is accurately portrayed, so too is the onset of symptoms. Histrionic PD is expressed most often in a person’s early adult years, and those with the disorder typically come from a family history of neglect or lack of attention from the primary caregiver during pivotal developmental years. For this reason, the attention-seeking and self-centered behavior tends to manifest later in life as a result of the early experience. This symptom is accurately portrayed in the show as well. Overall, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is accurate in many ways.

Treatment
The best course of treatment for Scott would be therapy. Cognitive-behavioral therapy would be beneficial in a similar way by helping him to cope with his emotional outbursts. CBT would provide Scott tools for controlling his behavior in a more systematic and structured way to be able to function more productively in the workplace. In addition to systematic planning, it is recommended that Scott be given assertiveness training to help with his propensity for taking advice from others. Behavioral rehearsals may aid in his workplace manner and help him to establish appropriate workplace behaviors. Although family counseling is not an option, it is recommended that Scott participate in relationship counseling to help establish a long-lasting, stable relationship.






Name: Regina George

Source: Mean Girls (movie, 2004)

Background Information
Regina George is a sixteen year old Caucasian female. She is a junior in high school at North Shore High School. Regina comes from a very wealthy family and does not have a job besides attending school. She is presumed to be in good health since the film did not mention any health conditions. Regina George is considered the ring leader of the meanest girl clique at North Shore High. She is the queen bee of the popular girls group that pride themselves on making each other look as hot as possible while they put others down in the process.

As previously mentioned Regina comes from a very affluent family. They live in a beautiful mansion considered to be the biggest and most lavish house out of any of the ‘mean girl clique’. Regina’s relationship with her parents is very twisted and abnormal. One example of this backward relationship is displayed when Regina brings her friends over and her mom insists on inserting herself into Regina and her friend’s conversations. Not only does her mom think of her as her best friend but her parents allowed her take the master bedroom simply because she desired it. Regina does not have a strong relationship with either parent but drifts more toward her mother.

Regina George has a preoccupation with her looks. She is constantly talking about how she is either too fat or that she is not pretty enough and also seeks confirmation about her body and looks through others. She does not have a regular drinking problem or drug abuse issue since she is so preoccupied with her appearance and that would definitely tarnish her ideal reputation. Her obsession with her appearance would have to be one of her biggest weaknesses. With regard to her weight, she is constantly seeking new and unsearched ways of losing weight.

Description of the Problem
This patient displays many of the traits associated with a number of personality disorders, but most strongly shows symptoms of Histrionic Personality Disorder. Regina George is an attention junkie. She seeks out attention from people in every aspect of her daily life. This hunger for attention has created tension between Regina and her group of friends. Her need for attention impairs her abilities to function inside the classroom, hindering her performance in school. Regina often wears seductive clothing that most girls and women would not walk out the front door in, let alone wear to school. Another way Regina actively seeks attention is by talking about people behind their backs. In a three way phone call, she deliberately tries to sabotage one of her close friend’s relationships with another close friend of hers. This attack displays her need to be needed. She felt threatened by their relationship so the only means of coping with the problem to her was by pinning two of her friends against each other. When Regina has a problem, the only way she knows to resolve it is by making someone else feel inferior. Along with these distorted coping skills, Regina displays extreme variances in her emotions. When she is happy she is through the moon happy and when she is mad she is definitely going to let someone know about it. When Regina has a problem going on in her life, she thinks that every single one of her friends must stop what they are doing and solve the problem with or for her. One example of this is shown when Regina is eating lunch, wants something else to eat, and then she says that she is really trying to lose five pounds. She is flabbergasted when the rest of the clique does not immediately pipe in to say that she is already flawless.

Diagnosis
The diagnosis that seems to fit most appropriately for Regina George is Histrionic Personality Disorder (301.50). To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (I.e., ways of perceiving and interpreting self, other people, and events)

2. Affectivity (I.e., the range, intensity, and appropriateness of emotional response)

3. Interpersonal functioning

4. Impulse Control

Regina George has shown impairments through all of these conditions. She has shown that all that consumes her thoughts is the obsession she has with her appearance and the appearance of others. Her displayed affectivity is most often over exaggerated to the situation. Most notable was her reaction to her “friend” not inviting her to her house party: she single handedly brought the entire student body to a crippling halt by sharing a “burn book” with them. This book contained pictures and captions (written by Regina herself) about different people in their school. The pictures were not the most flattering and the captions were mean spirited and hurtful to say the least.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

Her symptoms have caused her significant turmoil in her relationships at home, school, and in her daily life. Her behavior has caused many issues in all aspects of her life, such as with friends turning against her, her family not being very supportive and the entire student body rallying against her.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Regina’s apparent inflexible nature has caused tremendous impairment among her social life as well as her occupational or school life. Regina’s preoccupation with her outward appearance has left her little if any time to focus on things that really matter to people such as her character and demeanor towards others.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

The behaviors that Regina displays in the movie Mean Girls has been going on her entire life, per her mother’s report. She has been the same appearance obsessed girl since she was born. This pattern of attention seeking, mean behavior escalated in middle school when she made up a rumor about a girl being a lesbian in the eighth grade.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

This patient does display some of the characteristics of a person with narcissistic personality disorder and perhaps even some dependent PD characteristics, but the disorder that Regina displays through the entire movie is HPD.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

The symptoms are not as a result of drugs, alcohol, or any general medical condition.

To fit the Diagnostic Criteria for 301.50 Histrionic Type, at least five (or more) of the following criteria must be met:

  1. Uncomfortable in situations in which they are not the center of attention

Regina George is not only uncomfortable in situations in which she is not the center of attention but she most notably does not allow herself to be in a situation where she is not the center of attention. When a new girl starts going to North Shore, and the girl is as pretty as or prettier than her, Regina makes a consorted effort to make that girl her new best friend forever.

  1. Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior

Regina definitely displays this behavior in every aspect of her life. She cannot even sing in the Christmas talent show without being in a midriff tube top shirt with a matching much too short skirt.

  1. Displays rapid shifting and shallow expressions of emotions

Regina has an extremely wide range of shallow emotions. For example when she is confronted with an old friend (the one she spread the lesbian rumor about) she shrugs it off as if it never happened. Her ability to show no remorse and be so nonchalant about something that destroyed a young impressionable human being show her shallow expression of emotion.

  1. Consistently uses physical appearance to draw attention to self

She uses her body, her beauty, and her weight to keep people focused on herself. When someone tries to shift the conversation she always finds a way to get the attention back on herself.

  1. Has a style of speech that is excessively impressionistic and lacking in detail

Regina has an immature speaking style. When talking in the cafeteria she uses many words that are not even words such as ‘skeeze’ to describe other students.

  1. Shows self-dramatization, theatricality, and exaggerated expression of emotion

In regard to her constant obsession with her weight, Regina has all of her friends focus on the things that she should be doing on her own to lose the weight. When Regina goes to a dress shop to be fitted for her prom dress and finds that she cannot fit the one she wants she has a tyrannical outburst.

  1. Is suggestible, I.e., easily influenced by others or circumstances

Regina is highly suggestible especially since she does not focus on the facts. She is a person who will take a person for their word. When one of her friends tries to help her with a “weight-loss” bar she takes it without question. She is shocked to later find out that the bars she has been eating for the past few months has been the sole contributor to her slow but steady weight gain.

  1. Considers relationships more intimate than they actually are

Accuracy of Portrayal
To the average person watching the movie Mean Girls, Regina George would seem like the typical high school bitch. She is popular, pretty, and, most of all, rich. To most laypeople they would not think to make the connection that she has histrionic personality disorder even though she does a phenomenal job portraying an individual with this disorder. Regina displays the symptom most commonly associated with having histrionic personality disorder, those being sexually seductive behaviors. Regina is sexually seductive in appropriate times such as high school girls and Halloween but most notably she is seductive at times when it is completely inappropriate. Her extreme variances and range of shallow emotions are another key symptom of histrionic personality disorder. The fact that Regina is unhappy and uncomfortable with not being the center of attention is another symptom of histrionic personality disorder. The portrayal of Regina George in the movie Mean Girls is an accurate portrayal a person living with histrionic personality disorder.


Treatment
The best treatment for histrionic personality disorder is through therapy. The most effective therapy treatment would be Cognitive Behavioral Therapy. Cognitive Behavioral Therapy would help Regina to be able to control her emotionality better as well as give her some tools to cope with life in a more adaptive way. Regina would benefit from CBT in that it would help her in her interpersonal relationships to be better able to make and maintain friendships.





Mental Retardation

Name: Carla Tate

Source: The Other Sister (movie, 1999)

Background Information
Carla Tate is a Caucasian female around the age of 18-20 (her age was not specified.) She currently has no job, but is attending a vocational school called Bay Area Poly Technical school, and only took one class, Computer 101, which she passed. A lowered intellectual quotient (IQ) and slower processing overall characterize her mental health. No drug or alcohol usage has been reported or detected. Tate recently moved out of her parent’s house and into her own apartment, although her parents pay for it. She seems to have a very healthy family structure overall. She comes from an upper socioeconomic status. She has two sisters, whom she frequently talks to, and a mother and father that are still married. Her father seems passive and very supportive to Tate. In contrast, Tate reports and it has been witnessed that Tate’s mother is very controlling and overly protective. Tate complains that her mother inhibits her freedom and does not allow her to try new activities. Although this causes self-reported strain in their relationship, Tate still says she is close to her mother. Tate is very social and seems to have a positive base line of friends. Her goal is to become a veterinary assistant in the future and continue to gain freedom from her controlling mother. Her daily activities include going to her classes and spending time with her significant other and family.

Description of the Problem
Tate currently has a lowered IQ (probably around 70, although further testing would be necessary) and impaired cognitive processes. Her mother and father report that these symptoms were also present in early childhood. She also displays impaired social behaviors by violating social norms and over sharing. Tate’s physical condition is very healthy. She is in her weight class for her height. She has not reported physical problems and none have been observed. Her mood is very positive and open. However, she sometimes displays rapid mood swings and quickly gets upset at what most view trivial things.

Diagnosis
Carla Tate appears to meet the criteria for mild mental retardation (317.0).

A. Significantly sub-average intellectual functioning: An IQ of approximately 70 or below on an individually administered IQ test. For infants, a clinical judgment for significantly sub-average intellectual functioning.
Although not specifically told, Tate has been diagnosed with a lowered IQ because she went to a certified school for individuals with lowered IQ.

2. Concurrent deficits or impairments in present adaptive functioning (i.e., the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas:
1. Communication
2. Self-care
3. Home living
4. Social/interpersonal skills
5. Use of community resources
6. Self-discretion
7. Functional academic skills
8. Work
9. Leisure
10. Health
11. Safety
Tate displays a deficiency in communication when she is upset especially. Her words become slurred and rapid. She also qualifies for social and interpersonal skills impairment. Although she is an outgoing individual, she sometimes misinterprets situations. She also acts out and causes scenes in socially inappropriate places. Overall, she takes direction well, but she often misunderstands what the instructions are if they are not given to her very simplistically. Her functional academic skills are also impaired. Although Tate does attend Bay Area Poly Technical School, she struggles to keep up with the other students, and can only master basic concepts. Although no tests have been conducted, her IQ is estimated to be around 70. Tate also currently does not maintain employment at any job. Although Tate is relatively safe, there have been past reported incidences by her mother and Tate herself, of inflicting harm on other children by accident and setting accidental fires, which falls under safety. Tate does meet the criteria for mild retardation, which she has been diagnosed with and treated for in a special school, but she is relatively normally functioning in day-to-day life.
B. Onset before the age of 18
Tate’s parents were alerted of her learning difficulties and social impairments around the age of 8 or 9 (no specific age was given.) She was sent to a special school soon after
because her parents felt they could not help her adequately.

C. Stable IQs from early in life to adulthood
As reported by her mother, Tate has maintained a longitudinal average of a lowered IQ from her early childhood to present.

Accuracy of Portrayal
The average person watching this movie would automatically be able to diagnose Tate as someone who is mentally retarded. However, many individuals do not understand that different levels of mental retardation exist based on IQ scores. Although mild retardation is the most common level of retardation, accounting for 65-75% of all diagnoses of mental retardation, most of the population lump all forms of mental retardation together. Another fallacy which might be correct with an everyday person watching this movie is understanding that although mentally retarded individuals are limited in some of their functions, they can become with supportive help, a very productive member of society. One possible misconception the movie might give viewers is the idea that mentally retarded individuals normally come from a higher SES and often have people to take care of their needs. However, statistically most people with a mental handicap, especially people with mild retardation, come from a low SES neighborhood. They often become homeless or wards of the state because of lack of specialized training and education.

Treatment
There is no cure for mental retardation. The goal of treatment is to maximize her potential in every area of life despite her mental condition. Special teachers and programs intervention at the youngest age possible is recommended, which she received. Tate should be trained not only in life skills and academic areas at her level, but also in social skills and self-control. Family therapy should also be conducted to help the family better understand her condition and to help her family better know what are the most effective ways of dealing with her. They should also be informed of her abilities and limitations. Tate is a highly functioning female with mental retardation, and therefore, needs less care from her family. However, because her mother is slightly controlling, it limits Tate’s autonomy, which is very essential for all humans, especially for someone with mental retardation. This situation should be addressed and healthy boundaries should be agreed upon among Tate, her mother and the therapist. Autonomy will allow Tate to develop to her full potential and has shown great success in the past with other similar patients.



