Case 1
A mother brought her 17 year old daughter into treatment because the daughter seemed to be totally dependent on a boy who treated her very badly. The adolescent met this boy via the internet the year before and after only a short time, she wanted to move in with him (he lived 220 km away from her). Surprisingly the mother agreed to this plan, but the problem of changing to another school stopped the decision.
In the first meeting I saw a shy, quiet, mousy adolescent. She reported that she always was shy, didn’t like to speak in front of many people (e.g. in front of the class) and blushed. She was afraid of many people and preferred to be alone. On the other hand she reported she was absolutely dependent on other people and did not have the heart to do things alone. She described her relationship with her boy-friend as submissive (“humbleness for love”). On one hand she wanted him to be very near, and on the other hand she felt very scared about this nearness. She said she wanted him to be “part of me” and called him up to 20 times a day, not understanding how much she annoyed him, even when he threatened to leave her if she would not stop. When she could reach neither him nor her mother, she developed panic attacks and experienced dissociation and derealization.
She was not able to describe herself in an adequate way, using short and unelaborated descriptors (e.g. “I am shy, I need my boyfriend, I go to school”), had no coherent picture of herself (e.g. “I have no idea who I am”, “I only go to school and wait for the next day”), showed a lack of coherence (i.e. no capacity to be alone, suggestibility, no differentiation from others without feeling alone e.g. “I only want to be near my boy-friend or my mother”) and lack of continuity (i.e. no idea of the future and little connection to her past).
Her father was unknown; her mother was from the former German Democratic Republic (GDR, former communist part of Germany). The mother reported a childhood history in which she was separated very early from her own mother (after 3 weeks in a day nursery), leaving her feel insecure about “how to be a mother” herself. She was often beaten by her father and not protected by her mother “who had no empathy”. Despite the father’s abuse, she reported “The relation to my father was even better than to my mother, to her I didn’t even have one”.
Between 12 and 14 years of age, a teacher sexually abused the mother. After she confided in someone it became a scandal, because this teacher was a very high positioned officer in the “Stasi” (secret service of the GDR) and it became a big disadvantage to the family. In 1998, shortly before the fall of the wall in Berlin, they left the GDR.
The mother met the father of her daughter in Western Germany. He had a conduct disorder, so she left him early after the childbirth and brought up her daughter alone. She reported that in the first years she constantly thought about giving her daughter up for adoption because “I wanted to spare her my life of suffering”. She could not remember where her child was when she was hospitalised. Her daughter was placed in foster care at the age of 7 due to the multiple psychiatric inpatient treatments.
In the reality context of multiple separations from her mother, the daughter said she was extremely scared that the mother would give her away forever and when she was returned to the mother, she did everything to avoid this (i.e. was very quiet, honest, well-behaved and easy-going). This contributed to the history of separation anxiety since childhood, as she always was afraid that the mother would give her away. She gave the example; “I was always picked up last from kindergarten and was always afraid that she will not come”. When her mother brought her to foster care she thought it was a punishment and wondered about what she had done wrong.
She reported a suicide attempt 2 years prior to this consult. This was after a history of suicidal ideation since primary school, when she left little notes all over the flat in which she wrote, “I do not want to live anymore”. (The mother confirmed she had found those notes from her young daughter, but that she didn’t know how to react and therefore she did not react at all). The daughter described herself as, “I think that I already was a sad baby”. She reported 3 previous psychotherapeutic treatments, which she dropped out of, and a trial of medication (SSRI) without any improvement.
Discussion of case 1
The adolescent described above has severe problems in self and interpersonal functioning. Her description of herself is superficial, vague and unelaborated (“I am shy, I need my boyfriend, I go to school”) despite her intelligence (IQ 120). She shows severe depressive symptoms and separation anxiety from childhood until the present. She reports dissociative symptoms (“I cannot feel my body anymore”, “I see myself from the outside, like in a movie”). The adolescent has a very unstable and incoherent picture of herself (“I have no idea who I am”, “I only go to school and wait for the next day”), her identity is severely disturbed (no capacity to be alone, suggestible, no differentiation from others without feeling alone, self- description is empty and only related to what her boyfriend or mother does, no perspective). Her interpersonal relationship is only to stabilize her feelings of deep loneliness; it is exchangeable (it doesn’t matter if it is the mother or boyfriend who is present, the main thing is that a person is available). She does not enjoy intimacy with her boy-friend, and the relationship has a sado-masochistic tone (“humbleness for love”). She has no idea of the impact of her behavior on her boyfriend, who is extremely annoyed by her constant calls (no empathy).
Psychosocial background of case 1
There was a severe and chronic disruption of the relationship with the mother that interfered with bonding (during the first years the mother wanted to give her up for adoption). The mother herself suffered from severe psychiatric problems, as well as physical and sexual abuse in her childhood. The daughter experienced repeated and long lasting separations from her mother in early childhood (while the mother did not even remember where her child was when she was hospitalized) (Table
2).
