Amodei Annamaria

PSY 206

Prof. T. Walter

Psychological Paper

REPORT OF PSYCHOLOGICAL EVALUATION
DISCLAMER: The case that follows is fictional and was developed for educational purposes. Any resemblance in actions, events, or persons discussed herein to actual actions, events or persons is merely coincidental.

NAME: Michael Jackson
AGE: 50
DATE: May 25, 2009

PRESENTING INFORMATION AND REASON FOR REFERRAL:
Michael Jackson is a 50 year-old African-American male who under the advice of his family and friends, has agreed to seek voluntary counsel for on going issues related to an illness known as body dysmorphic disorder (BDD). Michael does not openly admit that he suffers from BDD, even though in the past 25 years he has gone through multiple cosmetic surgical procedures. Michael stated “I thought I was ugly - my skin was too dark, and I decided that my nose was too wide. It was no help that my insensitive father and brothers called me 'Big Nose”. ( J. Randy Taraborrelli, 2008). Michael Jackson was referred to me for a diagnostic evaluation.

HISTORY OF PRESENTING PROBLEM AND BACKGROUND INFORMATION:
Based on my clinical interview with the patient, from a very young age, he grew up in the spotlight, and as his career progressed his insecurities about his body have become increasingly apparent. At the age of 21, Michael had his first rhinoplasty after breaking his nose, he quickly followed this with two more, citing “ the surgery had not been done properly “, and a fourth procedure to create a cleft in his chin. Michael only claims to have had three surgeries, however the continuous distortion of his appearance implies otherwise. Contributing to Michaels’s growing discomfort with himself was his diagnosis in 1986 of vitiligo and lupus, both of which are chronic diseases that can cause lesions, discoloration and rashes on the skin. Vitiligo is a skin disease which causes a loss of pigment, resulting in light patches of skin. Lupus is an inflammatory disease that causes the immune system to attack its own tissues and organs, common side effects include skin lesions and butterfly rashes on the face. To conceal his symptoms, Michael has begun to use excessive amounts of make-up to disguise its spread. Viewing his constantly changing appearance, tendency to wear loose fitting clothing and hide his face in public implies that he is still uncomfortable with his body, regardless of how much he has altered it. Deepak Chopra, a medical doctor and friend of Jackson's for 20 years, once said: "His compulsion with cosmetic surgery is an expression of self-mutilation, a total lack of respect for himself."(The Daily Beast 2009). While Michael may seem like an eccentric pop star, he is an individual who appears to be suffering from BDD. From a psychological perspective, Michael had to respond to his childhood trauma of physical and emotional abuse from his father Joseph. Childhood trauma, intentional or accidental, can result in long term psychological and even physiological disorders. Depending on when in childhood such trauma may have occurred, one can anticipate a loss of self-esteem. Michael was emotionally and physically abused by his father during what Erik Erikson would identify in his model of human development as “the psychosocial stage of the latency years - age 6-11” (Erickson 1950). Michael describes his relationship with his father, Joseph, as "turbulent", adding “When I was a child my father held me upside down with one leg and pummeled me over and over again with his hand, hitting me on my back and buttocks, he sat in a chair with a belt in his hand while we as the Jackson 5 rehearsed and that if you didn’t do it the right way, he would tear us up, he also tripped and pushed all of us into walls and called us names” (Wikipedia.org). He also stated: “I often cried from loneliness. My mother said many times “Joe you're going to kill him "(ITV 2003). Because of this Michael did not have an opportunity to develop self-esteem through normal peer interactions, since he did not have the benefit of a normal childhood. In the latency years, an individual needs to resolve the conflict between “industry” and “inferiority” (Erickson, 1950), before one progresses to the next stage of human development in the life span. His multitude of adoring fans clearly could not make up for the need for normal emotional and psychological development, which is why Michael is so fixated on his childhood issues. Surprisingly, Michael is able to compensate for this to some extent because he is clearly receptive to inner promptings in the creation and expression of his music and dance. Michael stated that his best-selling album “Thriller” has allowed him to touch and connect with his shadow side. He continued by saying “Even though I am famous I feel lonely and a lot of times I am depressed and I seclude myself in my Neverland place where I feel that magic becomes my only reality”.