Name: Charles Gordon

Source: Flowers for Algernon (movie, 2000)

Background Information
The main character of this movie is Charlie Gordon, a mentally challenged 32-year-old man, with an IQ of 68, who works at a bakery as a delivery boy and moonlights as a janitor. He also attends the adult school for the mentally retarded at night after work. Charlie is a simple man with simple goals. One of his goals in life is for people to like him. When Charlie was little, his mother and father abandoned him shortly after they discovered that he is mentally challenged. Charlie was put in a foster home when he was merely a child. When he is old enough to make a living, he moves out and lives by himself in a deteriorated apartment in the middle of a suburban area, a place that he could afford. Isolated and alone since childhood, Charlie yearns for close relationships; as a result, it is no surprise that he wants to be liked and wanted. For example, occasionally at the work place, he would act like a clown (e.g., pretend to slip and fall, put flour on his nose, make funny faces, etc.) in hope to make his coworkers laugh because he thinks that they like him and are his “friends” but, alas, little does he knows that they are not laughing with him but at him.

One day at the adult school, his special education teacher, Ms. Kinnian –who is very impressed with his free-spirit, friendliness, and curiosity to learn –tells him about the brain-operation experiment, an experiment that promises to make people like him smart. Charlie immediately signs up for the experiment because he feels that if he is smart then maybe people would like him more. After the controversial experimental brain surgery, Charlie's IQ increases at an exponential rate, tripling his original IQ at 185. With Ms. Kinnian's guidance, Charlie also learned to read advanced level books, such as Robinson Crusoe, mathematical quadrants, etc., and write in comprehensive sentences, as demonstrated in his “progris riports.”

Shortly after the brain-operation, Charlie explores his inner feelings and emotions, such as betrayal, jealousy, love, and pain that he never thought he had. He begins to understand the world around him. For example, after the brain surgery, he begins to understand that his coworkers aren't really his real friends after all because real “friends” would not invite you to bars and poke fun at you in front of everyone for good laughs. In addition, before the brain-surgery, he never knew he could fall in love and reciprocate his feelings. But as time goes by, his feelings for Ms. Kinnian develop. Alas, the ephemeral love between Ms. Kinnian and Charlie does not last. The movie ends with Charlie telling Ms. Kinnian goodbye the day he learns that the experiment would not work and that he would have to go back to being the mentally challenged man that he once was. Before the reversal of his intelligence, while he is still able to think and make decision, Charlie moves far away to another place to live, a place where Ms. Kinnian cannot find him.

As a man who is mentally challenged, Charlie has many difficulties and challenges in life. As you can see, his life difficulties involve deficits in intellectual abilities and functioning, such as the ability to read, write, and speak in coherence sentences. He may have learning disabilities, such as Written Expression (as demonstrated in his “progris riports”), Reading Disorder, and more. He also has difficulties in establishing interpersonal and social relationships because he does not have the ability to read facial cues and expressions. Little is known about his family mental health history. Charlie does not seem to have drug or alcohol problems. He also does not seem to have physical impairments, but mostly psychological and cognitive impairments.

Description of the Problem
Life is already hard, and life is even harder if you have Mental Retardation. As demonstrated in the movie Flowers for Algernon, Charlie shows significant limitations in intellectual functioning, such as not being able to read, write, and communicate coherently. He demonstrates maladaptive symptoms, such as emotional deficits and interpersonal problems. He does not seem to have sensory symptoms. His sensory modalities work fine. He can work and make a low profile and honest living as a delivery person and janitor at the bakery. He is not physically handicapped or in any way.

From the movie, Charlie is a mentally challenged man with an IQ of 68 and the symptoms that he shows qualify him for Mild Mental Retardation (MMR), which will be discussed in the diagnosis section. He is portrayed as a care-free and happy person, whose personality is almost childlike. He is not passive, placid, dependent, nor aggressive. He does not have severe nor profound mental retardation and he does not depend on anyone to dress for him or take care of him. But he does show signs of lack of communication skills, developmental delays, social and emotional deficits, impaired ability to solve or understand social problems and issues, and impaired ability in recognizing emotion in others. His academic performance is also affected by his mental delays; as a result, he goes to the adult school for the mental retarded instead of going to college. He can adapt easily at his working place, such as working as a delivery boy, janitor, and running errands, except that he does not have the capability to use a dough mixing machine, which requires the ability to follow instructions. The symptoms that Charlie has qualify him for MMR. He does not have self-injurious behaviors or stereotypical movements.

Overall, Charlie can function adequately at a slow pace environment, an environment that does not require higher order thinking and decision making abilities.

Diagnosis
Charlie Gordon meets the criteria for mild mental retardation (317.0) using the criteria from the DSM-IV-TR:

A) Significantly sub-average intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test.

Gordon has an IQ level of 68 since childhood. This qualifies him as having significantly sub-average intellectual ability.

B) Concurrent deficits or impairments in present adaptive functioning (i.e., the person’s effectiveness in meeting the standards expected for his or her age by his or her culture group) in at least two of the following areas: (1) communication, (2) self-care, (3) home living, (4) social/interpersonal skills, (5) use of community resources, (6) self-direction, (7) functional academic skills, (8) work, (9) leisure, (10) health, and (11) safety.

Gordon meets more than two symptoms of the above areas. He has problems in (1) communication, (4) social/interpersonal skills, (6) self-direction, (7) functional academic skills, and (9) leisure. He does not have deficits in (3) home living, (5) use of community resources, (8) work, (10) health, and (11) safety.

C) The onset is prior to 18 years of age.

Gordon has shown signs of mental retardation since childhood. The onset must be before the age of 18; hence, he also meets this criterion.

Accuracy of Portrayal
The movie does a good job in describing someone with mental retardation, especially a man with mild mental retardation. This movie was adapted from the original novel, Flowers for Algernon, written by Daniel Keyes. Keyes knew what he was doing when he was writing this novel. He had worked at many mental retardation facilities and had worked as a special education teacher before he wrote this novel. With the skills and trainings that he developed, he was able to describe in details the behaviors that he had observed from his students with mental disabilities, such as how they talk, write, associate with others, and so on. A person watching this movie would not be misled but be persuaded by the information that this movie provides and how it accurately portrays someone with this mental disorder. A person watching this movie would also get to learn more about MMR and the symptoms that a person with this disorder has.

Treatment
Currently, there is no cure for mental retardation. Mental disorder are an enduring and pervasive disease (which is why it is listed on Axis II), but several empirical supported studies show that therapy, special education and training, and social skill training can help ease the symptoms of mental retardation. Mental Retardation is not an easy disorder to treat since it is related to genetic factors, such as irregular genes or genes that did not fuse together properly (i.e., Down syndrome), and environment factors (e.g., infections, chromosomal abnormalities, metabolic, and nutritional, especially for persons with low socioeconomic status [SES]). It is also important for a trained specialist to evaluate the person for co-morbidity with other disorders, such as Attention-Deficit/Hyperactivity Disorder, Mood Disorders, Pervasive Developmental Disorders, Stereotypical Movement Disorder, Down syndrome, Fragile X, and more since these disorders may also affect the diagnosis and outcomes. The prognosis depends on the severity of the disorder, such as mild, moderate, severe, and profound. The less severe the levels and the early the treatment, the better the outcomes. Many people may lead productive lives and function on their own; whereas, others need a structured environment to be most successful.



Specific Phobia

Name: Ronald “Ron” Billius Weasley
Source: The Harry Potter series by J.K. Rowling (books, 1997-2007)

Background Information:
Ron Weasley is first presented to the public audience as a young, goofy 11-year-old wizard boy. Throughout the series he transitions into a mature young adult. He attends Hogwarts School of Witchcraft and Wizardry. Overall he is an average student never going above in expectations and never going under. He is the youngest boy in the Weasley family out of Bill, Charlie, Percy, Fred, and George. He also has a younger sister Ginny, who he is very protective of. His mother, Molly, is an incredibly loving woman, taking care of her children and running a very crazy household. Her husband’s name is Arthur Weasley and he works a modest job at the Ministry of Magic. The Weasley family is very rare in the wizardry world because they come from what is known as pureblood. This means that the Weasley family only have witch and wizard blood in their biological line. It is rare and often used by other Wizardry family has a way to declare dominance among their kind. The Weasleys, however, do not mistreat others and do not consider themselves to be above the rest of the wizardry population. Their good nature is one of the few things they are rich with, as there are very poor with only a modest income. They have been known to pass on handed down clothing among the children and make them handmade gifts because they cannot afford much else. They struggle finically with getting their children everything they need for school and they live in a small house that is referred to as the Burrow. Ron has a particularly difficult time dealing with the teasing that is brought on to his family because of their financial standing. He often has to defend his family to other people, especially towards Draco Malfoy, who is not afraid to bring up the handed down clothing whenever he wants to insult Ron.

Ron has two best friends at his school. They are the beautiful and very smart Hermione Granger and the ever popular boy-who-lived, Harry Potter. They have all been close since their first year in Hogwarts, when they all started battling against the evil wizard Voldemort. The relationship among these best friends, however, has often been rocky. Hermione and Ron fight constantly and as the books progress you can start to see a romantic relationship form. It is not until the final book that the audience completely knows the true feelings between these two characters. Ron and Harry instantly became best friends, but it was often hard for Ron to stand in the background of Harry’s ever growing shadow. This caused a lot of tension between the two, but in the end the relationship stayed strong. The biggest problem Ron faced in his life was the financial well-being of his family. He was very lucky to have both of his parents still alive and not have to face the torment that was given to Hermione from being muggle-born. Once he completes his seven years of training at Hogwarts, Ron wants to become an Auror, who are known for catching evil wizards. He is very good at chess and likes to use strategies to help him in difficult situations. During his years in school Ron saw himself as the Head Boy and the Gryffindor Quidditch captain. Ron has difficultly dealing with certain situations and often lets his anger get the best of him. He tends to explode and lash out against others when things become too difficult to bear. The biggest weakness he faces is jealousy of those around him. He is not completely satisfied with what he has been given and normally wants what others have. This makes his relationships sometimes difficult, but over time Ron began to get over his jealousy issues.

Description of the Problem
In the second book of the Harry Potter series, The Chamber of Secrets, the audience becomes aware of the fact Ron is incredibly afraid of spiders. The being around them scares him immensely and the mere idea of spiders turns him into the world’s biggest baby. When he is around them he begins to shake and he starts screaming at a high pitch. If he is able to form words at all, they are difficult to understand. His fear stops him in his tracks. Physiologically, his eyes get big, he has difficulty breathing, and his face sometimes turns white. His anxiety is so high in fact that he thinks the end of the world is happening and he must escape from the situation.

Diagnosis
It is very clear to see that Ron is suffering from a Specific Phobia, in particular Arachnophobia. This falls under the DSM-IV five general types of specific phobias in the animal type category.


As mentioned earlier, Ron does not even need to be in the around spiders to be afraid of them. Only mentioning them is enough to scare him and make him want the conversation shifted to a different topic.

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. Children can show affects and characteristics when it comes to specific phobias. Children can show anxiety by crying, throwing tantrums, experiencing freezing or clinging to the parent that they have the most connection to.
His level of anxiety definitely rises, as evidenced by how his voice changes, he begins sweating profusely, he starts shaking, and he does everything he can to avoid the situation.

C. The person recognizes that the fear is excessive or unreasonable.
In Ron’s case his fear of spiders started long before his traumatic experience with them in The Chamber of the Secrets. This even may have enhanced his fear, but he knows that is fear is often the point of joke and he understands that he sometimes takes it to an extreme level of anxiety. However, the amount of teasing he gets from others does not stop his fear from being expressed.

D.The phobic situation(s) is(are) avoided, or else endured with intense anxiety or distress.
It is clear that Ron will do anything to avoid being around spiders, including using his wizardry skills on them.

E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, social activities or relationships, or there is marked distress about having the phobia.
This does not seem like the case for Ron. He is able to conquer his fear after he builds up some esteem to do so. It is rare for him to walk away from a situation just because spiders are present, but it does require him to build up a lot of motivation in order to follow through. His normal routine is often just delayed when a spider is present or mentioned.

F. In individuals under age 18 years, the duration is at least 6 months.
Throughout the majority of the series, Ron is under the age of 18. He has had this fear of spiders in the second book when he and Harry had to go into the Forbidden Forest in order to find out if Hagrid was really opening the Chamber of Secrets. In the third book, The Prisoner of Azkaban, Ron and his fellow students at Hogwarts were learning how to battle of Boggarts, which turn into their biggest fear. For Ron’s case it would turn into a spider since that is his biggest fear. In the seventh book, The Deathly Hallows, Ron is trying to destroy an evil force and it uses his fear against him by making spiders appear. In the other books, Ron’s fear does not have a huge part, but it is mentioned in small sections of the book with comments explaining that his fear has been around for quite a long time. It is quite clear that every time spiders are mention that Ron’s fear comes up as well. This definitely exceeds six months.

G. The phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as obsessive-compulsive disorder (e.g., fear of dirt on someone with an obsession about contamination), post-traumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor), separation anxiety disorder (e.g., avoidance of school), social phobia (e.g., avoidance of social situations because of fear of embarrassment), panic disorder with agoraphobia, or panic disorder without agoraphobia.
Ron has no other signs of a mental disorder with his fear of spiders. It seems like the phobia is the only thing that is causing problems to come about in his life. He is actually quite open about his fear of spiders and it is often mentioned in the books to release tension during difficult and dramatic times.
It is very obvious that Ron is afraid of spiders. The difference between him and other individuals is that he faces his phobias despite how bad is anxiety responds. He fits the criteria and allows for a very clear and diagnosable explanation about his disorder. It is not unrealistic to place him in this category of anxiety disorders.

Accuracy of Portrayal
The portrayal of Ron does a very good job of explaining what it would feel like to live with specific phobia and for the audience presents many realistic ideas about Arachnophobia. The books give good examples about what is going on with Ron’s anxiety about the spiders and why he reacts to them in the way he does. The main problem with the portrayal is that it is often used for humor in the majority of the books. There are points when the phobia is quite obvious and understood in its full meaning, but the majority of the time is spent on Ron’s phobia being mentioned as a joke. For the readers, it is used as a nice little sigh of relief during the dramatic parts of this intense book series. It is important to remember that the Harry Potter series is mostly used for entertainment purposes and that sometimes it can over dramatic about humorous moments and complex storylines that allow for a more enjoyable read. This causes some of Ron’s phobia tactics to be displayed humorously and causes it to be funny and less like a mental disorder.