Table 2
Summary: DSM-5 classification of case 1
Level of impairment in self and interpersonal functioning (0=not disturbed; 4=extremely disturbed) |
Levels of personality functioning scale
|
- Identity: 4 | - Empathy: 4 |
- Self-direction: 3 | - Intimacy: 3 |
Personality disorder type
|
Personality disorder-trait specified
|
Trait domains (0=not disturbed; 3=extremely disturbed) | Negative affectivity: 3 | Detachment: 0 |
Antagonism: 0 | Psychoticism: 0 |
Disinhibition: 0 | |
Trait facets (0=not disturbed; 3=extremely disturbed) |
Facets of the trait domain “Negative affectivity”
|
Emotional lability: 1 | Anxiousness: 3 |
Separation insecurity: 3 | Perseveration: 3 |
Submissiveness: 3 | Hostility: 0 |
| Depressivity: 3 | Suspiciousness: 2 |
Case 2
Patient is a 15 year old boy who was brought to treatment by his parents because of “laziness” regarding school work, “disobedience” within the home (e.g. not following the rules regarding his diet, exercise or TV/Video game time), as well as lying (e.g. about homework completion, food eaten, TV/Video time, but also money missing), conflicts with siblings (e.g. envy at perceived favoritism resulting in dismissive, critical or aggressive verbiage), mood (e.g. oscillations from irritability or sadness, to elation or excitement), and long standing attentional problems (e.g. distractibility or perseveration). He was easily hurt by the perceived criticisms of others, had difficulties in social skills evidenced in a limited number of friends, few invitations to other children’s parties, and being a target for bullying. However, with little awareness of the hurt, he responded to perceived attacks with arrogance and devaluation of others. His teachers also reported that his arrogant and prideful behavior provoked his peers.
He was originally brought for consultation at age 9 for inattention, distractibility and difficulties completing tasks in school. At this time, it was also reported that he had an “obsession” with food and eating. For example, prior to going to an event he would ask (with an anxious tone and need for reassurance) what food would be available there. He presented with a low activity level (parents described this as his having an “engine on idle”) and resistant to almost any change. Parents and he would engage in “negotiations” to do or change things. He had pronounced self-esteem issues, constantly putting himself down and berating himself for poor performance in school (e.g. even when he received a 97% on a spelling test). Psychological testing indicated an intelligent boy, with reading and decoding skills in the superior range, but with a weakness in writing, attention, and executive functioning. The parents sought treatment with a psychiatrist for the attentional problems and school difficulties. He was treated with 54 mg Methylphenidate and had regular therapy sessions, until he “stopped talking”. He was then brought to a Social Skills group, but no improvement was observed.
Parents return for this evaluation, reporting he “is showing a complete and total lack of motivation” by not doing his homework, not studying, lying about it, etc. The parents are frustrated as “he claims to have goals but won’t do anything to achieve them”. The mother reports she has “had enough”, is hopeless that things can change, and has “no more energy” to invest in helping him. The father “has not given up” and is trying to fill in the “extra attention” that mom is not providing, but then feels resentful of the mom and the son. School performance is significantly impaired and the family tensions are very high, with constant arguments between him and his parents, and tensions with the two younger siblings who compete for parent’s attention. Although objectively, he received a lot of attention, he had no feeling of gratefulness because he was convinced that everything was due him (entitlement). When asked about the impact on his siblings, he was dismissive of their concerns and spoke in a callous way.
There is a family history of mood disorder, attentional problems, and Obsessive Compulsive disorder on both sides.
The son presents appearing younger than his age, overweight, with the look of “baby fat”. He does not understand that his parents are concerned about him and want to help him. Instead, he described their hopelessness that things can change with bitter contempt and sarcasm. His report minimizes the consequences of his poor school performance and he is convinced that he can succeed. He says he understands what he has to do to perform the tasks and achieve the goals, but is not willing to sustain or take productive action. He says he “just hates school”, and explains his lack of motivation because “school is of no use to him”. When questioned “how” he thinks he can succeed, he explains that his father will call the school and talk with the teachers to get extensions or reductions in the work. He sees no contradiction between his insistence he can do the work while having no sense of having to invest in his own actions, and his simultaneous reliance on his father to negotiate less work for him. The poor self-esteem is defended against by grandiosity regarding his abilities, while at the same time he relies on others for help. His descriptions of important others was affected by obvious envy, which he however in reverse described as their envy of him.
Taken together this indicates a lack of “integrity of self-concept” defined in the DSM-5 Levels of Personality Functioning as “Regulation of self-esteem and self-respect; sense of autonomous agency; accuracy of self-appraisal; quality of self-representation” [
34].
