Jane Appears to Be Suffering From Dissociative

Jane appears to be suffering from dissociative identity disorder based on the first three diagnostic criteria for this condition (American Psychiatric Association [APA], 2000). A person with dissociative identity disorder maintains multiple mutually-exclusive personalities in order to distance themselves from past traumatic events. Her behavior when interacting with the therapist suggests that she experienced at least two distinct personalities (criterion A) that recurrently appeared (criterion B) and had mutually-exclusive psychological experiences (criterion C). Jane's self-reported history of sexual assault and exposure to violence is consistent with this diagnosis, and could be contributing to her depressive symptoms. The attention deficit hyperactivity disorder (ADHD) diagnosis could in fact be a sign that Jane also suffers from borderline personality disorder, since impulsivity is included as a relevant symptom. ADHD is commonly diagnosed in children and involves severe focusing problems, impulsivity, and an inability to be calm. Borderline personality disorder represents a condition of significant social impairments, including an inability to form lasting, intimate relationships with others that are not primarily co-dependent.

Treatment would begin by validating the diagnosis. This can be accomplished by assessing Jane's susceptibility to being hypnotized, degree of dissociation, medical history, evidence of self-inflicted injury, evidence of physical assault, substance abuse history, and family history of mental illness (APA, 2000). If the diagnosis is validated then the primary focus of treatment would be integrating the different personalities as much as possible through psychotherapy (International Society for the Study of Dissociation, 2005). Psychotherapy involves the patient meeting periodically with a clinically-trained social worker or psychologist to discuss and work through behavioral and cognitive problems. Other treatment concerns include stabilizing the patient in a safe environment and possibly treating the symptoms of major depressive disorder with antidepressant medications. Major depression is a condition involving melancholy, apathy, and an inability to enjoy life. Contemporary antidepressant medications act by increasing the effective serotonin levels in the brain to improve mood.

Tom

The first "great mood" that Tom experienced fit the diagnostic criteria for a manic episode, consistent with a diagnosis of mania (APA, 2000). The first manic episode lasted for about four weeks, which exceeded the minimum requirement of one week without hospitalization (criterion A). His claims that he feels invincible and can do anything is consistent with an inflated self-esteem and grandiose feelings, which is one of the three elements needed to meet criterion B. The other two elements that help meet criterion B. are his talking rapidly and engaging in illicit drug use and promiscuous sex. During periods of elevated mood he does not experience any depressive symptoms (criterion C). The case history does not explicitly indicate whether Tom is experiencing occupational or social impairment during the manic episodes, but his rapid talking, feelings of invincibility, drug use, and promiscuous sexual behavior could be reasonably expected to interfere with normal social interactions (criterion D). The symptoms do not appear to be due to a general medical condition or substance abuse, because the drug abuse began during the second manic episode (criterion E). Tom was therefore experiencing a cyclic pattern of manic episodes.

If the manic episodes were being caused by the antidepressant medications he was taking then the diagnosis would be substance-induced mood disorder (APA, 2000). If not, then the alternating cycle between manic and depressive episodes indicates Tom is suffering from bipolar disorder, with rapid cycling.

If Tom can be tracked down and encouraged to seek treatment, the first step would be to stop antidepressant treatment under the care of a psychiatrist to see of the manic episodes are being caused by the prescribed medication(s). Treatment for bipolar disorder can entail a number of approaches, depending on symptom severity and how much of a danger Tom is to himself or others (Mayo Foundation for Medical Education and Research, 2011, Bipolar disorder). Hospitalization may be required in severe cases. Treatment will likely include medications, such as lithium and psychotherapy. Electroconvulsive shock therapy or transcranial magnetic stimulation may also be prescribed, depending on the symptoms and how responsive they are to more conservative treatment approaches.

Mary