Treatment
The most recommended treatment for Ron would be Behavioral Therapy. In this process exposure techniques would be used to allow Ron’s anxiety levels to lower during different stages of exposure. The exposure to the spiders over a long period of time would eventually causes his anxiety levels to lower greatly. This would also cause less intensity with his fear. Ron’s sessions would start with a small amount of exposure to spiders by first talking about them, showing him pictures, and being in the same room as one. The steps would increase only after Ron became comfortable with the spiders and his anxiety levels would level out. The steps would increase with exposure until Ron was able to hold a spider and not attack it or be afraid. It would also be beneficial for Ron to go through some cognitive therapy as well. This would help him identify with the truth about spiders and help him to stop thinking that they are terrible creatures. This would be important because Ron is in the magical world and his interactions are different from those in the muggle world. Ron would be able to show great improvements with his mental disorder, but he is however a stubborn red head. This might be the only thing to stop him from being successful with his treatment.





Conduct Disorder

Name: Nelson Muntz
Source: The Simpsons (Television series, 1989 – present)
Background Information
Nelson Muntz is a 10 year old Caucasian boy who is a student at Springfield Elementary School. Nelson is unemployed and although he is a full-time student, he is on the verge of dropping out. His health appears to be in good condition, but there was a time when he was exposed to second hand smoking. Other than that, the patient does not seem to have any physical illness. However, some problems that are observed are how he behaves towards his peers and others. Nelson is feared by many of his classmate and peers. He is known to pick fights with the “nerds” and other kids that get in his way. Nelson is known by the community as the” bad kid on the block” and “the school bully.” Parents of other students, as well as school faculty, see him as a delinquent. Nelson’s family consists of his father, Mr. Muntz, mother, Mrs. Muntz, grandfather, Judge Muntz, and a sister who is unnamed. Little is known about the relationship between his parents as well as his relationship with them. Currently he lives with his mom, who works at Hooters as a waitress. His father is mostly absent in his life and as the story goes, Mr. Muntz abandoned his son and wife when Nelson was really young. However, there were few times in Nelsons’ life where his father does appear, such as after a football game where Nelson was the star player. Mr. Muntz came to congratulate him and invited him to have dinner at Hooters, but Nelson refused because he did not want to see his mother working there. Mrs. Muntz is known in the community as a jailbird, a prostitute, and a stripper. Mrs. Marge Simpson adopts Nelson informally. Nelson has difficulties in school when it comes to keeping up with his grades. Although he is known as a bully, there are occasions where his good nature comes out and befriends Bart Simpson and even dated Lisa Simpson. Nelson can be very disruptive and noncompliant to rules at school. He hangs out with older kids from high school, who also show no interest in education. Nelson has very little in the way of a support group, and keeping a friendship is difficult for him. Nelson can be very demanding and if he does not get what he seeks, then there will be consequences to those who get in his way. He enjoys seeing the misery of others and in many situations will laugh at their face. Nelson does not have very strong coping skills, if not any. He expresses his emotions physically by beating up someone and or by committing pranks and small crimes. There is no known history of drug or alcohol use.
Description of the Problem
Nelson Muntz displays a multitude of symptoms that are associated with Conduct Disorder. He displays anger and frustration through the act of bullying his peers. He shows no respect to authority figures and is disobedient towards them. He places no importance on school and constantly picks on the nerds and geeks that attend his school. He performs delinquent acts such as stealing, looting, vandalizing, and cheating. Nelson has made threats to other students and physically harmed them. For example, when one of his buddies stole Lisa Simpson’s cupcakes, her brother went to defend her by telling Nelson’s buddy to back off and soon they engage in a physical fight. Nelson, seeing Bart Simpson fighting his buddy, joins in the fight to defend his friend. Bart accidently makes Nelson’s nose bleed causing Nelson to become angrier. The fight was interrupted by the school bell indicating recess was over and it was time to go back to class. Nelson, full of anger, threatens Bart and tells him to meet after school. For the next few days, after school, Nelson physically beats Bart, shoves him into a trash can and rolls him down a hill. At one point or another, Nelson has terrorized virtually everyone in Springfield. He takes great pride in seeing those he believes to be inferior to him suffer pain and is in misery; he delights in other people’s pain and suffering. He shows guilt or shame about his misbehavior and often justifies his cruel actions. His close friends, who are just like him, only encourage his behavior and his parents show no concern or interest in their son’s behavior.
Diagnosis
The diagnosis that is appropriate for Nelson Muntz is Conduct Disorder (312.81).
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules that are violated, as manifested by the presences of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months.
  1. Aggressive conduct that threatens physical harm.
  2. Nonaggressive conduct that causes property damage.
  3. Deceitfulness or theft.
  4. Serious violations of rules.
Nelson Muntz meets all three of the above criteria. His aggression has led to physical harm to others as well as to him. He has been involved in vandalism and property damage due to recklessness. He has bullied his way into getting things that are not his. He has broken many state and school laws as well as showing no obedience to authority figures.
B. To the diagnosed with Conduct Disorder an onset of at least one criterion characteristic must be displayed prior to age 10 years:
Aggression to People and Animals:
  1. Often bullies, threatens, or intimidates others.
  2. Often initiates physical fights.
  3. Has used a weapon that can cause serious physical harm to others.
    1. A bat, brick, broken bottle, knife, gun
  4. Has been physically cruel to people.
  5. Has been physically cruel to animals.
  6. Has stolen while confronting a victim.
    1. Mugging, purse snatching, extortion, armed robbery
  7. Has forced someone into sexual activity.
Nelson Muntz has displayed more than one of these symptoms of Conduct Disorder prior to age 10 and currently still does. These symptoms are described above under the headline “Description of the Problem.”
C. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
Nelson Muntz has no interest in school and often he is found to cheat on his assignments and exams.
D. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
Nelson Muntz is only 10 years old.
Accuracy of Portrayal
An average person watching The Simpsons would be able to come to conclusion that the character Nelson Muntz shows abnormal behaviors when compared to his peers. They will notice that his lack of a stable home does have a huge role in his delinquent behaviors. A person with an Abnormal Psychology background could easily identify Nelson’s behaviors are symptoms of Conduct Disorder. The character Nelson Muntz is an accurate portrayal of how a child with Conduct Disorder behaves and acts towards others. However, in the realistic world, such symptoms are worse.
Treatment
Nelson Muntz should have a full medical examination before any treatments are given. First, Nelson’s parents should be educated about the disorder as well as provided with well-established treatments. Nelson’s behaviors should be modified in the class rooms as well as the play grounds. Treatments such as goal setting and developing ways to reach those goals should be taught to Nelson on a one-to-one basses. Nelson’s parents need to be more involved in his life, and therefore family therapy is recommended. According to research, the optimum method seems to be an integrated approach that involves both the child and the family, within a variety of contexts throughout the child’s developmental stages as well as his and his family’s life. Also, when Nelson misbehaves, he should have some sort of consequences for his actions instead of encouraging his behavior, therefore, grounding or timeout should be enforced.


Attention-Deficit/Hyperactivity Disorder

Name: Bart Simpson
Source: The Simpsons (Television series, 1989-present)
Background Information
Bart Simpson is an eight-year-old male with no history of a mental health diagnosis. Bart has been labeled an “underachiever” by authority figures and has poor grades in school ranging from D-minus to F. Bart can be ingenious regarding things that interest him such as learning portions of the Talmud to help reunite his idol, Krusty the Clown with Krusty’s father, Rabbi Krustofsky. However, this drive is absent for school-related performance. His academic achievements are behind those of his fourth-grade peers.
He has a history of consistent and sometimes significant trouble making. He also reports feelings of frustration with the narrow-minded people in his town for judging him by his problematic thoughts and actions. His relationship with his father is volatile and dysfunctional. One minute he is being strongly scolded by his father and the next him and his father bond over a collaborative prank. He once told Bart it was not okay to lose a children’s miniature golf tournament and made Bart stare angrily at this opponent for 15 minutes a day. There is evidence that his father forgets his youngest daughter even exists (Bart’s infant sister). Bart’s mother tends to “over-mother” her children and once left the family for a brief period due to a mental breakdown. Despite this, Bart has no significant problems in the relationship with his mother. Bart enjoys skateboarding, bubble gum, Squishees from the Kwik-E-Mart, and a single-handedly bringing a homicidal TV sidekick to justice – twice.

Family Mental Health History:
Marge Simpson is Bart’s mother. She is described as a happy homemaker and mother of three. Marge puts up with the antics of her husband (Homer, Bart’s father) and children in good spirits, for the most part. Though, in 1992 the combined stress of her workload and family’s problems caused her to have a mental breakdown. She went away to spend time at “Rancho Relaxo” before returning home to her overly-dependant family. Marge over-mothers her children and reports staying with Homer because he makes her feel needed. Marge speaks out about issues such as violence and moral hygiene. The townspeople respond with frustration for her disregard of social norms. However, she also has a history of gambling addiction. She worked to overcome this addiction but it always lingers as a possible problem.
Homer Simpson is Bart’s father. Homer’s father Abe raised Homer in the absence of his “radical hippie mother.” Homer has a reported low IQ of 55 accompanied by periods of forgetfulness and ignorance. A crayon was discovered to be lodged in his brain and when removed his IQ rose to 105. However, he did not like his new ability to understand reason so he had the crayon re-inserted. This returned his IQ to 55. Other contributors to his low functioning include his exposure to radioactive waste, his alcohol use, and repetitive cranial trauma. It is uncertain whether his low level of functioning can attributed to genetics or to his life events. Homer works in a nuclear power plant and has remained an entry-level employee longer than any other employee. Prior to that, he attempted other jobs on impulse. At work, he falls asleep constantly and does not perform his duties. Homer displays regular instances of explosive anger. He does not attempt to hide this in public. He is ruled by his impulses. These impulses combined with his intense rage leads him to strangle Bart on occasion. His impulses change frequently affecting his attention span. He pursues many hobbies and enterprises and then quickly changes his mind about them.
Abraham Jay "Abe" Simpson is Bart’s paternal grandpa. He is a grizzled old man who is incredibly long-winded and often ignored. The stories he tells seem wildly inaccurate and often consist of events that are physically, or historically impossible. For example, he reports serving in World War I, although he was a small child at that time. He reports many confrontations with famous figures and writes letters to organizations making unreasonable requests such as asking the president to get rid of three states because there are too many and requesting that Modern Bride Magazine feature more people with wrinkles and toothless grins. He reports homicide attempts of Adolf Hitler via javelin throw in the 1936 Olympics. It appears that Grandpa Simpson suffers from some mental health impairment(s). Without knowing his history, it is hard to tell whether this is a lifelong disease or one that attributed to old age. If he has suffered these delusions for a long period, suffice it to say some of Bart’s mental health problems could be genetically linked to his grandpa.
Bart’s eight-year-old sister Lisa is a high-achieving student who is already a member of MENSA with an IQ of 159. She is smart, witty, and goal oriented. Lisa does not appear to have any limiting mental health symptoms. Bart’s younger sister Maggie and two maternal aunts are also featured on the show but do not seem to have any notable mental health limitations.
Description of the Problem
Bart displays multiple symptoms that are indicators for several mental health disorders. He shows very consistent symptoms for ADHD. Several problems arise as a result of Bart being distracted by video games. Specifically, he misses important family announcements because he is so distracted by his video games. Similarly, upon getting a satellite dish, Bart and his father became so distracted by the television that he could not study for an important achievement test. During the test, Bart continued to be distracted by daydreaming about things he saw on television the night before. This resulted in him failing the test and being held back a grade. In another instance, Bart got an F on a test so the school psychiatrist recommended he repeat the fourth grade. Out of desperation to avoid being held back, he promises to study but is repeatedly distracted so did worse on the next test. For the third test, Bart tries to focus while he is studying, but is still easily distracted and is forced to slap himself continually to continue his studying. The next day, still slapping himself, he finishes the test to receive a D- allowing him to pass by one point. During another instance, Bart also spontaneously interrupts an important lecture. There are many more instances where Bart becomes distracted, leading him to fail at tasks.
Diagnosis
The most appropriate diagnosis for Bart seems to be Attention-Deficit/Hyperactivity Disorder (under code 314.0). He fits the Inattentive Type meeting the following symptoms: 1, 2, 3, 4, 6, 8. Bart displays many problems with attention and distractibility. His symptoms seem sufficient for satisfying this ADHD, Inattentive Type criteria. However, he also displays some dominant symptoms for ODD and CD. These symptoms undergo dramatic changes from episode to episode creating some difficulties in rendering a diagnosis.

Two types of ADHD: 1) Inattentive Type, and 2) Hyperactive-Impulsive Type.


  • DSM-IV-TR criteria:
  • Inattentive Type and Hyperactive-Impulsive Type:
    • 1. Inattentive Type:
    • Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
      1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
      2) Often has trouble keeping attention on tasks or play activities.
      3) Often does not seem to listen when spoken to directly.
      4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
      5) Often has trouble organizing activities.
      6) Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
      7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
      8) Is often easily distracted.
      9)Often forgetful in daily activities.

    • 2. Hyperactive-Impulsive Type:
      • Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
        Hyperactivity:
        1) Often fidgets with hands or feet or squirms in seat.
        2) Often gets up from seat when remaining in seat is expected.
        3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
        4) Often has trouble playing or enjoying leisure activities quietly.
        Is often "on the go" or often acts as if "driven by a motor".
        5) Often talks excessively.
        Impulsiveness:
        6) Often blurts out answers before questions have been finished.
        7) Often has trouble waiting one's turn.
        8) Often interrupts or intrudes on others (e.g., butts into conversations or games).