At home, he reports daily conflicts with both parents, but particularly the mother, who chastises his food choices. He hoards food, sneaks it into his room, leaves the empty containers in his room and then denies having eaten the food (despite the evidence in plain view). Food is often used to bribe him to participate or complete activities that the parents require (e.g. school work, going to the tutor, etc.). The pattern of negotiating and demanding as well as taking action only toward his immediate goal (contrary to expected) and then lying or denying this, are now chronic and pervasive, characteristic of manipulativeness and deceitfulness (aspects of “antagonism”) His behavior is singularly motivated and he is unable to integrate this into the expectations of others or his own long-term goals indicative of problems in “Self-directedness” as well as difficulties in the “Interpersonal” realm, especially with respect to “Empathy” or “Intimacy and cooperativeness” [
34].
His self-description demonstrates a lack of “identity integration” [
34,
37], when he speaks in vague and impressionistic terms, oscillating between grandiose statements of his intellectual capacities and plans to go to an Ivy League college, and self-deprecating statements of inferiority, inability to perform or complete tasks well. This also illustrates his inability to make links between his past, the present and his future, speaking in a disconnected way. When he describes his difficulties with his weight, he focuses not on the problem of his overeating and poor food choice (a real health concern as he has been medically diagnosed as pre-diabetic), but on how his parents “hide” the snack food, and “won’t let him” eat Chinese food. He emphases how “mean” his parents are because they force him to run on the tread mill while he watches TV, instead of just being able to “relax”. He distorts the reality in the service of feeling like the victim, without recognizing the reality of his own behavior (lack of self-control and motivation) that had provoked the parent’s “incentives” program. This view indicates a problem in the “Complexity and integration of representations” of others [
34].
When asked to describe a friend, he hesitates, unable to think of a person to describe. When pushed, he identifies one boy, younger than himself, who he plays video games with online. There is no depth to the description, “He plays games with me”, and no indication of the relationship as being anything other than of convenience (he belongs to their community group and the parents are friends). He also described preferring to spend time with adults, as “they like me better”. He reported difficulty in making or keeping friends as a result of how they just see “how special” he is and were envious of him and aspire to be like him.
Discussion of case 2
This adolescent presents criteria for a narcissistic PD, reacting to criticism with anger and shame, imaging unrealistic fantasies of success, power and intelligence and in setting unrealistic goals. He appears unemotional and requires constant attention from his parents and teachers without any empathy regarding their feelings. He is obsessed with himself, easily hurt and becomes jealous easily. Due to this, it is impossible for him to keep healthy relationships to his parents, peers or even siblings. In addition to these presenting difficulties, initial testing showed weakness in executive functioning and difficulty in integration of affect. These processing weaknesses are associated with problems in regulatory aspects of personality functioning [
38]. Despite treatment for the attentional and social difficulties with standard psychopharmacotherapy and behavioral social skills training, these regulatory and organizational processes which are related to personality, showed a decline over the 6 years as observed in the current significant functional difficulties in school, family and with peers. Additional issues within the family, the conflict between mom and dad over the image of the child (e.g. his physical image, weight especially), the shifting attribution of “blame” and “responsibility”, and the maintenance of the “negotiating” strategy of regulating action compound the difficulties of this boy. As can be seen in the clinical description, this boy has significant impairments in the areas of self (problems in identity integration, integrity of self-concept and self-directedness) and interpersonal (problems in empathy, intimacy and cooperativeness, and a lack of complexity and integration of representations of others). His difficulties indicate a need for a specialized treatment that focuses on development of identity integration and differentiation (clarifying the interaction between himself and his family) (Table
3).
Table 3
Summary: DSM-5 classification of case 2
Level of impairment in self and interpersonal functioning (0=not disturbed; 4=extremely disturbed) |
Levels of personality functioning scale
|
- Identity: 4 | - Empathy: 3 |
- Self-direction: 3 | - Intimacy: 4 |
Personality disorder type
|
Narcissistic personality disorder
|
Trait domains (0=not disturbed; 3=extremely disturbed) | Negative affectivity: 3 | Detachment: 2 |
Antagonism: 3 | Psychoticism: 0 |
Disinhibition: 2 | |
Trait facets (0=not disturbed; 3=extremely disturbed) |
Facets of the trait domain “Negative affectivity”
|
Emotional lability: 2 | Anxiousness: 1 |
Separation insecurity: 0 | Perseveration: 3 |
Submissiveness: 1 | Hostility: 3 |
Depressivity: 3 | Suspiciousness: 2 |
Facets of the trait domain “Detachment”
|
Restricted affectivity: 2 | Withdrawal: 3 |
Intimacy avoidance: 3 | Anhedonia: 2 |
Facets of the trait domain “Antagonism”
|
Manipulativeness: 3 | Deceitfulness: 3 |
Grandiosity: 3 | Attention Seeking: 2 |
Callousness: 0 | |
Facets of the train domain “Disinhibition/compulsivity”
|
Irresponsibility: 3 | Impulsivity: 3 |
Distractability: 3 | Risk Taking: 1 |
| Rigid perfectionism: 0 | |