Case Report 
Marie, a 30 year old American-born Hispanic female, was first seen in the emergency room with suicidal ideation (the impulse to jump in front of an oncoming car), depression, anxiety, and distress about  always getting attacked so much

Miller, MD, Mark

English

Case Report 
Marie, a 30 year old American-born Hispanic female, was first seen in the emergency room with suicidal ideation (the impulse to jump in front of an oncoming car), depression, anxiety, and distress about \u22always getting attacked so much.\u2

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A Case of Recurrent Dissociative Episodes in a Patient with Congenital Defects

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Jefferson Journal of PsychiatryVolume 1 | Issue 1 Article 5January 1983A Case of Recurrent Dissociative Episodes in aPatient with Congenital DefectsMark Miller, MDThomas Jefferson UniversityFollow this and additional works at: https://jdc.jefferson.edu/jeffjpsychiatryPart of the Psychiatry CommonsLet us know how access to this document benefits youThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inJefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationMiller, MD, Mark (1983) "A Case of Recurrent Dissociative Episodes in a Patient with Congenital Defects," Jefferson Journal ofPsychiatry: Vol. 1 : Iss. 1 , Article 5.DOI: https://doi.org/10.29046/JJP.001.1.004Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol1/iss1/5A CASB OF RECURRENT DISSOCIATIVE BPISODBSIN A PATIENT WITH CONGENITAL DBFBCTSMark Miller, M.D.Case ReportMarie, a 30 year old American-born Hispanic female, wa s first seen inthe emergency room with suicidal ideation (the impulse to j ump i n front ofan oncoming car), depression, anxiety, and distress abou t "a lwa ys gettingattacked so much."Further history, mainly from her husband, disclosed a repeti tive patternof dissociative states, occurring at least monthly during t heir eight yearmarriage . Marie typically arose during the night and wande r ed the streets,or took "trips" lasting from several days to six weeks and coveri ng distancesfrom a few to a thousand miles. These episodes often culmina ted wi th a callfrom a hospital to the husband, stating that his wife had been found wande r i ngin a dazed state, often dehydrated, and with evidence of physic a l a ssa ul t .The husband reported that he knew she had been raped on at l east two o c casion s .The episodes always had an abrupt onset, sometimes following a d i s ag reeme n twith the husband, and characterized by an "argumenta tive mood ," a hostilevoice, and often the throwing of household objects . The husband d escribeda "glazed look," when Marie walked by as if she d id not r ecognize him.Early in their marriage, the husband often followed the patien t t o localbars where he found her with strange men. At times, the hu sband a t t e mptedto convince her to return home, only to be met with hostile responses a nddenial of their previous acquaintance. The patient's recollection of t hesetrips is at best scanty. Her responses include: "I can't r e membe r." "Some -times I don't remember anything." "My husband tells me I do these things - -maybe I do--I don't know." She describes no clear prec ipitant . "I justget the urge that I have to walk. I was hoping you could explain i t t o me ."Marie reports an occasional associated mild frontal headache, b ut den i e sany preceding odd smells, hallucinations, or alcohol or drug use . The r eis no history of head trauma, epilepsy, or relationship to the menstrua lcycle, nor dizziness or accompanying physical discomfort .Prior to returning from a "trip," Marie often c a l l s he r husband t o saythat she is cold or hungry, and that she feels hopeless and is cons ide r i ngsuicide. She has made several attempts at cutting her wr ists., the most rece n ttwo months prior to admission . When pressed for an explanation of t heseevents, she stated, "I think there is someone else inside of me, a ' bad'Marie."Dr . Miller is a second year psychiatry resident.15Mental status revealed a slightly overweight, a ttra c t i ve Hi s pa n i c femalewith many scars on her arms. She sat with hands c l a s ped between her legs,and head hung forward. Marie spoke in a