Accuracy of Portrayal
A viewer of the Bart Simpson character can see many accurate symptoms of ADHD, but his character has many overlapping symptoms of Oppositional Defiant Disorder and even Conduct Disorder. His problems with attention are displayed in numerous experiences. However, he also displays multiple symptoms of deceitfulness, serious violations of rules, deliberately annoys people, and often argues with adults. These symptoms are found in individuals with ODD or CD. However, Bart does not demonstrate the temper, anger, or aggressiveness problems that can also be found in ODD or CD. The Bart Simpson character does display ADHD symptoms with fair accuracy, over many different episodes but also displays the ability to effectively organize delinquent behaviors in others, which would be less likely for someone with ADHD. So, there are some inconsistencies in his character but that is to be expected for a character with such different dramatic storylines, in weekly episodes for over 20 years.

Treatment
Treatment of Bart should begin with a structured or semi-structured clinical interview discussing developmental and family history, ADHD symptoms, and symptoms of co-morbid problems. Intelligence testing, achievement testing, and reports from parents and teachers will also provide valuable insight. In light of the 2011 study by Dr. Lidy Pelsser of the ADHD Research Centre in the Netherlands, it seems appropriate to begin Bart on restricted, non-allergenic diet to eliminate allergens related to ADHD symptoms. A strictly supervised restricted elimination diet is a valuable instrument to assess whether ADHD is induced by food. This diet should be followed and monitor his symptoms closely for five weeks.
If ADHD symptoms have not drastically improved or disappeared after five weeks, the diet should be ceased and medication will be the next course of action. Medication should be used to treat Bart’s core ADHD symptoms. Central nervous system (CNS) stimulants have a high success rate for ADHD. Bart would begin taking a low dose of Ritalin. It should be taken two times a day; morning before breakfast and at night before dinner. He should begin taking 6mg tablets and then can move up to 60mg a day. A combination of medication and behavior therapy will be used to treat co-occurring problems for the long term. This therapy will promote improvements in the parent-child interactions, aggressive responses, and social skills. Parent training can also provide parents with skills to effectively interact with a child with ADHD.




Name: Clark Griswold

Source: National Lampoon’s Christmas Vacation (movie, 1989)

Background Information
Clark Griswold is a forty-four year old male patriarch of a traditional middle-income family with a wife and two teenage children (one son and one daughter). Clark works as a food additive designer for a large firm. His achievement is inconsistent and fluctuates from high level (creating a new “varnish” to keep cereal crispy in milk) to minimal effort and being “invisible” to his boss. Although Clark proclaims himself as “a regular family man, trying to do what’s best for his wife and kids,” his actions contradict his behavior. On more than one occasion, Clark has introduced his children as “Rusty and what’s-her-name”. This verbal outburst demonstrates a subconscious disconnect between beliefs and actions. Clark’s wife, Ellen, does not display outwardly noticeable symptoms of mental health disorder. She demonstrates a loving relationship to her husband (a.k.a “Sparky”) and children, although she tends to enable the household behaviors and live in a state of denial about Clark’s eccentricities until his behavior is extreme. The children both display typical teenage angst and disinterest in family situations. Both minor children have past experience with illegal substances, but do not present addictive behaviors (see National Lampoon’s Vacation, 1983). Clark’s cousin Eddy displays a possible genetic link to maladaptive behaviors. For example, when Clark does not receive his anticipated Christmas bonus from work, Eddy kidnaps Clark’s boss. Clark displays poor coping skills and reacts abruptly and inappropriately in both public and private settings. Although he lives in constant pursuit of the ultimate family vacation, his overall achievement goals are shallow and limited to materialistic gain.

The close proximity of relatives that may or may not always get along under normal circumstances, increases tensions and exacerbates Clark’s ADHD symptoms. Family support and understanding for display of symptoms is minimal and inconsistent, although time spent together is abundant. Most of Clark’s outbursts or behaviors are dismissed as normal for him. As of 1989, Clark has received no official mental health diagnosis but has displayed multiple symptoms that his family normally dismisses as “part of his character.” Individuals from the outside view Clark as impulsive and prone to quick outbursts. It is possible that Clark displayed symptoms before age seven but went undiagnosed due to the lack of information regarding ADHD prior to 1970. Subsequent controversy and downplay of ADHD from critics may have interfered with proper diagnosis and treatment.

Description of the Problem
Clark presents with several significant symptoms pointing to Attention-Deficit/Hyperactivity Disorder. Clark is easily distracted and demonstrates an inability to stay on task with everyday items. However, he does overindulge on items he deems important. Clark becomes so involved in his quest for the perfect family vacation and Christmas lights for the house that he misses quality family time and activities with the group. Clark has a tendency to behave in an overly energetic manner and is unable to rest or at times maintain an even temperament. He is quick to anger at even mundane situations and consistently holds extreme grudges. Furthermore, he shows inappropriate affect and significant impairment in both personal and professional settings. For example, while Christmas shopping for his wife; Clark is unable to maintain composure with the female working the counter. He also displays inappropriate affect and coping behaviors with anger towards his boss by demonstrative and abrupt outbursts.

Diagnosis
Clark’s symptoms fit best with a diagnosis of Attention-Deficit/Hyperactivity Disorder (314.0) from the DSM-IV-TR, with the specific subtype of Inattentive Type best describing his symptoms. Clark meets the following symptoms for Inattentive Type: 1, 2, 3, 4, 5, 8, 9. Although he presents with symptoms for Hyperactive-Impulsive Type, he does not display the required six or more for a complete diagnosis. Clark’s hyperactive and impulsive behaviors may be caused by environmental factors. The following symptoms must be met to be diagnosed with Attention-Deficit/Hyperactivity Disorder:

1. Inattentive Type:
Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Clark overlooks specific details in personal activities with an elevated risk such as driving or home improvement. During a family trip to choose a Christmas tree, Clark became distracted by his frustration with another driver and drove the car directly parallel under the bed of a semi-truck. He was unaware of his wife’s warnings to stop or that he was pulling under the truck until after the action was complete. His home improvement skills lack detail such as the time he stapled his shirt sleeve to the top floor guttering while precariously balanced on a ladder.

2) Often has trouble keeping attention on tasks or play activities.

While Christmas gift shopping for his wife, Clark was distracted by the counter attendant and unable to focus on the task at hand. He continuously rambled, stumbled on words, or changed sentence syntax by saying “hooter” instead of “hotter”. Clark displayed difficulty staying on task or keeping his attention on the purpose of his trip.

3) Often does not seem to listen when spoken to directly.

Clark’s daughter, Audrey continuously updated him of her “freezing” body parts during a trek to find the family Christmas tree. He remained unaware of the situation, even after his wife expressed concern that Audrey’s eyes were frozen. He dismissed the problem once he realized he was being addressed.

4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

Failed to latch the ladder placed against his house and slid down to the ground from the second floor. Clark also overlooked the directions for the “twinkling” holiday lights and was unable to change them from the constant on position.

5) Often has trouble organizing activities.

Clark forgets to bring the saw necessary to cut down the tree on the family Christmas tree trip and also manages to freeze most of his daughter’s body by leading them through massive snow and freezing temperatures without adequate preparation. His son, Rusty, spends most of the time during the Christmas light installation retrieving items from various locations or untangling the jumbled mess of string lights.
6) Often avoids, dislikes, or does not want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8) Is often easily distracted.

Clark asks his wife about his mother-in-law waxing her lip during a serious conversation about holiday tension. He becomes trapped in the attic and becomes distracted by the case of home movies he found while searching for warm clothing. He proceeds to watch the movies instead of trying to find a way out of the attic.

9 )Often forgetful in daily activities.

Clark is easily distracted and forgets basic activities or the involvement of others.

Some symptoms that cause impairment were present before age 7 years. There has to be an onset of symptoms prior to 7 years old, but a diagnosis can occur much later.

Unable to find medical history confirming childhood diagnosis but this could be due to the lack of information regarding ADHD prior to 1970.

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

Clark’s behavioral problems are consistent at both home and work, with home being his largest source of symptomatic display.

There must be clear evidence of significant impairment in social, school, or work functioning.

Clark displays inappropriate affect and displays attentional deficits at work and home.

The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Clark’s does not demonstrate the symptoms associated with other disorders to warrant a full diagnosis of Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder. He does present with OCD like symptoms and should be observed to assure an accurate diagnosis.

Accuracy of Portrayal
Clark’s ADHD oriented behavior traits are consistent over the course of each movie. His excessive talking, trouble organizing activities, trouble staying focused when spoken to directly, and forgetfulness of daily activities are just a few of the direct ADHD symptoms that Clark displays. However, He does not consistently display the passiveness normally associated with Inattentive ADHD. Clark is compliant and passive during some events, yet he is also prone to outbursts and demonstrates a quick temper. ADHD shows a high comorbidity with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), but Clark’s temper and outbursts are more likely caused by environmental and psychological factors, thereby presenting an inaccuracy in the portrayal. The average viewer watching Clark Griswold may consider his behaviors are more consistent with Obsessive-Compulsive Disorder (OCD). Clark displays an inability to curb impulses and recurrent thoughts and is prone to act according to his own volition, regardless of the outcome on others. Although these attributes illustrate OCD, they are just a few of the many symptoms of ADHD that Clark exhibits.

Treatment
The best course of treatment should begin with a structured or semi-structured clinical interview to obtain Clark’s family and medical history, and pervasive symptoms pertaining to ADHD and co-morbid disorders. Empirically supported treatment includes stimulant medication to relieve core symptoms. FDA-approved medications are useful for reducing physical symptoms. Specifically, ADHD responds best to stimulant medications such as Ritalin, Cylert, and Dexedrine. Due to the severity and inability to predict side effect occurrence from Cylert, the better pharmaceutical choice is either Methylphenidate (Ritalin) or Destroamphetamine Sulfate (Dexedrine) for Clark’s symptoms. Potential stimulant medication side effects include insomnia, decreased appetite, and potential dependence. Dosage is prescribed based on patient age, weight, and medical history. Clark should begin with the lowest possible dosage and gradually increase prescription strength only at the advice of a therapist or doctor. Behavior therapy is preferred as the primary treatment choice in conjunction with pharmacotherapy and can be useful for improving social skills, modifying behavioral deficits, and reducing aggression. Additionally, family support methods are vital to effective treatment plans.






Generalized Anxiety Disorder

Name: Piglet

Source: The World of Pooh by A.A. Milne (books, 1954)

Background Information
Piglet is a young male pig and Winnie the Pooh’s friend. Since he is portrayed as a baby, he is probably in the age range of 0-3 years old. Piglet does not have a job and his family history is unknown. He does not have any physical health problems but he displays characteristics of anxiety and nervousness. He stutters quite a bit and he is fearful of wind and darkness. Piglet also does not like bees or woozles (which are creatures that Piglet has not yet seen). Piglet lives in the Hundred Acre Wood with Pooh and all of the other Winnie The Pooh characters. He lives in a house in a large beech tree with a sign outside that says “Tresspassers W” which to Piglet means his Grandfather lived there and his name was “Tresspassers William”. Piglet’s goals are to become brave, not so timid, and to catch a heffalump (a creature that resembles an elephant).

Description of the Problem
Piglet is a very timid piglet. He shows characteristics of anxiety and he stutters. He thinks of how any situation can go wrong and he argues with himself about what he should do if a situation does go wrong. For example, while trying to catch a heffalump, Piglet thinks to himself how he can fake a headache so he will not have to face one of these creatures, in case it is fierce. Then he thinks to himself that if he fakes a headache he will be stuck in bed all morning, so he does not know what to do. These are the types of scenarios that make him anxious. He has thoughts that he creates that jump from one bad scenario to another. Piglet also shakes and blushes. His ears twitch when he is scared or nervous, which is often. He is usually very flustered.

Diagnosis
The diagnosis that would best fit Piglet is Generalized Anxiety Disorder (300.02).
  1. In children, to be diagnosed with Generalized Anxiety Disorder, only one of these symptoms must be present:
(1)Restlessness or feeling keyed up or on edge
(2) Being easily fatigued
(3) Difficulty concentrating or mind going blank
(4) Irritability
(5) Muscle tension
(6) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Piglet definitely shows signs of restlessness or feeling keyed up or on edge. He also has difficulty concentrating (his thoughts jump from one bad scenario to another).
  1. Excessive anxiety and worry (apprehensive expectation), occurring more days for at least six months about a number of events or activities (such as work or school performance).
Piglet has had anxiety problems his whole life as far as we know from the books. He definitely has probably had anxiety problems for more than six months.
  1. The person finds it difficult to control their worry.
Piglet cannot control his worry which is why he struggles with trying to be brave. He manages to live with his worry and anxiety but the thoughts are still there and he voices his worry to his friends.
  1. An unrealistic fear or worry, especially in new or unfamiliar situations.
Piglet is afraid of the dark and wind. He has an unrealistic fear of heffalumps and woozles.
  1. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during post-traumatic stress disorder.
Piglet anxiety and worry are not due to any of the above features.
  1. The anxiety, worry, and physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Piglet’s anxiety and worry does cause him clinically significant distress because he is always worrying about or is afraid of something. He shows distress from his anxiety.
  1. The disturbance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
Piglet does not use drugs, nor does he suffer from any physical medical conditions and he does not have any of the above disorders.

Accuracy of Portrayal
The average person reading The World of Pooh by A.A. Milne would be exposed to an accurate portrayal of generalized anxiety disorder in Piglet. Piglet trembles, twitches, and is shaky. Piglet also has exaggerated startle responses to things that scare him. He also shows symptoms of autonomic hyperarousal, like rapid heart rate and shortness of breath. When Piglet is in stressful conditions his anxiety levels tend to elevate and worsen. This is typical of young people with generalized anxiety disorder. Children with this disorder may also show signs of being unsure of themselves. The book accurately portrays generalized anxiety disorder in Piglet.

