rachelmanija | Diagnosis: Alec

Swordspoint

Presenting Problem: Alec is a white male in his late teens or early twenties, of above-average height and below-average weight. His clothing was shabby, but his hygiene was good. Partially healed, shallow cuts were visible on his wrists when his sleeves fell back. He appeared tense and guarded. His affect was markedly labile, swinging from contempt to brittle wit to open anger to sadness. His reason for coming in was stated to be “idle curiosity.” Upon further questioning, he stated that he had recently been the victim of a kidnapping.

Client reported that the cuts on his wrists were from a suicidal gesture. He went on to recount a history of self-injury and self-destructive acts, sometimes with the intent of suicide, and sometimes as impulsive acts in the heat of emotion. When he feels emotional tension build up unbearably, he either commits a self-destructive act, or provokes someone to attack or insult him so that his lover (a swordsman) will kill the person. Client then feels relief.

Client states that he “can’t do anything right” and that he expects to die violently and young. (Client is not a swordsman himself, so this belief, which predates his kidnapping, is not realistic.) He has attacked his lover, with the knowledge that his lover is a professional killer.

Client periodically (not regularly) uses drugs, and regularly gambles. He denies addiction to either.

He denied suicidal ideation when the question was asked, but said that it could come on at any moment. Client stated that his lover is aware that he is suicidal, and is keeping an eye on him. Client stated that he might also have the impulse to have his lover kill someone at any moment.

Personal History: Client currently lives in Riverside, supported by his lover. He used to attend the University. He became upset when asked how he came to leave it, and refused to state. He also declined to give his surname.

Family Background: Client declined to say anything about his family. From his speech and manner, however, he appears to be upper class and well-educated.

Psychiatric/Treatment History: Client stated that he has had no previous diagnoses or treatment.

Differential Diagnosis: Client states that he has had both depressive and mixed (manic and depressive) episodes. He agrees that he might be having a mixed episode now. He denies recent substance abuse or somatic symptoms, and says that he has never had hallucinations or delusions.

Though client’s relationship with his lover appears to be stable and not marked by idealization and devaluation, he matches other criteria for Borderline Personality Disorder: impulsivity in at least two areas that are potentially self-damaging (drugs, gambling, deliberately provoking violence in others); recurrent suicidal and self-mutilating behavior; affective instability (intense, brief periods of anger, anxiety, or dysphoria); transient, stress-related paranoid ideation; inappropriate, intense anger.

The extreme tension followed by provocation of violence followed by relief and pleasure is similar to the pattern of impulse-control disorders like Intermittent Explosive Disorder and Trichotillomania. Since client typically does not personally commit the violent acts, but achieves relief by witnessing another do so, this is better accounted for as an Impulse Disorder Not Otherwise Stated than by IED.

Rule out Antisocial Personality Disorder. Client is impulsive, exhibits reckless disregard for the safety of self and others, lacks remorse, and is irritable and aggressive. However, there is no evidence of a previous Conduct Disorder, and the antisocial behavior may have been during the course of Mixed Episodes.

Substance use and gambling don't appear to meet criteria for abuse, but client may be minimizing his use.

Rule out PTSD. Client's PTSD-like symptoms predate his kidnapping.

Recommendations:

5150 (involuntary psychiatric hold) for being a danger to himself and others.

An immediate medication consultation.

Individual therapy services to address his Bipolar I Disorder, Impulse Control Disorder, Borderline Personality Disorder, and recent trauma.

Referral to local Narcotics Anonymous Group to address his history of substance use.

Axis I (clinical disorders): Bipolar I, Most Recent Episode Mixed, Recurrent, Without Full Interepisode Recovery, Without Dysthymia, With Rapid Cycling. Currently in a Mild Mixed Episode. Impulse Disorder Not Otherwise Stated (compulsion to provoke others to commit violent acts.)

Axis II (personality disorders and mental retardation): ): Borderline Personality Disorder.

Axis III (general medical conditions): ): None.

Axis IV (psychosocial and environmental problems): ): Domestic violence. Victim of kidnapping. Unsafe neighborhood.

Axis V (GAF: Global Assessment of Functioning): ): 20. Some danger of hurting self or others. (Suicide attempts without clear expectation of death; frequently violent or provoking violence in others.)

Rachel’s note: This was a tough one. I went ahead and diagnosed Bipolar I, but it’s hard to tell from textual evidence whether that’s actually going on, or whether Borderline could account for everything all by itself. I also diagnosed an Impulse Control Disorder, though technically you’re not supposed to if it might be caused by some other condition (like mania), because it was such a significant pattern that I thought it was worth getting its own diagnosis.

I reasoned according to a safety hierarchy, which states that you should err in favor of diagnosing conditions which are dangerous (very bad consequences if you don’t treat them), comparatively easy to treat (potentially very good outcome if you do), and not severely stigmatizing (the diagnosis itself won’t cause severe problems). Bipolar I qualifies on all counts, so I went with it even though I wasn’t positive about it.