BEHAVIORAL OBSERVATIONS AND MENTAL STATUS EXAMINATIONS:
At the time of the interview, the patient was dressed in a very eccentric way, with black baggy pants, a multicolor metallic shirt, a medical face mask, a black hat, black large sunglasses, a white glove covering his right hand and lots of make up. It appears that the patient is underweight, weighing approximately 110 pounds. The patient also admitted that he became dependent on morphine and Demerol since 1994 (J. Taraborrelli, 2004). Additionally the patient complains of having difficulty initiating sleep. It was hard to really see his face at first, but then as the interview continued, the patient started to feel more comfortable by taking his hat off, his mask and finally his glasses. During the interview, I noticed sadness in his eyes and in his voice, which very often changed pitch while covering his face when he began to cry while talking about his childhood. “We were terrified of him—terrified” (Bashir, 2003). He went on to discuss how he would “regurgitate” and oftentimes faint when his father would walk into the room. The patient admits that sometimes he has panic attacks and has trouble sleeping, especially when he recalls the abuses. He continues saying “when I look in the mirror I see my father in me, I hate him. I don’t want to be and look like him. I go through periods of looking at my face constantly like an obsession to periods where I covers all my mirrors so that I don’t have to look at him anymore” In everyday life, the patient appears to be a shy individual; however, on stage, he is anything but. Typically introverted in his personal/public life, the patient’s personality can be described by the Five Factor Model (FFM). Possibly, he has more than two sides to his personality. FFM theory lists common personality traits for Neuroticism, Extroversion/Introversion, Agreeableness, Conscientiousness, and Openness. Object Relations theory could also be used to describe this patient’s personality and psychological development. This theory focuses on the interpersonal disturbance and the mental processes that underlie the capacity for relatedness to others. (Kowalski & Westen, 2005). He has admitted to feeling awkward in front of cameras during interviews and that he has difficulty sustaining eye contact with individuals he does not know well. Throughout the interview, he would go from being childlike and animated to quiet and withdrawn within moments during conversations. I am concerned about Mr. Jackson because he really does not seem to know that he has an oobsession with plastic surgery, attempting to camouflage the imagined defect such as his face and especially his nose. He also displays compulsive mirror checking behavior, alternating at times with an inability to look at one's own reflection by covering all the mirrors in the home.

CLINICAL IMPRESSION:
The patient’s present symptoms and psychological profile as determined by the present evaluation, appears to be consistent with Dysmorphic Disorder in comordity with Major Depression and Obsessive Compulsive Disorder (OCD). Body dysmorphic disorder (BDD), is categorized as a somatoform disorder, it belongs to a group of illnesses within the obsessive-compulsive disorder spectrum. Like OCD, body dysmorphic disorder involves persistent and recurrent obsession-like thoughts which are distressing and often uncontrollable. People with body dysmorphic disorder engage in repetitive, compulsion-like behaviors such as looking in the mirror over and over again, asking other people about the imagined defect and skin-picking. As can be the case with OCD, body dysmorphic disorder often involves a preoccupation with symmetry and perfection. I would say that an Axis I diagnosis for BDD, Drug Abuse and Major Depressive Disorder and Anorexia Nervosa would be appropriate. I also would suggest an Axis II borderline personality disorder. Axis III because of the medical condition Lupus, and Vitiligo which are causing some of the patient’s psychological disorder. An Axis IV diagnosis would also be appropriate due to psychosocial and environmental problems in the patient’s life such as the physical and emotional abuse he was subjected during his childhood. (APA, 2000)

DIAGNOSIS:
Axis I: Major Depressive Disorder, BDD, Anorexia Nervosa, Drug Abuse, Insomnia
Axis II: Narcissistic Personality Disorder
Axis III: Vitiligo, Lupus

Axis IV: Victim of Child Abuse,
Axis V: GAF = 40
TREATMENT RECOMMENDATIONS;
Given the patient’s history of plastic surgeries, bizarre behavior, OCD and sleep disorder, a combined approach of Cognitive Behavioral Therapy (CBT); pharmacotherapy such as SSRIs like fluoxetine (Prozac) and fluvoxamine (Luvox) and possibly trazodone (Desyrel) would be appropriate to help alleviate stress and insomnia. Because BDD is a problem in self-perception, CBT is an effective method of talk therapy that focuses on helping clients identify their negative thoughts, and focus on establishing positive ones. It involves letting the client take charge of their thoughts and gives them useful techniques to change their thinking from harmful to helpful. This therapy involves two processes: evaluating the patient’s beliefs about his body, and safely and systematically exposing the patient to previously avoided situations while he abstains from body-checking behaviors. Another very important step in CBT is exposure and response prevention. The patient will be safely and systematically exposed to feared circumstances and then refrain from performing rituals and other activities to reduce anxiety. The result is that the patient’s level of anxiety will diminish over time. Another technique that I would suggest to the patient is to engage in habit reversal technique, where the patient will make a record of the habit, make a list of advantages and disadvantages of engaging in that behavior, identify the situation that triggers the behavior, developing an alternative behavior, practicing that other behavior, and finally rewarding oneself for using the alternative behavior. Finally I will work on rebuilding the patient’s self –esteem, because frequently people with BDD focus on the negative, self-defeating evaluations and disregard positive evaluation. (APA, 2000) The therapy will be ongoing, very extensive and difficult. The patient will be reassessed and reevaluated.

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