Treatment
In treating Piglet, one would try to avoid medicines since he is a child and some of the side effects of certain medications can be suicidal thoughts in children.Starting out treating Piglet with cognitive behavioral therapy (CBT) would be optimal. CBT could help Piglet recognize his negative thoughts and try to change his thoughts to more positive thoughts that are more realistic. It would also help Piglet with relaxation techniques such as breathing exercises that could help him learn to relax better in stressful situations that cause anxiety for him. After participating in the behavioral therapy and learning relaxation techniques Piglet could better handle and manage his own anxiety. This could lead to a much happier, comfortable, and positive life. His quality of life would be better after the treatment.




Gender Identity Disorder

Name: Brandon Teena (Teena Ray Brandon)

Source: Boys Don’t Cry (movie, 1999)

Background Information
Brandon Teena is an adolescent,Caucasian female who grew up in Lincoln, Nebraska. Teena prefers to live her life as a male. She does not currently appear to have a stable and persistent means of income or employment. Teena steals because of her low social economic status and non effort to obtain an occupation. Her delinquent activity has led her to attain a juvenile record before she has reached the age of 21. Although, the whereabouts of her mother is unknown, there seems to be a distant to an almost nonexistent relationship between her and her mother. Her father died before she was born so there is absent fathering in her life from the beginning of her years. She lives with her cousin from time to time in a trailer home, yet her cousin does not support the trouble she gets into with the locals and the law. Her cousin and presumably other family members do not except her transgender choice to act as a male either. Teena mainly lives out of her travel bag with no stable, consistent place to call home. There doesn’t seem to be any health concerns. There is also no evidence that there is any family mental history as well. Brandon Teena, who‘s legal name is Teena Brandon, has always looked like a girl, yet reported that she had always felt as guy. Cutting her hair short, wrapping up her breasts, and wearing a fake penis has in fact resembled her as looking as a male. Her past does not show any previous drug or alcoholic abuse; however, recently she has been introduced to a selected few of drugs, such as marijuana, with a group of new friends in Falls City, Nebraska. Teena’s weakness appears to be females. Her goal is to have a surgical procedure to change her female sex characteristics.

Description of the Problem
Teena currently displays symptoms that indicate that she does indeed reject her identity as being a female physically. She seems to have emotional symptoms, especially when someone may mention that she is a girl and not a boy. Her cousin continued to tell her that she was a girl, that she needs to leave the girls alone, and that she needs to accept the fact that she is a lesbian. Although Teena knows that she is physically not a male, she denies being a lesbian or homosexual. Teena cross dresses and wears a fake penis and socks in her pants in order to portray body types like a male. She denies having sexual attributes such as a having a menstruation and tries to hide all of her sexual characteristics from others. She will claim to be a hermaphrodite before she claims to be a female. Teena has not ever had sexual intercourse with a male and has resisted from being touched any areas by her genitals from any of her sexual partners. Teena could pass for a male fairly easily with a short hair cut like a guy her age, male stature, and her cross dressing efforts.

Diagnosis
The diagnosis for Teena Brandon that seems to fit appropriately is Gender Identity Disorder in Adolescents or Adults (302.85).
A. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the opposite sex, frequent dressing as the opposite sex, desire to live or be treated as the opposite sex, or the conviction that he or she has the typical feelings and reactions of the opposite sex.

Teena acted like a male and desired to be treated like a male by everyone. Teena cross dressed to look like a normal guy her age would as well. She was also very attractive to girls.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of their sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

Teena desired to change her sexual characteristics through surgical procedures. She wrapped her breasts down in order to flatten them and wore a counterfeit penis in her underwear.

C. The disturbance is not concurrent with a physical intersex condition.

Even though Teena claimed that she was a hermaphrodite, she was full characterized and constructed as a female physically and biologically.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if (for sexually mature individuals): Sexually attracted to males, sexually attracted to females, Sexually attracted to both, Sexually attracted to neither

Teena was a part of the low social economic status population and also did not indicate a means of trying to obtain an occupation while she continued to steal things. Teena seemed to have a hard time getting along with everyone except for her female partners.

Accuracy of Portrayal
The average person watching this movie would see a reasonably accurate portrayal of the onset of Gender Identity Disorder, especially since Teena Brandon denies her gender and sexual characteristics as well as being a homosexual in any part of the movie. The movie helps the portrayal of gender identity disorder in a significant way by giving good examples of all the symptoms of gender identity disorder. Because the movie portrayed true events of someone’s life, most symptoms did seem neither inaccurate nor exaggerated. Teena fits the adult presentation of gender identity disorder because of her persistent frustration of her biological sex. She passed as the opposite sex by cross dressing and abstained from touching or letting female partners touching her genitalia. One may think that parental relationships were being mislabeled in the movie about gender identity disorder because the only whereabouts that were known about the parents were mentioned very briefly. The course of the disorder was also mislabeled because nothing about her childhood was revealed during the movie. If her childhood was identified during the movie, then gender dyshoria would have been prevalent in her life because research shows that children with gender dysphoria that persists into adulthood results in gender identity disorder. Teena showed to have constant discomfort with her sex as being a female which fits into the general descriptive feature of gender identity disorder. The reason why majority of people, friends, and family of Teena did not accept her sexual orientation is because there is a 1 in 100,000 occurrence opposed to 1 in 30,000 in men and men are more accepted than women. Throughout all of the details and information that was made available in the movie, the movie portrayed gender identity disorder appropriately.

Treatment
There are empirical studies that help support treatments for people who portray gender identity disorder. Psychotherapy would have been more helpful for Teena if her disorder was identified earlier. However, psychotherapy can still help Teena cope with her biological sex and behavioral patterns associated with the roles of her biological determined sex. It may reduce Teena’s transsexual behavior in a very subtle way, but probably not as much because her disorder was not caught in the beginning. Another treatment that could help Teena would be hormonal therapy of surgical procedure(s). Before having any surgical procedures Teena may be given hormonal therapy in order to prevent undesired sex characteristics of the unwanted opposite sex. Various behavior therapies could help Teena by helping her to modify her behavior towards the sex she wants to be. Triadic therapy may help Teena as well. This therapy includes three differ elements; living as the desired gender, sex reassignment therapy, and hormone therapy. However, she would not have to include all of these elements into her therapy.


Name: Dil
Source: The Crying Game (movie, 1992)
Background Information
Dil is a young mid-twenties biracial male that prefers to live his life as a female. Dil works as a hairdresser at a salon during the day and performs as a nightclub singer at night. The bar that Dil performs at is called “The Metro”. The Metro is a gay bar filled with lesbians, gays, and transsexuals. Most of the performers at The Metro are transsexual males. Dil states in the movie, that she has a blood condition that causes her to grow weak. There are several medications that she has to take for this condition. My interpretation is the blood disorder she is speaking of is HIV/AIDS. Dil does not have any family close to her. The closest, most stable relationship in her life is the bartender at the Metro. Dil is currently single because the love of her life was killed when he was a soldier in Ireland. Dil suffers from depression and loneliness and uses alcohol to cope. She also lives a very promiscuous lifestyle in search of love and acceptance. Dil’s weakness is men and she is often abused and manipulated by the men that she “loves”.
Description of the Problem
Dil displays symptoms that she wants to be perceived as a female. Although she still has a penis, she wants others to perceive and treat her like a female. If a man that she potentially wants to date or “mess around with” does not perceive her as a female she gets angry. However, she also blames the man if he does not recognize that she was born a male. At first, Dil would refuse to have sex with Jimmy; instead she preferred to perform oral sex on Jimmy. This was in an effort to keep him from seeing her penis. One night, after they had been drinking, Dil decided to disrobe and show Jimmy her penis. Jimmy was shocked and he hit her. Then he proceeded to vomit in the bathroom. This further sent Dil believing he would never love and accept her for who she was. Dil seemed to get really emotional when Jimmy threatened to leave her and refused to stay with her or show any type of affection toward her. The man Dil refers to as her true love did know that she was born a male and he accepted her for who she was.
Diagnosis
The appropriate diagnosis for Dil is Gender Identity Disorder in Adolescents or Adults (302.85).
A. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the opposite sex, frequent dressing as the opposite sex, desire to live or be treated as the opposite sex, or the conviction that he or she has the typical feelings and reactions of the opposite sex.
Dil was an adult male that chose to live his life as a female. Dil often stated that she was a lady and wanted to be treated as such. Mostly everyone around Dil (except Jimmy) knew that she was born a male. However, the still called her a woman and treated her like a woman. Dil dressed, talked, walked, and acted like a woman. Dil was a very emotional person and some may perceive that as acting like a woman. Most men would view Dil as a very attractive woman.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of their sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
Dil did not speak of wanting to have surgery to change sexes; however, she never went out without a padded dress or bra to make the illusion that there were breasts there.
C. The disturbance is not concurrent with a physical intersex condition.
Dil was not a hermaphrodite, he was simply born male and wanted to live his life as a woman. He did not state that he wanted to have surgery to change his genitals but he did want others to view him as a female.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if (for sexually mature individuals): Sexually attracted to males, sexually attracted to females, sexually attracted to both, sexually attracted to neither.
Dil lived in what seemed to be a low-income part of town; however, she worked as a hairdresser so she was able to pay her bills. She seemed to be liked by others such as her co-workers and people at the bar. Men especially found her very attractive and likeable. However, some men often took advantage of her low self-esteem and would physically abuse her. Dil was attracted to only males, especially males that told her they loved and cared about her.
Accuracy of Portrayal
The average person watching this film would not have guessed that Dil was born a male. They would have just viewed her as an attractive woman in the beginning of the movie. Most men could probably identify with the main character in being unaware that Dil was not a born female. First of all, there are many men that look for the large Adam’s apple first and if they do not see it, they assume that the female was born female. Dil did not have a large Adam’s apple or a deep voice; however, she did have very large hands and feet. People watching this movie could learn that not everyone that has Gender Identity Disorder, or feels that they were born in the wrong body wants to have surgery. Some choose not to undergo surgery and hormones and all of these things because of the side effects. Others choose not to have surgery because they are comfortable living as the opposite sex without making surgical changes. Dil was a person that was comfortable living as a female without seeking out surgery. The actor in this film definitely performed an accurate portrayal of Gender Identity Disorder. The emotion that was expressed throughout the film that Dil experienced seemed genuine. Anytime she felt jealous, scared or rejected that is when she would either seek attention from men or turn to alcohol.
Treatment
If I were a mental health professional and Dil walked into my office, I would first gather all of the proper background information and medical history and then proceed accordingly. One of the treatments for Gender Identity Disorder is hormones and surgery, but I do not think that would be a good fit for Dil because she has not expressed any interest in changing her biological sexual identity. Instead, I would recommend psychotherapy for Dil. I think Dil would benefit from psychotherapy because it would help her with gather and implement coping mechanisms to deal with her sexual identity. Also, empirical evidence supports that Dil would have better benefitted from psychotherapy if it was administered early in life but I think that she could still benefit from psychotherapy as an adult. The main purpose of psychotherapy in Gender Identity Disorder patients is to help them cope with their biologically determined sex and reinforce the behavioral patterns associated with those roles. However, with Dil the approach may be different because the role she is comfortable in is the role of the female. So as a professional, I would focus more on making her more comfortable with her biology and not trying to change her into becoming a male.


Transvestic Fetishisim

Name: Glen

Source: Glen or Glenda (movie, 1953)

Background Information
Glen is a heterosexual Caucasian male and presumably in his late twenties. He appears to be in good physical heath, appropriate weight for stature and is a smoker. Glen was raised by his biological parents and has one younger sister. According to Glen his relationship with his father was strained. Glen’s father wanted a son that was interested in sports and who would be a great athlete, none of which Glen was interested in. He expressed that his mother was more affectionate towards his sister and that he longed for that type of affection. He lives in the city, has a stable job, maintains friendships and has been engaged to be married for 1 year to his fiancée Barbara. Glen and Barbara have a healthly relationship displaying respect, open communication and expressions of affection. Glen has no history of drug, alcohol or other mental health issues.

Description of the Problem
Glen has a desire to dress in women’s clothing (cross-dressing). He has expressed that being able to dress in clothing of the opposite sex makes him happy and more comfortable in his environment. While living at home he fulfills this desire by wearing his sister’s clothing when none of his family members are at home. In order to fulfill his desire to wear women’s clothing in public he wears one of his sister’s dresses to a Halloween party. After Glen moves from his family residence, he finds it easier to cross-dress. He purchases more clothing but still hides them in case his family was to visit. Living alone also provides more instances to cross-dress in public. He is happy being male and has no desire to change his sexual orientation. Since his engagement to Barbara he is experiencing stress brought on by his need to dress in women’s’ clothing and whether or not to disclose this information to Barbara or keep it a secret. He finds support from a close friend (who is also a transvestite) who encourages him to be forthcoming and not hide his secret.

Diagnosis
DSM-IV-TR criteria
A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
Glen did not meet criteria for Transvestic Fetishisim. He exhibits symptoms more associated with being a Transvestite or cross-dresser. He exhibited no recurrent, intense sexually arousing fantasies, sexual urges, or behaviors in addition to his cross-dressing.

B. The fantasies, sexual urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning. It involves using nonliving objects to obtain sexual arousal.
Glen’s cross-dressing created distress within himself and his relationship with Barbara. She began to see signs of difficulty or stress in Glen which create trust issue for her. Glen experiences extreme stress about the idea of telling Barbara and possible losing her because she could not understand his obsession.

Accuracy of Portrayal
Glen did not meet criteria for Transvestic Fetishisim. The movie portrayed an individual who did meet criteria for cross-dressing: A desired to wear clothing of the opposite gender in some instances to relieve stress brought about by daily encounters. The essential feature of Transvestic Fetishisim is defined as recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. Glen did not exhibit any sexual urges or sexual fantasies while engaging in cross-dressing. He expressed his desire to cross-dress was only for comfort and happiness within his environment. This movie did not address any of the aforementioned criteria in regards to Transvestic Fetishisim.