soft, g ir lish man ne r , compla iningof anxiety and requesting immediate answers for he r prob lems . She resistedprobing of her younger life saying that she couldn I t r e me mber, didn't know,or that it wasn I t pertinent to her present problems. What memor i e s we reconveyed were devoid of associated affect. Her speech was un r e ma r ka b l e andthere was no evidence of formal thought disorder. Mar i e admi t t e d to achronically depressed mood that had worsened over the pa s t t wo mon t h s , wi thoutcrying spells or vegetative symptoms. Her verbal and cogn i t ive skills wereconsistent with her high school education.Personal history revealed that she was born with an i mperforate anus .A later diagnosis of lJirschprung I s disease necessitated a colos t omy at agethree, and fourteen subsequent abdominal surgeries f rom i n f a ncy to ageseventeen for recurrent recto-vaginal fistulas, colostomy revi s ions, subtotalcolectomy, bowel obstruction, and pelvic abscess. This med i ca l i n format ionwas obtained from her hospital record, as Marie showed a poor und e r s t a nd i ngof her illnesses and altered anatomy, stating: "I only know I had s ome t h i ngwrong and I needed a colostomy."Marie is the third eldest of eleven children, the younge r s i x o f whomwere fathe red by multiple men. She was raised in a ma jor ci ty , a nd wa s placedin a girls I home by child welfare at age fifteen when he r mothe r d e c i d e dshe "would be better off there." Marie's early memories a re f i lled withreferences to feelings of pain, degradation, uncertainty, and f reak ish ne s s .She recalls hiding her colostomy at school, feel ing sexual l y d e f e c t i ve , andbeing told that she was sterile.With the aid of tutors and a supportive school, Marie g raduate d fromhigh school with above average grades. She married shortly therea fte r, andmoved to another city where she worked as a pediatric nurse I s aid for sixyears. She divorced her first husband for his infidel ity after thre e years,subsequently left work and obtained welfare. She married her present hu s ba ndtwo years later. Her husband describes Marie as sweet, loving, and ameticulous housekeeper. He feels affection for "that Ma r ie," b u t has becomeincreasingly intolerant of her baffling "trips" ove r the yea rs. He now seesher as dependent, demanding, and unjustifiably j e a l o us . He a lso feels thathis increasing alcohol consumption is his way of escaping f rom her .her first sexual intercourse at age seventeen , a l t ho ughrathered fragmented. She denies s peci f ic s exual symptoms,"I can take it or leave it; I only have sex fo r my husband. "Marie reportsher memor ies arebut says of sex:Brain CT Scan, EEG with nasopharynegeal leads, and med ical e va l ua t i o nvere all unremarkable.Marie began her hospital course with a gua rded and i s o lated manner.She claimed to enjoy group therapy, since she rare ly interac ted wi t h peopleother than her husband. A visit from the ostomy therapist (also po ssessinga colostomy) brought a flood of tears and statements such as: " No o ne everexplained it to me that way ." "I never knew anyon e wi th c o l o stomy." "Shehas a colostomy, but she's so pretty ." ~16There were no d issociative states ob s e r ved i n t he hospital although once,on the evening prior to being presented as a ca s e conference, she had theimpulse to "walk" off the ward.· In anothe r i n s t a nce, he r faithfully visitinghusband, who often arr ived with alcohol on his breath , called to say thathe could not come that day . Marie concluded that he wa s drunk. She becameirate, threw an ashtray across the room, and became agi tat e d enough to requiresedation and temporary seclusion.With supportive therapy involving the husband , o s tomy education, andlow dose benzodizapines for anxiety, Ma r ie improved i n he r grooming, social-ization, and subjective comfort. She was d ischarged a f t e r sixteen days withplanned weekly follow-up.DiscussionOf the many facets of this complicated case , Harie' s early childhoodsurgical traumas clearly are paramount . This woman ne ve r had a normal bodyimage. Her childhood and adolescence were marked by fre quent, lengthy hospi -talizations for her bowel disease and