https://www.gotomeeting.com/register/544675590
Case Report (As of 5/26/07)
Emily (39)
First Seen: 5/2/07
Presenting Problem:
"Panic attacks - diarrhea, palpitations, difficulty breathing, apathy, and profuse sweating - since 11 months ago."
She has had 5 panic attacks during the last year, and has been on Paxil since 2 months ago, without an attack.
Emily came to U.S. 15 years ago, and studied at a local college majoring in graphic art. She then worked for 10 years at an interior-design office, till 2 years ago when she had the second child. She married Norman (40) 10 years ago and has two children (ages 6 and 2).
She acknowledged that she has lived with ‘stress’ since her youth, but particularly since 12 years ago, when she started working for the interior-design office, where she had started as an intern. She enjoyed her work, but felt tense and self-conscious in interpersonal contacts. She felt she was not given fair recognition or compensation, but would not dare protest.
She had been worried about her 6-year old daughter, who has been acting ‘nervous’ often over-reacting with exaggerated fear of terrorism. She thought her mother-in-law’s casual remarks of terrorism had triggered panic attacks in her daughter.
She described herself as serious, fastidious, perfectionist, self-sufficient, proud, giving, and idealistic. On the negative side, she hates to depend on others, gets irritated by carefree people, doesn’t know how to ask for affection, and uncertain of her decisions. She met 7 out of 9 APA criteria for diagnosis of borderline personality disorder.
She described her father (who had favored her) as ‘chronically depressed’ often staying in bed till afternoon, while her mother ran the family business of selling flowers and plants, while raising two small children and doing all the housework without help. She recalled her father complaining even at the bedside of her sick mother.
Her mother was ‘a super woman’ who single handedly managed house and the family business on 2-3 hours of sleep. She prepared three meals herself every day for the family, without ever complaining about her unhelpful husband who woke up just in time to close the business in the afternoon, pretending as if he had worked all day.
Emily remembered constantly trying to keep peace in the family, between demanding and often yelling father, and struggling mother.
She came to U.S. two years after high school for further study and to escape from her unhappy family.
She described her husband Norman as an ideal husband for her, being optimistic, confident, tolerant, straightforward, and idealistic. Only thing that bothers her about him is that he is too carefree and eats too much.
His father was a quiet and nervous banker, who favored him. His mother was tender, loving and carefree. His older sister was affected by lack of affection from her father, and lives with a man 63 years-old, an openly admitted ‘father substitute.’
He graduated a local college majoring in accounting, and has successfully worked for several leading firms and has been recruited to his current job at a prestigious investment company.
Mental Status (Emily):
She reported symptom peaks as self rated on a 10-point scale (10 as maximum previous experience, and zero as minimum). Her positive peak experiences were also similarly rated. She rated for the day of first consultation.
Symptom Peaks
Positive Peaks
Anxiety
1
Peace
7
Anger
2
Friendliness
9
Physical Symptoms
5
Physical Well-being
7
Depression
1
Happiness
9
Psychosis (Confusion)
0
Sense of Mastery
10
Symptom Average 1.8
Positive Peak Average 8.4
| Her self sphere (9 parameters) averaged at | 7.9 |
| Her achievement (9 parameters) averaged at | 8.9 |
| Her sense of closeness with Norman was averaged at | 8.5 |
Formulation:
Emily has developed borderline personality, because of her emotionally deprived upbringing, growing up with 'chronically depressed father' and 'busy and overwhelmed mother.' She became prematurely and excessively 'self-sufficient' to survive in adversity in which she had no one to depend on. She is now being overwhelmed by her life as a married woman, and mother of two children, despite near ideal circumstances – wonderful husband, two children, and financial security. Her low threshold of tolerance of closeness - which increases her sense of dependency and hence sense of vulnerability - has been exceeded by escalating closeness with her loving husband. She is manifesting defensive reactions (psychiatric distress), such as anxiety attacks and explosive anger at her daughter, precipitating behavior problems in her daughter.
Diagnosis:
1. Adjustment Disorder with Mixed Disturbance of Emotion and Conduct - 309.24
2. Borderline Personality Disorder - 301.83
Treatment:
The goal of therapy is to help her break out of her borderline personality through ‘Breakthrough Intimacy’ (closeness far beyond their previous maximum experience) with her husband Norman.