Treatment
There is no empirically supported treatment for Transvestic fetishism. Two types of therapy have been utilized in an effort to treat this disorder: aversion therapy, involving electrical shock and orgasmic reorientation, an attempt to help individuals learn to respond sexually to generally acceptable stimuli. Both of these treatments were developed when little was known about the disorder and when it was less accepted. Today there is less focus on treatment of the disorder and more encouragement for societal acceptance. In cases where individuals have come in for treatment it is mainly due to others, such as spouses and /or family members requesting they seek treatment. Prognosis for this disorder is poor due to the fact that most individuals with this disorder do not want to change. Treatment that is demanded by others such as one’s spouse or family members is almost always not successful.


Posttraumatic Stress Disorder

Name: Nick (Nicolas)

Source: The Deer Hunter (movie, 1976 )

Background Information
Nicolas (Nick) is a white male who seems to be in his late twenties. He lives in a small town where he has two long time friends, Michael and Steven. United States (U.S.) is still in war with Vietnam and Nick and his two friends plan to go to Vietnam War and protect their country but Steven is engaged and decides to get married before his departure to Vietnam. Nick and Michael go to Steven’s marriage ceremony and seem very happy and do not seem to have any physical or psychological complication; they dance, laugh, drink and enjoy the entire night. Nick’s behavior and attitude is normal and there are no observable sign of physical or mental illness associated with him. Michael is scared of going to Vietnam and very hopeless about returning back alive but Nick talks to Michael in several occasions and calms him down, promising that everything will be fine. Nick seems to be a very helpful individual in community as he lends a hand to people. Nick has a girl friend and would like to propose to her before going to Vietnam, so he proposes to his girlfriend at the end of the marriage ceremony and both decide to get married after Nick comes back from the War. After Nick’s plan for marriage, he also feels bad about going to Vietnam; he is emotionally connected to his fiancée and hard for him to leave. Before Nick and his friends depart to Vietnam, they decide to go for their last deer hunt, up in the mountains close to their town. “One shot” deer hunting is Michael’s favorite slang, meaning that he always wanted to catch a deer with only one shot. Michael successfully hunts a deer with only one shot and everybody enjoys the hunting that day. On the next day, they depart to Vietnam and face an unexpected battle with the Vietnamese army. It is not hard to see that they are all shocked in battle. Vietnamese soldiers attack them from all directions. After a couple of days, all three of them are taken captive in Vietnam. While captive, Nick, Michael and Steven are forced to play Russian roulette while their captors gambling on who will, or will not, blow out his brain. Russian roulette is a lethal game in which one bullet is placed in a revolver and participants (captives here) spin the cylinder, place the muzzle against their head and pull the trigger. This is a horrifying moment for Nick and his friends. Steven who is a newly married groom, shows extreme symptoms of stress and anxiety. Nick visibly disintegrates under the abuse and torture of their captors while Michael refuses to capitulate. Michael plans to free himself and his two other friends by requesting a three bullet Russian roulette game from his captors. He manages to kill the captors and runs away with Nick and Steven. An American helicopter shows up and transports Nick to army hospital, while Michael and Steven wait for the next helicopter.

Description of the Problem
While Nick is in the U.S. army hospital inside Vietnam, he displays mild symptoms of anxiety; insomnia, lack of appetite and anxiety, are among the major symptoms he displays. When a nurse comes and talks to him, he keeps staring at people who are brought to the hospital and does not talk to anyone. After about a month, he leaves the hospital and starts to have more severe symptoms of anger, especially when he is reminded of his time in Vietnam. He completely forgets that he has a fiancée or friends; he does not call his friends to see if they are still alive and seems detached from his social environment. He has a sense of a foreshortened future because he does not have a plan to go back home or do anything while he is in U.S. camp in Vietnam. Nick is very busy with his thoughts and does not communicate with his surroundings; social impairment is vivid at this point. He accidently visits a bar in that town where people gamble on playing Russian roulette. As soon as he enters the bar, he starts to have intrusive distressing recollections of the time when he was captive and forced to play this game. He experiences a high level of anxiety and anger. As he is watching a candidate place a revolver to his head, Nick grabs the revolver and passionately places it to his head and pulls the trigger. He disrupts the game and the gamblers kick him out, however on the next day as he is walking down a street, he reaches the same bar. He goes inside and sits in one of the empty seats designated for a Russian roulette player. Michael, who was more emotionally stable than Steven and Nick, shows only very mild symptoms of anxiety and goes back home. His friends and family welcome him but he goes back to Vietnam to bring Nick home. He meets Nick, however Nick does not show any emotion to him, so Michael tries to play Russian roulette with him in that bar to perhaps unfreeze Nick’s memory. Nick starts to communicate with Michael a little. However, Nick dies when he pulls the trigger in front of Michael.

Diagnosis
Based on the observed symptoms, the diagnosis for Nick fits well with Post-Traumatic Stress Disorder (309.81).

A. The person has been exposed to a traumatic event in which both of the following have been present:
1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
2. The person's response involved intense fear, helplessness, or horror
Nick’s symptoms certainly meet above characteristics as Nick experienced and witnessed an event in Vietnam which he was threatened to death (by the Russian roulette game). He has intense fear and feelings of hopelessness while being captive in Vietnam (Background information).
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. NOTE: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. NOTE: In children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). NOTE: In young children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Nick re-experienced very intense psychological distress when he observed people who were gambling on players (playing Russian roulette) in a bar. In there, he acted as if he was a captive in Vietnam and therefore took the gun from one of the players and after he pointed the gun toward his head, pulled the trigger. So he was exposed to external cues which symbolized an aspect of the traumatic event in Vietnam. Therefore he qualifies for more than one of above conditions (3, 4 and 5).

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
  1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
  2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
  3. Inability to recall an important aspect of the trauma
  4. Markedly diminished interest or participation in significant activities
  5. Feeling of detachment or estrangement from others
  6. Restricted range of affect (e.g., unable to have loving feelings)
  7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
As it was mentioned in the background information, Nick showed no interest in any activity or in friendships. He was certainly detached from his social environment and also had no feelings of love. When his friend Michael showed up to take Nick back home, Nick did not show any interest and was not passionate about his fiancé. Therefore, he met four of above conditions (4, 5, 6 and 7).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
  1. Difficulty falling or staying asleep
  2. Irritability or outbursts of anger
  3. Difficulty concentrating
  4. Hypervigilance
  5. Exaggerated startle response
Nick clearly shows outburst of anger in several scenes of the movie. He also had difficulty concentrating when his friend Michael tried to remind him of his fiancé and home. Unfortunately it was not shown in the movie whether Nick has difficulty sleeping. But his condition meets above criteria (2 and 3).

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
Nick had above symptoms for more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Nick’s symptoms reveal an intense social impairment as well impairment in his interpersonal relationship. Therefore his symptoms meet this criterion. Nick’s condition is a representation of an acute PTSD.
Accuracy of Portrayal
Nick’s symptoms were well demonstrated to portray Post Traumatic Stress Disorder (PTSD). Nick experienced intense and horrifying moments in Vietnam in which he was threatened with death through Russian roulette. He observed and watched other prisoners die. Therefore, the war portrayed an accurate condition which could be the cause of PTSD. However, this movie showed Nick revisit the bar (while he is suffering from PTSD) and playing Russian roulette over and over again. Although Nick showed intense anger toward this game, PTSD patients mostly avoid experiences that remind them of their stressful event. Therefore, this part of the movie does not accurately resemble the condition of a PTSD patient, while all other symptoms are well matched with PTSD. Overall, there was an accurate portrayal of a person’s descent into PTSD.

Treatment
PTSD is highly comorbid with other anxiety problems and as such it would be beneficial to control the anxiety before starting other treatments. Therefore the primary treatment action for Nick would be to start a low dosage of an anti anxiety medication such as escitalopram (Lexapro) after a full medical examination. Once pharmaceutical treatment begins, the next level of treatment for Nick would be Prolonged Exposure (PE) therapy. This therapy will help Nick to decrease distress about his trauma and approach trauma-related thoughts, feelings, and situations that he is avoiding due to the distress. In the first part of prolonged exposure therapy, Nick needs to be educated about his disorder and common trauma reactions. This would allow Nick to learn and become more familiar about his symptoms and better understand treatment goal and process. The second part of the treatment is to train Nick how to have long breath and relax. One of the symptoms of PTSD, especially in Nick’s case, is abnormal breathing habits when the patient is scared or anxious. This part of treatment will help Nick to overcome his distress by breathing differently. Real world exposure practice is the third part of this treatment in which Nick is exposed to Russian roulette game (without any bullets) over and over again. Such in vivo exposure helps Nick’s trauma related distress to lessen over time. In the last part of prolonged exposure therapy, therapist should talk to Nick while he is exposed to Russian roulette game. This helps to unfreeze Nick’s memory and to let him communicate about his experience and memories with therapist and not being afraid of his memories. Talking through the trauma can also help therapist to identify Nick’s negative thoughts about past event and help to modify his negative thoughts, allowing him to make sense of what happened and have fewer negative thoughts about the trauma. Family therapy is also recommended for Nick since he no longer seeks any friendship and does not have any emotions for his fiancée. Family therapy can help the Nick’s friends and fiancée understand what they are going through, and help them work through relationship.





Schizophrenia

Name: Nina Sayers

Source: Black Swan (movie, 2010)

Background Information
Nina Sayers is a Caucasian female who is presumed to be in her early to middle twenties, although her actual age is unknown. She currently works as a ballerina in a New York City ballet company whose name is undisclosed. Although there are not any known distinct physical illnesses, abnormalities, disorders, or disadvantages currently within Sayers, there are observable health concerns. The patient is visibly underweight and has serious cuts, bruises and other wounds on her feet, although both of these concerns can be attributed to her career as a dancer. However, there are also various lesions and abrasions throughout the surface of Sayers’ body which cannot be attributed to anything in her current daily environment. It is speculated that these lesions could be self-inflicted. Sayers currently lives by choice with her mother. Her mother, although not diagnosed, has observable generalized anxiety disorder symptoms, as well as some neurotic personality traits. It is also observed that the mother displays a very rich sense of control over Sayers’ life, such as her scheduling, room design, personal decisions, etc. Sayers appears to not have very many, if any, close friends or relatives outside of her mother. It is undisclosed whether or not Sayers has had any contact with her biological father. It is assumed that he does not actively participate in her life. Until recently, there was not any reported drug or alcohol history. However, as of late she has reported experimenting with ecstasy, a derivative of MDMA, as well as engaging in small amounts of social drinking. Her current goal is to become the principle dancer of her current ballet company. Most of her daily activities are related to improving her performance as a dancer.

Description of the Problem
Sayers currently displays a whole host of symptoms that could be indication of several disorders. The lesions and abrasions as aforementioned fit the description of self-mutilation; however, Sayers denies ever abusing herself, and frequently reports not knowing how the lesions and abrasions appeared on her body in the first place. Sayers often suffers from both visual and audio hallucinations. These hallucinations include items such as seeing feathers physically protrude from her skin, seeing and hearing paintings laughing at her, having conversations and encounters with people that never took place, and peeling off pieces of her own skin that are obviously still in tact, among many other hallucinations. She is also currently under some delusions as well. She believes that another one of her co-dancers is trying to take her starring role in the next upcoming production from her when there is not any evidence to support such a claim. She also believes that this co-dancer is sleeping with the program director, when there is no evidence to support this claim either. In general, Sayers is very convinced that various people are intentionally trying to take this acclaimed dancing role from her, or as she refers to it, her chance to be “perfect.”

Diagnosis
The diagnosis for Sayers that seems to fit appropriately is Schizophrenia, Paranoid Type (295.30).
  1. To be diagnosed with schizophrenia, two or more of the following characteristics must be present:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia, or avolition
Sayers definitely has both the first and second characteristics of delusions and hallucinations, as described in the section of “Description of the Problem.”
  1. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.
The delusions and hallucinations have made both Sayers’ work and personal life dysfunctional. She has been late for rehearsals and has caused a great amount of interpersonal disturbance amongst her coworkers.
  1. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromalor residual symptoms.
The hallucinations of skin peeling and the delusion of denial of having part of her own lesions and abrasions have been present with Sayers for the majority of her life. During the last one to two month period is when her visual and auditory hallucinations have become more frequent. It is also during the last one to two month period that the persecutory delusion of having her role taken from her has become prominent. It is unknown if she has suffered from other persecutory delusions previously.
  1. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
During observation, Sayers has not met any criteria that would indicate any of the mood disorders. Her persistent amount of dance practice may signify a possible manic episode, but since she has always spent a great deal of time practicing, it appears as if it is too consistent to be considered an episode, therefore disqualifying her from any mood disorders.
  1. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
As previously stated, there is not any known, distinct physical illnesses, abnormalities, disorders, or disadvantages currently within Sayers that would explain her schizophrenic symptoms. She did not have any drug history until recently, but her symptoms were present long before her intake of any substance.
  1. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month.
There is no history of either of the above listed disorders present in Sayers.
To fit the Diagnostic Criteria for 295.30 Paranoid Type, the following criteria are met:
  1. Preoccupation with one or more delusions or frequent auditory hallucinations.
Sayers is completely preoccupied by her persistent tactile, visual, and auditory hallucinations. She is also completely preoccupied with her delusion of someone trying to take her role from her.
  1. None of the following are prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
Sayers displays none of the above listed behaviors.
Accuracy of Portrayal
The average person watching this movie would see a reasonably accurate portrayal of the onset of Paranoid Schizophrenia, especially since Nina Sayers is in the perfect age range for onset, but not necessarily the daily experience after onset. Of course, the movie overdramatized a lot of the symptoms that the average schizophrenic would experience, but not to the point that the symptoms were so exaggerated that to make the case that she was schizophrenic was invalid if one were to make an assessment. In fact, this movie actually somewhat helps the portrayal of schizophrenia in the media, as many movies and television shows give examples of the symptoms of Dissociative Disorder as evidence of schizophrenia, which are totally inaccurate and confuse the audience as to what schizophrenia actually is. Although symptoms would not occur as rapidly as they do in Nina Sayers in most common cases of schizophrenia, it is plausible. Therefore, Black Swan is a decent portrayal of a person’s descent into paranoid schizophrenia.
Treatment
To treat Sayers, after a full medical examination, it would be best to immediately start her on a mid-level dosage of an anti-psychotic, such as Vesprin. Most people with schizophrenia respond very well to current medication in comparison to people with other Axis I disorders. After pharmaceutical treatment begins and an appropriate dosage has been stabilized, it would be best to start Sayers and her mother into family therapy, as to educate and help both of them find ways to cope with this disorder, and to help Sayers’ mother be more tolerant and understanding of Sayers’ symptoms. Social Skill training would also be beneficial to Sayers, because as previously stated, she has no close friends or any type of social support outside of her mother. Social Skill training would also help Sayers interact more efficiently with the other people who work at the dance company, lessening interpersonal disturbances caused by her disorder.