its complications. This s eve r e l y limitednormal schooling, peer relationships and family r elationships . No familywas available to interview, but hospital records descr i be a di stant, uninvolvedmother who never visited Harie in later hospitalizat ions and who stated shewould be better off placed in a group home . Fa t he r visited periodicallyand is recalled favorably. Harie has not had a ny contact with her motheror s iblings for the pa s t e ight years, nor with he r father for three years,explaining unconvinc ingly that she lost the i r addres s e s .Studies of children with physical d isf i gu remen t from surgery have shownthat attempted inattention to deformities c a n r e s ult i n a poorly integratedimage of the body and the self. The child's deva l ua t i on . of the diseasedpart extends to his whole person, and generally r eflects the view of familymembers . The absence or withdrawal of parenta l s uppo r t du r i ng the worstperiods of Harie's i l l ne s s is highly s ignif i cant. Surgically traumat izedchildren also often express aggressive fantas ies i n p l ay therapy, with defensesagainst i n t e n s e rage anxiety. Harie's bland lack of interest in findingher mother may represent a defense against r a ge towa rd the mother.Har ie's ego fun c t ioning isuse of denial of t he e x t e n t ofher l ow self image, perceivedf o r total emotional s us t e na nce :fr iend. "qu ite pri mi t i ve, a s e v i de nce d by aer massiveher il l ne s s and a l t e r ed anatomy, as well ashelplessnes, and dependence on her husband"He's my f ather , mothe r , husband, and onlyDissociative states often are a fi na l , despe r a t e defense againstintolerable impulses, particularly sexual and aggress i ve one s , that threatento ente r consciousness . Harie i s probably enraged a t t hose whom she i dentifieswith her childhood suffering, pa r t icular l y he r parents who a ba ndo ned her.She apparently displaces some of this ange r on to her husba nd, the currentrepresentat ive of he r i mpo r t a n t ea r ly life fi gures. Harie denies thei mport a nce o f sexuality, bu t clearly has ma jor conflicts regarding her deformedbody , i nferti li ty , a nd altered and d iseased s exual organs ("All I rememberi s tha t I had pu s d ra in ing from my va gina. " ) During her wanderings, Marieo fte n s eemed to be s e a rching fo r missing l ov e objects in her frequept relations1 7with strange men. Perhaps she was unconsciously striving t o prove he rworthiness in spite of her deformities. Or, in light of the frequent phys i ca land sexual assaults experienced during her "trips," perhaps she has anunconscious wish to be bruised, cut, or denigrated in a way s imilar t o he r"injuries" under the scalpel. Marie' s surgical mutilations may have be comepsychologically linked with the consistent care and attention during mul t i p l ehospitalizations.Therapy with this patient will be quite difficult, in light of her ear lychildhood trauma and deprivation. Her propensity for dissociation , whenexperiencing anxiety, will interfere with the use of exploratory techniques .My current approach is chiefly aimed at support and ego strengthening.18REFERENCES1. Brown SL: Dissociation of pleasure in psychopathology. J Ner v Me nt Dis169:3-17, 1981.2. Christenson R, et al: Reactivation of traumatic confl i c ts. Am J Psychi a t r y138:984-985, 1981.3. Freud S: Studies on hysteria. The Complete Works - -Standard Edition,London, The Hogarth Press, 1921.4. Krystal H: Trauma and affects. Psychoanalytic Study of the Child 33 : 81-117, ·19 78 .5. Ludwig AM, et al: The objective study of a multiple personality. Ar c hGen Psychiatry 26:298-310, 1972.6. Marmer SS: Psychoanalysis of multiple personality. Int J Psychoanal61:439-459, 1980.7. Schenk L, Bear 0: Multiple personality and related dissociative phenomenain patients with temporal lobe epilepsy. Am J Psychiatry 138:1311- 13 16 ,1981.8. Watson EJ, Johnson AM: The emotional significance of acquired physicaldisfigurement in children. Am J Orthopsychiatry 28:85-97, 1958 .19

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A Case of Recurrent Dissociative Episodes in a Patient with Congenital Defects

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