Psychotherapy: Nancy Shaffer, Ph.D. -- Letter 2/23/2000

TO: Nancy Shaffer, Ph.D.
FROM: Gary Freedman
DATE: February 23, 2000
RE: Diagnosis -- Adjustment Disorder 309.40
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I submit a copy of a case report that offers perspective to my developmental disturbance. See Spitzer, Robert L. DSM-III-R Casebook at 342-44 (Washington, DC: American Psychiatric Press, 1989).

The case (titled "Nighttime Visitor") discusses an 8-year-old girl who was repeatedly sexually-molested by her father. The mother refused to believe the child or offer any protection against the assaults.

The child developed an adjustment disorder that featured depression, anger (particularly toward mother), inappropriate self-reproach and guilt, and social difficulties. The author suggests the use of the term "victimization disorder" to describe similar cases, which can include sexual, physical, or psychological abuse. (Dr. Spitzer is a clinical professor of psychiatry at Dr. Palombo's alma mater, Columbia in New York.)

Note that in certain ways the reported case is less severe than mine. In my own case, the psychological abuse lasted throughout childhood and adolescence, involved more than one direct aggressor, there was no psychotherapy ("you don't need to see a psychiatrist, there's nothing wrong with you"--possibly an expression of enforced isolation seen in abuse cases), there was collusion among family members, the victim was not permitted to complain, the entire family functioned as a disturbed unit, and there were no sympathetic siblings. I attempted suicide at age 23.

The reported case raises several issues:

1. What would be the likely psychological outcome for the child in this case if she did not receive psychotherapy, and the abuse and failure to protect were chronic features of her developmental environment?

2. How does the nomenclature describe a personality that would have been diagnosed as "adjustment disorder" in childhood, but was never treated and the adult victim now has deep-set personality problems that feature dysthymia, guilt, anger, obsessive rumination, and social difficulties?

3. Note that a psychotherapist in treating this child can--with disturbing ease--ignore the victimization and employ a pure intrapsychic model. "My dear child, what your father did is irrelevant. We can interpret your concerns as a projection of your own erotic and aggressive trends. Your concerns about the outer world evidence your own ego's failure adequately to sublimate

erotic and aggressive drives. You are simply projecting aggression

and an erotic interest onto your father."

In fact, when Jeffrey Masson's former wife Terri consulted a psychoanalyst about her experiences in the Warsaw Ghetto during WWII, the analyst said to her: "You talk about the 'Aryan side' and the walled-off 'Jewish Ghetto'--this is really an expression of your own splitting. You see the world in black and white terms."

Truely, this amounts to the use of an intrapsychic model to rationalize the therapist's "identification with the aggressor," specifically the therapist's identification with those persons in the patient's environment who have aggressed on the patient.

4. Note also that if you deny the victimization of the patient and fail to see the patient's personality problems as a consequence of aggressions and deficits in her environment you are left with persuasive and mutually complementary (and dubiously confirming) evidence of a narcissistic personality disorder.

"Narcissistic personality disorder" will always serve as an adequate and independent diagnosis of a patient who reports that he was a victim of abuse. Thus, "narcissistic personality disorder" will always be the preferred diagnosis used by therapists whose own ego warps dictate that the patient serve as a projection of the therapist's own "bad child" imago and the patient's environment serve as the therapist's own parental derivative (the "Good Object").

-- patient reports father aggressed on her

evidence of the patient's need to preserve by means of projection an idealized self-image and displace a debased (aggressive) image onto father; patient is exploitive and engages in narcissistic blaming behavior

also evidence of ego immaturity, specifically, failure to sublimate early erotic and aggressive trends -- with consequent implications for superego development; patient projects forbidden sexual impulses

possible evidence that child is histrionic and hypersensitive, and has an inappropriate need for attention

-- patient reports mother failed to protect child

evidence of child's age-inappropriate dependence on mother, separation-individuation problems

--patient reports feelings of anger for mother and is aggressive toward mother

evidence that child has feelings of shame concerning her age-inappropriate dependence on mother, and that she discharges shame through use of aggression against the weakest party in the child's family matrix (Dr. Shaffer: "Was your mother the weakest person in your matrix?" 2/16/00)

evidence of lack of impulse control consistent with disturbed superego development (see above: patient's report of abuse reflects the patient's own failure to sublimate her aggressive trend with all that implies about the child's defective superego development)

--patient is socially isolated

evidence of separation-individuation problems, hypersensitivity, inappropriate aggressiveness toward peers, and dependency problems (independent evidence of the child's dependence derives from the child's report that the mother "failed to protect" the child against the child's fantasied aggression by father)
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Nighttime Visitor

Tina was eight years old when her guidance counselor at school referred her to the Family Treatment Center in Cleveland because of disruptive, aggressive behavior. Her 11-year-old brother, Don, and her 9-year-old sister, Sara, were also evaluated, together with their mother.