Pathological Gambling


Name: Geoffrey Chaucer (aka Chaucer)

Source: A Knight’s Tale (Movie, 2001)

Background Information
Geoffrey Chaucer is a male in his late 20’s to early 30’s. He is in good health and with no serious illnesses. We have no information from this movie about his past. This includes no information about his parents or where he is from. He announces that he is a writer for hire. He says that he has written a few poems and is known for his book “The Book of the Duchess”. During the time of the movie, he acts as a writer and a herald for William. He seems to have no social ties to his past other than the people who have collected his debts. During the movie, he does start to gain close relationships with the four people he is traveling and working with. There is no evidence that he has any other vices such as drinking or drug problems throughout the movie. He has difficulty dealing with his gambling urges and knowing when to stop.

Description of the Problem
Chaucer starts the story in a very depressed mood. He is first introduced to us while he walks completely naked down a trail. He comes upon a group of men along the road. He then lies about how he has lost all of his possessions. He says that he had been robbed in a sense rather than that he had lost of his possessions to his gambling problem. To get passage to the next city he blackmails the group. He blackmails them by uncovering that the group had lied about their identities and saw that they would need forged documents that he could provide if they gave him money. After forging the documents, Chaucer presented them for authentication and had them accepted. The group offers Chaucer the job of being a herald, which he accepts. At the same time, though, he is very preoccupied with watching people gambling along the alleyway. He then immediately cuts off is conversation with William to go and gamble. This leads him to be in the same position where we had first seen: naked and with a large gambling debt. When Chaucer is unable to pay for his debts, he calls on William to get him out of the bad situation. William is given the choice of paying off Chaucer’s debt or let his new friend pay for it from his hide. Chaucer admits after this that he has a problem with gambling.

Diagnosis
Based on the DSM-IV-TR criteria Chaucer fits at least eight of the ten maladaptive behaviors listed.
  • A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:
    • (1) is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)
When Chaucer is given a small amount of money he immediately see people gambling and is fixated his attention on them. He then says, “I must see a man about a dog” this is a cover up so that he can leave to go gamble the little cash that he had just received.
    • (2) needs to gamble with increasing amounts of money in order to achieve the desired excitement
    • (3) has repeated unsuccessful efforts to control, cut back, or stop gambling
Chaucer is found walking naked after losing all his possessions to gambling in the last town, he then gambles away what little money he was given in the next town.
    • (4) is restless or irritable when attempting to cut down or stop gambling
    • (5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
Chaucer is in a depressed state trudging (the slow, weary, depressing yet determined walk of a man) and then prays to his god to get him out of his tribulations. Then he gambles at the first opportunity to escape his current living style.
    • (6) after losing money gambling, often returns another day to get even ("chasing" one's losses)
He had lost everything but in the next town, he bet again to try to win what he lost earlier.
    • (7) lies to family members, therapist, or others to conceal the extent of involvement with gambling
Chaucer when asked if he had been robbed stated that he had taken an involuntary vow of poverty. This is rather than saying that he had lost all of it gambling.
    • (8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
Chaucer knowingly forges patents of nobility for the group to be able to compete in tournaments.
    • (9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
Chaucer was a herald and his gambling debt he pushed off on his newly found friends almost lost him this position and their friendship.
    • (10) relies on others to provide money to relieve a desperate financial situation caused by gambling
Chaucer loses all his positions again and tells the collectors that William can pay for his debt that he has made while gambling, later William does come and wipe out the debt.
  • B. The gambling behavior is not better accounted for by a manic episode.

Accuracy of Portrayal
The portrayal of Chaucer struggling with gambling is only a small side story. With that said, it is still easy to tell that he has a problem with his ability to control his Pathological Gambling. It is demonstrated how it is affecting him and his friends in negative ways. He even goes on later in the movie to admit to his friends that he does have a gambling problem. The only flaw in the accuracy of portrayal is that once he admits to the group that he has a problem it is never a problem again in the movie. Overall this is an accurate portrayal of Pathological Gambling

Treatment
The treatment for Chaucer’s Pathological Gambling is already taking place during the movie. He makes a great first step in admitting to his friends that he does have a problem and that he needed help. After his admission, he does not have any more problems with gambling. A long term goal would be to identify why he has the urge to gamble in the first place. That is because gambling is just the symptom of an underlining problem. I would look at handling his depression. His depression is seen only shortly but with the high comorbidity of pathological gambling and depression it is important to examine it. Aversion therapy can be used to treat his urges to gamble. This is done by putting him into a condition that he would usually gamble but also exposing him to something that would cause him discomfort. This is to learn self control and to overcome the illusion that they will win the next time. He should not gamble again for any reason. He should also look for support groups like Gamblers Anonymous to help him over his urges.




Delusional Disorder

Name: Marshal Edward “Teddy” Daniels (Andrew Laeddis)
Source: Shutter Island (movie, 2010)

Background Information
Marshal Teddy Daniels is a hard working investigator in his mid-thirties. He is a Caucasian male who seems to be highly intelligent and somewhat healthy. Teddy smokes several cigarettes a day and tends to abuse alcohol. He served in World War II and encountered many traumatic experiences at the Dachau Concentration Camp in Germany. Little is known about his family history or life situation when he was young. Teddy did, however, have a wife and three children and it is stated that his wife was emotionally unstable. Teddy is very goal orientated and spends many hours concentrating on work. His work ethic keeps him detached from family and friends. When he encounters conflict he becomes angry quickly, which interferes with his ability to control his temper. Teddy’s current investigation involves the disappearance of Rachel Solando from Ashecliffe Mental Institution, located on Shutter Island.

Description of the Problem
Edward (Teddy) Daniels claims to be an investigator at Ashecliffe Mental Institution located on Shutter Island. As Teddy enters the facility with his partner, Chuck, the patients doing yard work creepily smile and wave as if they know him. Teddy asks for records of every patient on the island and is denied. He does not understand why the officials will not hand over the documents because he is well respected military personnel on a mission to discover facts about the disappearance of Rachel Solando. Teddy becomes frustrated with the institution’s faculty and decides to end his mission.

A storm develops preventing Teddy to leave the island. During the storm he has delusions in which he believes patient number 67 is being kept a secret. The delusions convince him that the patient is Andrew Laeddis. He then ventures out to Ward C, which he has not been granted permission to investigate, in search of Laeddis. Upon entering Ward C, Teddy discovers George Noyce, a schizophrenic patient, who then informs Teddy about a conspiracy theory that the institution is performing lobotomies in the nearby lighthouse. Teddy begins having dreams of a little girl asking him to save her. His wife continues to appear in hallucinations, telling him that Laeddis is still in the institution and Teddy must find him and kill him.
After the storm, the institution provides Teddy with a set of dry clothes and a fresh pack of cigarettes. The clothes happen to be those that the patients wear. The lightning from the storm affects Teddy and he begins to experience migraines. The institution then provides him with headache medication. Shortly after waking up the next day he ventures out to the coast again in search for the lighthouse. Through the hallucination of meeting a former psychiatrist in a cave, he is convinced that the institution has drugged from through the pain medications and cigarettes, causing him to experience wild dreams, sleepless nights and migraines. He feels as though everyone in the institution is purposely attempting to keep him as a patient.
Teddy makes his way to the lighthouse, finding absolutely nothing unordinary. He finds his psychiatrist in a room at the top. He confronts the psychiatrist about the conspiracy theory and how he needs off of the island to report the institution to the government. The psychiatrist debriefs Teddy about his Delusional Disorder. The psychiatrist tells Teddy that he has been a patient for over two years. He explains to Teddy that he created fictional characters by using anagrams from his name, and the names of his loved ones. The psychiatrist informs Teddy that he murdered his wife after coming home to find his children floating in a pond. Teddy refuses to believe that he murdered his wife or that he had children. The psychiatrist persists in explaining that he had been trying a new type of therapy known as role-play therapy. The role-play therapy is used in hope for Teddy to realize on his own that he is Andrew Laeddis.

Teddy begins to have flash backs of the afternoon he came home and found his children dead. He realizes the little girl from his dreams is his daughter. He remembers that he killed his wife in the spring of 1952. He finally realizes that he is the lost patient, Andrew Laeddis. He realizes his partner, Chuck, is actually his specialty psychiatrist who had to be with him at all times because he is the most violent patient on Shutter Island. Teddy, now Andrew, is eligible to be released from Ashecliffe Mental Institution. He says to his specialty psychiatrist “What now? We need to find a way to get off of this island”. Teddy fakes a relapse because he did not want to go out into society and possibly hurt anyone else. The officers at the institution escort Teddy to have a lobotomy to “cure” his disorder.

Diagnosis
The diagnosis for Edward Daniels is Delusional Disorder, Mix Type (297.1)
  1. Non-Bizarre Delusions for at least one month.
    1. Teddy experiences non-bizarre delusions over the course of two years. The delusions are not due to Schizoaffective Disorder, nor Mood Disorder. He does not have an alcohol dependency nor is he chronically depressed.
  2. Criterion A for schizophrenia has never been met.
    1. Teddy does not show flat inappropriate affect. He is very sociable and his delusions are not bizarre.
  3. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
    1. Teddy is able to function normally. He is sociable and is able to properly communicate.
  4. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
    1. Teddy is generally in a good mood. He is not depressed or anxious. He is always looking forward to catching new hints about Rachel. He gets angry when people refuse to give him want he thinks he needs, such as case files for patients in the mental hospital.
  5. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
    1. Teddy does smoke and drink however; he does not have negative episodes which develop from the substance abuse, but not alcohol dependence. He takes medications which help his migraines to go away.
  6. Specify Type
    1. Mixed Type
i. Delusions characteristic of more than one type.
  1. Grandiose Type
    1. Delusions which are inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.
i. Teddy believes that he is a valued marshal with specialized privileges to the mental hospital. He feels that people should obey his requests.
  1. Persecutory Type
    1. Delusions that the person (or someone to whom the person is close) is being malevolently treated in some way.
i. Teddy feels that the employees of the mental institution are trying to commit him at a patient. He feels that they are controlling him by giving him special medications other than simple pain killers. Teddy is also convinced that the cigarettes the institution provides are laced with drugs to cause him to become powerless

Accuracy of Portrayal
The portrayal of Delusional Disorder was accurate throughout the film. It was not apparent until the end of the film that he was suffering from a disorder, and not an actual investigator. The delusions were believable to those who do not have a complete understanding of psychology and psychotic disorders.

Treatment
The treatment psychiatrist used in the film was ultimately performing the lobotomy. Lobotomies were accepted in the fifties as reasonable treatments for psychotic disorders. In current treatment procedures lobotomies are unethical. The lobotomy procedure is the use of an ice pick type probe which is inserted through the eye in order to dismantle the brain. This develops a calming effect on the patient.

Recent treatment used for Delusional Disorder would include both medications and psychotherapy. Medicinal treatments may involve anti-psychotics and antidepressants such as SSRI and Clomipramine. Psychotherapy treatments involve supportive therapy and cognitive therapy. The treatment used for patients must be individualized. The treatment for Andrew Laeddis should consist of cognitive therapy combined with medication.






Anorexia Nervosa


Name: Trevor Reznik

Source: The Machinist (movie, 2004)

Background Information
Trevor Renik is a middle aged male of Euro-Asian decent. Trevor is a blue-collar worker. Trevor works for a company, National Machine, as a welder. Trevor’s work environment is not a positive or friendly one. Trevor’s age and family history are not known through the film. Trevor Reznik is not a healthy individual: he smokes cigarettes, he does not sleep, he does not eat at all, and consumes large amount of caffeine. Trevor states he does not drink frequently, but is seen drinking throughout the film. Trevor is not seen eating once throughout the film, nor does he engage in any physical exercise.

Trevor is socially withdrawn and does not have any close friends or family members. The interactions with women in the beginning of the film indicate that Trevor is lonely. Trevor’s interactions with women show he does not have healthy relationships with women. One is with a prostitute, Stevie, whom he is a patron of throughout the film. Another woman is a waitress, Maria, whom Trevor believes he interacts with, but is actually one of Trevor’s hallucinations. Realistically, Trevor never interacted with his waitress, whom was unrecognizable to Trevor when he is not hallucinating. Trevor’s work environment is a constant stressor. Trevor’s boss informs Trevor he “is on his shit list”. Trevor is confronted by his bosses and asked for a Urinary Analysis because they believe he “looks like shit” thus he must be on drugs. Co-workers invite him to play poker and Trevor declines, upon doing so a co-worker responds “What’s wrong with you, you used to be alright” while another co-worker says “You were never alright, but you used to hang”. Trevor creates a hazardous situation at work while in an induced fatigue hallucination resulting in a co-worker losing his hand due to Trevor’s actions. Trevor’s co-workers are hostile and aggressive towards him after the work-related accident, thus Trevor experiences persecutory delusions and referential delusions. Trevor experiences many life-stressors throughout the film such as injuring others, himself, losing his job, losing relationships, and legal issues.