From Progress Notes:
During the month of May, she was seen in 4 sessions (5/2, 5/11, 5/16, and 5/26). Emily and her husband Norman seemed well motivated and faithfully performed daily self-rating on 41 parameters according to Lifetrack Total Adjustment Sheet, producing accurate and comprehensive record of their daily conditions.
Emily’s graph 2 below tracks her symptoms during the first month, showing repeated high spikes of symptoms usually lasting no more than two days – characteristic of borderline personality disorder.
On 5/2, history taking and initial evaluation was performed. The couple was introduced to Lifetrack concepts and daily self-rating exercise. They were further encouraged to think, feel, and act in such ways that their closeness would increase through conscious and unnatural efforts.
By 5/11, Emily had two surges of symptoms. On 5/5, she was tense during her 6-years-old daughter’s school visit, where her daughter misbehaved in class. On 5/9, her daughter refused to do her homework.
By 5/16, she had another crisis on 5/12 with high spike of anger, physical symptoms, and depression. She struck her disobedient daughter in anger in the midst of frantic rush to do what she had promised to do with her friends, overextending herself 'as usual.’
On 5/13, on Mother’s day, her physical symptoms and depression rose as her previously patient and tender husband was unusually cold and distant. She thought his ‘guerrillas’ (defense against closeness) have emerged as predicted at the outset, just as she has recognized her problems and started trying in earnest to overcome it through therapy. She had nightmares of falling form a tree on which she had been sleeping, while being threatened by a tiger on the ground.
By 5/27, Emily had another crisis with highest symptom spikes thus far. On 5/20, Norman told her that he would come home late, despite her having had an anxiety attack. He went to watch Yankee’s game. However, the couple managed to make up on the same day. On 5/21, she had another anxiety attack in the morning. On 5/23, her husband took care of their daughter’s homework while eating dinner. He was upset as she had brought a dish too close to his computer. On 5/25, she developed stiff shoulder (she often has stiff shoulders for several days after panic attacks). On 5/26, she felt depressed, as she could not finish all the things she had planned for the day.
Emily’s graph 26 below tracks her overall progress during the first month of therapy, showing her intimacy struggling its way up, provoking and overcoming waves of defense (spikes of symptoms), with intimacy finally rising above its previous maximum of 10, reaching 13.3 (5/26).
Emily's Graph 26: Stress Peak and the Three Spheres
Norman's graph 2 below showed spikes of anger and surges of physical symptoms – stiff neck and shoulders.
His graph 26 below tracks his progress over the first month, showing his intimacy finally emerging above his self and achievement spheres, coinciding with the surge of defense (physical symptoms).
Norman's Graph 26: Stress Peak and the Three Spheres
The couple was congratulated for their excellent progress.
During the last session, she said, 'My daughter has been transformed, she has stopped fighting with her younger brother, and is even tender to him. She used to be tense around me and was quick to apologize, expecting to be punished. Now, she writes love letters to me, and has become tender even towards my husband! ‘I don’t get irritated with my husband as I used to. My husband does not look at my face immediately in fear when he makes small mistakes.’
She said, 'I feel secure in bed with my husband now', adding that she used to feel 'secure and happy' only when she was in bed covered by a bug net. She used to cover her ears even in bed to block out her father’s yelling.
She grew up 'developing a taste for suffering'. Her favorite sport was long distance running. 'My father was very tender towards me, while mistreating my younger brother. My father had no friends and was constantly demanding of my mother. My father was raised by a stepmother, and siblings from the previous marriage often physically abused him, while he could not even complain. 'He used to tell us, you can never imagine how lucky you are, growing up in such a fortunate circumstance.' She recalled often pitying her father, trying to comfort him in his erratic behavior.
Three yeas ago, she had a confrontation with her father, while she was visiting her parents with her children. She told her father, 'Are you going to abuse your grandchildren as you did your children!? I used to stay awake in bed while you yelled and screamed. You must suffered much from abuse yourself as you grew up.' ‘I respect you for not physically violent with us, despite physical abuse you suffered in your childhood.’ Since that day, her father suddenly changed and has not yelled at his mother for 3 years now.
Comments:
1. The couple is well motivated and is making excellent progress in her intimacy.
2. She had several panic attacks in the process of trying to get closer to her husband while on Paxil as before.
2. Her husband Norman, who has been patient and always tolerant of her behavior has started showing his own defense, just as she has started making rapid progress.
3. Their daughter's behavioral problems have started subsiding as her mother has become calmer and happier through improving closeness with Norman.
(5/26/07) Yukio Ishizuka M.D.