Several months earlier Tina had been admitted to the hospital with vaginal bleeding and a discharge. A diagnosis of vaginal warts (condyloma acuminatum) was made, and the vaginal culture proved to be positive for gonorrhea. When questioned by a social worker whom the pediatrician asked to see the children, Tina revealed that she and Sara had been sexually molested by their father for the past two years. According to her, he would come into their bedroom regularly at night and have vaginal intercourse with her, and, more rarely, with Sara. The girls noticed that if they were awake, their father often would not bother them. Nevertheless, Tina was so frightened that she would close her eyes and feign sleep during the molestation. Their father threatened them with beatings if they were to divulge the secret, so they had never told anyone.

Their brother, Don, after witnessing one of the molestations, told their mother. She did not believe him, told her husband, who then proceeded to beat Don. In fact, Don had often been beaten by his father. After Don's disclosure, Tina and Sara told their mother what had been happening, but she scolded them for "making up stories."

When the social worker talked with the mother about these events, she admitted that she had suspected that her children were telling the truth, but was afraid of confronting her husband about his sexual abuse because she feared his murderous rage. During their 12-year marriage, he had frequently beaten her, but she never thought of leaving him because her religion forbade divorce.

After the medical confirmation of the sexual abuse, the children were temporarily placed in foster care, the father was jailed. and the family court cited the mother for neglect because she had failed to intervene to protect the children from the father's sexual abuse. The children were subsequently placed with their maternal grandmother, and then returned to their mother after she agreed to a psychiatric evaluation and treatment for herself and her children.

When interviewed at the Family Treatment Center, Tina is a sad, unusually quiet child who rarely smiles. She describes nightmares about her father coming into her room. Tina has talked with the children in school about being molested, and now believes that they all dislike her because of it. When she testified in court, she was certain that she would be sent to jail because she had done something wrong. She also fears that her father will return and attack her. At home she often fights with Sara and Don, and feels "picked on" by her mother, whom she feels has always favored her siblings.

Discussion of "Nighttime Visitor"

Tina's reaction to having been sexually abused by her father and not protected (or even believed) by her mother has included depressed mood, nightmares about the trauma, anger, inappropriate self-reproach and guilt, and the feeling that schoolmates dislike her. There is no evidence that the depressed mood is accompanied by the characteristic symptoms of the depressive syndrome, other than self-reproach and guilt. Therefore, a diagnosis of Major Depression cannot be made. Although the sexual abuse has been going on for two years, there is no description of a persistent depressed mood that would justify a diagnosis of Dysthymia. In fact, during this time Tina seems to have been more frightened than depressed.

The reexperiencing of the trauma (nightmares of her father) suggest the diagnosis of Post-traumatic Stress Disorder. This diagnosis requires at least three symptoms indicating persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. We find evidence only for a feeling of estrangement from others (her classmates). In addition, the diagnosis requires persistent symptoms of increased arousal, and we find no evidence for this. We are therefore left with the residual diagnosis of Adjustment Disorder with Mixed Disturbance of Emotions and Conduct.

Although there is no specific DSM-III-R diagnosis that captures the clinical picture that Tina demonstrates, some have suggested that the syndrome, particularly the victim's inappropriate self-blame, is often seen in adults or children who have been sexually, physically, or psychologically abused. This syndrome might be called "Victimization Disorder," and could be considered for possible inclusion in DSM-IV.

DSM-III-R DIAGNOSIS:

Axis I: 309.40 Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (p. 330)

Follow-up

After the evaluation of the family, individual psychotherapy was recommended for Tina, Sara, and their mother. In addition, family treatment was instituted in order to improve the relationship between the children and their mother and to help establish structure and discipline in the home. Tina's mother was encouraged to allow the children to express their feelings of having been betrayed by her. At home Tina began to overeat and steal money from her mother's purse, as a way of expressing anger toward her mother and of getting attention.

In the treatment setting, Tina acted frightened and needy, and she clung to her female therapist. She expressed her yearnings for nurturance and safety by caring for doll babies and stuffed animals. She was frequently involved in "traumatic play," in which she acted out various elements of the trauma. These dramas often involved a witch who poisoned children and devils and monsters who attacked them when they tried to run away.
Spitzer, R.L., et al. DSM-III-R Casebook at 342-344 (Washington, DC, American Psychiatric Association Press, 1989).