Trevor is consumed by his own delusions and hallucinations, which are induced from a hit-and-run. Trevor allows his memory to torment himself and has poor coping skills. Trevor’s coping technique of thought repression to handle the hit-and-run make him feel enormous amounts of guilt. The implicit guilt Trevor experiences is explicitly seen throughout the film by his sticky notes in his home. Trevor’s hit-and-run provoked the negative image of self to control all aspects of his life. Trevor has no desired goals or outcomes from his life, except to answer sticky notes he leaves himself. “Who are you?” is a sticky note Trevor leaves himself to remind him to seek for whom he really is. Trevor’s weaknesses are his inability to interact socially and distinguish what is actually reality. Trevor is paranoid from his hallucinations and delusions and he frequently feels as if people are following him. Trevor thoughtfully analyzes situations to “expose” plots against him, while doing so he throws himself in front of a moving car in order to get information from the police. Upon doing so, the police inform him he is committing a felony and so he runs through underground tunnels to evade pursuit. Trevor finally realizes who he is by the end of the film: he is an individual that killed a little boy by committing a hit-and-run. After realizing who he is, a “killer”, Trevor turns himself into the police for the hit-and-run. The individual who he hallucinated throughout the film was himself as Ivan and Maria, the victim’s mother. Trevor is able to sleep once he turns himself into the police.

Description of the Problem
The opening scene is Trevor standing in front of a mirror looking at his self then replies, “shit”, in disgust while looking at his reflection. Trevor holds a negative image of himself. In this scene, Trevor’s shirt is off and his underweight body is revealed. Trevor displays physical symptoms of Anorexia Nervosa such as his body weight, sunken eyes, and puffy cheeks.

Individuals who interact with an individual suffering from Anorexia Nervosa display concern for their health. This is displayed as Trevor is asked “Are you alright?” throughout the film, indicating others do not perceive him as being in an okay state. Others ask Trevor if he uses drugs throughout the film. The prostitute and waitress try to feed Trevor food in many scenes. The women say, “If you were any thinner, you wouldn’t exist”.

Trevor’s actions of not eating and properly nourishing his body are common for individuals suffering from Anorexia Nervosa, specifically the restrictive type. Trevor orders pie at a diner he goes to but he is never seen eating the pie. Fatigue is a common sign of Anorexia Nervosa due to malnourishment. Trevor reports to always be tired, cannot sleep, nor has slept in the past year. Trevor’s sexual relations are not atypical of one with Anorexia Nervosa since he is the prostitute’s “best costumer”.

Trevor socially withdraws, which is a symptom associated with Anorexia Nervosa. Trevor loses touch with reality and those whom interact with him call him crazy and psycho. The persecutory delusions and referential delusions may be a side effect from long-term malnutrition and dehydration. Trevor believes his coworkers are plotting against him and ends up losing his job when he behaves erratically by physically attacking his co-workers. The physical attack results in Trevor becoming short in breath, another common symptom displayed with the disorder.

Diagnosis

One possible diagnosis for Trevor Reznik from the DSM IV-TR would be Anorexia Nervosa, Restrictive Type, (307.1). Trevor experiences many social and economical stressors as well, including a hostile work environment, negative co-worker interactions, social interaction non-existent, job loss, committing a hit-and-run, and a loss of relationships.

Criterion that are met for Anorexia Nervosa include:

A. Refusal to maintain body weight at or above a minimally normal weight for age and height.

Trevor was substantially under 85% of the body weight he should have maintained.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight.

Trevor was disturbed by his body image as indicated with his response to his reflection. Trevor denied the seriousness of his underweight body. He does not seem aware of his diet, weight, or health thus, in denial of his personal health.

Difficulties diagnosing Trevor Reznik include: lack of knowledge about family history, lack of personal history, lack of medical history, and lack of self-report from him.

Accuracy of Portrayal
Trevor Reznik’s suffering from Anorexia Nervosa is not very apparent due to his inattentiveness about his body weight. Therefore, Anorexia Nervosa may be mislabeled in this film. Trevor never explicitly states or indicates he has a fear of gaining weight, which is typical for those whom suffer from Anorexia Nervosa. Trevor’s lack of concern with his body weight is not an accurate portrayal of an individual who suffers from Anorexia Nervosa.

If an individual watching the film knows what signs and symptoms to be aware of when assessing an individual who suffers from Anorexia Nervosa, then they may be able to diagnose Trevor Reznik as having the disorder. An individual who is aware of common symptoms and signs of Anorexia Nervosa may be able to decipher Trevor’s disorder as an accurate portrayal. A stressor, murdering a little boy, may have been the on-set for Anorexia Nervosa and, as such, the film does accurately depict the course typical of individuals with Anorexia Nervosa. This includes Trevor not eating, acknowledging his poor health, and holding a negative image of self. Trevor never ate food during the film. Trevor’s physical symptoms were very apparent but others in the film attributed this to drug use. Trevor’s fatigue, delusions, and hallucinations may be symptoms due to severe malnourishment and dehydration. Individuals who watch the film would be able to understand how one who suffers from Anorexia Nervosa lives with constant paranoia of his self-image and induced on-set of Anorexia Nervosa that may have caused the delusions and hallucinations from inadequate diet. The film is accurate because people suffering from Anorexia Nervosa do not acknowledge the pervasiveness of their disorder. Trevor never acknowledges that his poor health is due to his lifestyle.

Treatment
Treating Trevor Reznik would require him to acknowledge having the disorder, Anorexia Nervosa. The patient’s willingness and acceptance of the disorder are essential for treatment to a progressive lifestyle to changing behavior. Treatment would focus on two main goals: 1) Trevor must gain weight and nourish his body with an adequate diet and 2) address Trevor’s psychological and environmental stressors. An empirically supported treatment widely used is family and group therapy. Trevor lacks a support system such as family and friends who are usually the people who initiated treatment for individuals suffering from the disorder. Typically, family and friends monitor diet and exercise for individuals suffering from Anorexia Nervosa. The lack of a social support Trevor receives makes treatment difficult. Trevor would have more success in self-help groups since he lacks a family for family therapy. The self-help group meetings would allow Trevor the opportunity to interact with others suffering from Anorexia Nervosa. The self-help group meetings would enlighten Trevor about Anorexia Nervosa tremendously. In order for self-help treatments to be successful Trevor must attend the meetings regularly and change his behavior through the acquisition of new knowledge. The self-help groups may be the social support Trevor needs to overcome Anorexia Nervosa. Trevor must change his attitude, behaviors, diet, and physically exercise to live a healthy lifestyle. If Trevor avoids situations and environments that are mental triggers for his disorder he will overcome the disorder with successful treatment. Trevor’s successful treatment seems unlikely and he seems vulnerable to enduring a chronic episode that will ultimately end in his body’s expiration.




Cyclothymic Disorder


Name: Dolores Price

Source: She’s Come Undone, (book by Wally Lamb, 1992)

Background Information
The book follows Dolores through childhood, adolescence, and young adulthood. Dolores Price begins as a young girl growing up in New England. After her father leaves her and her mother, they move in with her uptight grandmother. Her mother experiences a nervous breakdown and is sent off to a mental hospital. Dolores claims it’s her “nerves.” Her grandmother represses everything and has difficulty speaking of her mother’s mental issues. At the age of 13, Dolores is raped by her grandmother’s upstairs tenant. Following the rape, Dolores’ mother constantly gives her food. Throughout adolescence, Dolores continually gains weight until she weighs 257 pounds at age 18. She attempts to go to college, but ends up leaving and goes to Cape Cod to attempt suicide. After a failed attempt at drowning, she ends up in a private mental institution where she undergoes immense amounts of psychoanalytic therapy. Once released, she goes to Maine and gets a job as a grocery clerk. Now, as an adult, she marries an abusive and manipulative man. She does nothing to anger him until her grandmother’s death. Because of his aversion to children, she has an abortion for him. Throughout her entire life, Dolores has issues with relationships. She had one close friend in childhood but never made many more in adolescence. Due to her weight and the rape, she kept to herself in high school. In college, she works tirelessly to please her roommate and the other girls she is around. She does the same with her husband, Dante. Her main goal is to please others around her to achieve approval. She is short and rebellious with her mother and her grandmother. She experiments with marijuana a few times but never uses any drug heavily. She drinks occasionally, but again never heavily. She has no real goals. She strives to be loved but gives up on it easily when it fails her. She strives to gain power over others at times but also gives up on that. Towards the end of the story, she simply wants a child, after obsessing over her abortion. It is incredibly hard for her to handle sexual relationships after the rape and only enjoys it sometimes with Dante. She cannot handle rejection or abandonment. The only coping skill she really has is eating, and it causes her just as much pain as the issue she aims to avoid.

Description of the Problem
Dolores’ weight gain stemmed from her traumatic rape. This unnecessary weight causes her to feel extraordinarily inferior to others around her. She goes through periods of depression, believing she has harmed everyone around her. She then goes through periods of what she describes as “power.” She spews vicious sarcasm at those around her and is, at times, cruel. After a lesbian encounter in college, she kills the woman’s goldfish to prove she has control. She enjoys leaving her therapist upon her release from therapy. She waves the fact that a psychic has given her more help in front of his face in order to anger him. In Maine, she feels accomplished often. During these times, her job performance improves, her sexual life increases, and she cleans and cooks every day for her husband. Her depression and “power” continue after therapy. If Dante is unhappy, Dolores is unhappy. She feels useless, especially when she angers him. After her grandmother’s death, Dolores leaves Dante and again becomes depressed. She says she wishes she could hold on to the power and go back in time to fix what she did to others. Dolores describes her life in sections. Her parents’ divorce is one section, the rape is another section, her adolescence is one section, her college life is a section, her therapy is a section, and her adult life is a section. Throughout each section, she develops an obsession with whales. She describes a parallel between herself and whales. She craves their power and feels their hopelessness when they wash up on the beach.

Diagnosis
The diagnosis that seems most appropriate for Dolores Price is Cyclothymic Disorder (301.13).
Diagnostic criteria:
A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note; in children and adolescents, the duration must be at least 1 year.

Dolores’ times of “power” contain within them hypomanic symptoms such as excessive involvement in pleasurable, yet possibly dangerous, activities. This is manifested through her increased sex drive and sexual activity with Dante the first night they met, her increased interest in sex throughout certain times in her life, and her lesbian experience with her dorm’s maid. She has elevated mood and feels control over others around her. She is grandiose and believes that she will succeed in imagining her life with Dante, who is clearly abusive and unfaithful. She also exhibits grandiosity in her correspondence with her college roommate prior to moving in. She makes up stories and a completely different life in order to create a good image. She becomes highly distracted during her stay in the halfway house with an etch-a-sketch. She spends hours recreating artistic masterpieces on multiple etch-a-sketches and tunes out the rest of the world. Dolores also exhibits depressive symptoms at many times. She exhibits weight gain, not only in adolescence but later in her adult life after she moves back into her old house. She tries once to cut herself but is taken aback by the blood. She expresses feelings of inferiority and worthlessness and tries to stifle them with food. In her marriage, she is depressed when Dante is not happy. This drives her to an abortion. Even during the course of her heavy psychoanalytic therapy, she swings between depression and power. At times, she hates her therapist and wishes she could leave. At other times, she idolizes him and imagines sexual activity with him.

B. During the above 2 year period (1 year in children and adolescents), the person has not been without the symptoms in Criteria A for more than 2 months at a time

There is never a time in Dolores’ life where she does not experience any of these symptoms. Even after therapy she still experiences hypomania and depression.

C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.

Although at one point Dolores contemplates committing suicide, she does so because she wants to feel united with the dying whales at Cape Cod. She does not sincerely want to die, she just wants to feel one in the same with something else. Her plan is disorganized and incomplete. She also never reaches full mania.

D. The symptoms in Criteria A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Dolores exhibits no psychotic symptoms. She possesses no firmly held delusions.

E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug abuse, a medication) or a general medical conditioned (e.g. hyperthyroidism).

Her weight gain stems from her own belief in herself, not a medical condition. While she experiments with alcohol and marijuana, she has no history of substance abuse or dependence.

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Dolores fails at almost all of her relationships. She has no friends in high school and her only friend in college was the dorm’s maid. Her marriage is unsuccessful and she fails to relate to grandmother her whole life. She does not care about school so she fails in high school and drops out in college. She only manages to succeed at a job when she is in control, or in power. After she moves back to Easterly, her jobs are menial and she only works when she is experiencing hypomania.

Accuracy of Portrayal
Dolores is not a likable character by any means. She is unsympathetic, hard to relate to, and it is almost impossible to feel bad for her. She manages to ruin her relationships all on her own and she takes tragedy to an extreme. The book demonstrates the difficulty that may be faced by others who have relationships with cyclothymic individuals. It also demonstrates the impacts a mood disorder can have on every aspect of one’s life. It is accurate in its depiction of the feelings that accompany cyclothymia, describing hypomania as “power” and depression as “oppressive.” Dolores’ mother may also have bipolar disorder, reflecting the possibility that bipolar disorder may be more common in first degree relatives. There are some inaccuracies, though. The therapy that Dolores undergoes is inaccurate. Her therapy is very psychoanalytic in nature, focusing on her mentally unstable mother and sex. Her therapist even goes as far as to pretend to be her mother. Her treatment is also only slightly effective and she still experiences cycles as she gets older. The book does not do much to describe any sort of mental disorder. Instead, it paints a picture of a woman who has lived a miserable life, caused mainly by her own hands.

Treatment
The first treatment that should be implemented for Dolores is a lifestyle change. Her extremely sedentary lifestyle would benefit from exercise and diet, which could help stabilize mood. This would have to be highly regulated in order for her to follow it and actually make the changes. Following the implementation of exercise, cognitive therapy should be used. Cognitive behavioral therapy, interpersonal therapy, or group therapy could be utilized. Due to Dolores’ inability to relate well with others, cognitive behavioral therapy should be used. If therapy is ineffective, medication could be used, but only as a last result due to the health problems Dolores already has due to her weight.