CASE STUD therap

CASE 19

"You Decide: The Case of Fred

This case is pre""You Decide: The Case of Fred

This case is pre"

"You Decide: The Case of Fred This case is presented in the voices of Fred and his wife, Margaret. Throughout the case, you are asked to consider a number of issues and to arrive at various decisions, including diagnostic and treatment decisions. You can find Fred’s probable diagnosis, the DSM-5 criteria, clinical information, and possible treatment directions in Appendix B. Margaret “My Husband’s Brain Stopped Working Properly” About 8 years ago, my life changed completely. The reason? My husband’s brain stopped working properly. We had been married 34 years and Fred was 67 years old. He had worked for the same construction company in New Jersey for 32 years, first as a laborer, then as a security supervisor and union leader. He was a big strong man, a good husband, and a good father to our son, Mark. Together, we had managed to make a decent living with him in construction and me an actress in television commercials—the original Odd Couple, our friends would call us. Life was good. And then Fred’s brain went downhill, taking the whole family down with it. The problems seemed small at first, hardly noticeable really. Sometimes, when telling me about his day at work, Fred would talk about the foreman, Jimmy, driving a “tractor” when he meant “bulldozer,” or he’d say that he had made a “revision” instead of “decision.” Little stuff. And he’d catch himself. I didn’t worry too much about it, but it was odd. It doesn’t sound like much, but it wasn’t like him. I even thought, “Oh, well, the old boy’s slipping,” and would laugh to myself. But when he forgot the anniversary of our first date, well. . . I knew something was wrong. I gave him all kinds of hell for that—I accused him of having an affair, I cried, I really let him have it. But I was also scared. I mean, maybe an anniversary like that doesn’t mean much to other people, but for us—well, over the years, he’d taken me to Atlantic City for shows and to dinners in expensive restaurants. Once, after Mark was grown, he even got us a hotel room in the Catskills for a weekend. There was always some sort of surprise. So, 8 years ago, in anticipation of a special evening, I got all dressed up. When he got home from work that night and sat down on the sofa, I knew he’d forgotten; and when he saw the disappointment in my eyes, he realized the same thing pretty quickly. In fact, he felt terrible about it, and took me out to a very fancy Italian restaurant after I calmed down. But it was a bad sign. That year turned out to be a rough one. Forgetfulness is universal, and increases in forgetfulness are a normal part of aging. How might we distinguish normal forgetting or normal aging from the symptoms of a clinical disorder? It wasn’t as if he suddenly forgot everything, but it seemed like he was forgetting a bunch of things that he’d never forgotten before. I had always been the one with my head in the clouds, forgetting dates and losing car keys. Fred would be the one telling me, “Maggie, you’ve got to stay more on the ball. If you forget to pay the bills, they’re gonna shut off our electricity.” Or he’d chew me out about forgetting to make a doctor’s appointment for Mark. Of course, I’d joke, “Why don’t we switch jobs and you’ll see who’s got it tougher,” but he definitely had a sharper head, no denying that. Now, suddenly, he was losing his wallet and we’d find it later in the study, where he’d sworn he hadn’t been in days. Or he would leave half-full glasses of juice on the floor of the living room, and when I’d chide him about it he’d say, “Oh, I’m sorry,” and change the subject. This was Mr. Neat Freak who, in the past, couldn’t stand it if a dirty dish sat on the kitchen table more than a half hour after dinner. What might be the most difficult aspects of observing a spouse, parent, or other close relative gradually lose their memory or other cognitive faculties? He also had little accidents, spilling food on himself, or knocking over a pile of papers or the jar of pencils from the counter. Then he started asking me to drive him to work all the time. He said that he’d caught himself veering off the road a few times and had just barely avoided an accident. “It’s all the stress,” he’d tell me. “We’ve got a new contract coming up and I don’t think it’s gonna go our way. I’ve just got too much on my mind.” As the forgetfulness and unusual behavior mounted, it couldn’t be ignored any more. Yet somehow I found a way to do just that. I wanted to believe that he was fine. Then, one day, he missed a meeting with an important contractor—just didn’t show up. Instead, he went to his office like it was any other day. The company lost the contract and a lot of money, and it also was bad for their image. Actually, by that point in time, I wasn’t all that surprised by his error. This strong and organized man, who had taken care of everything for so many years, was by then becoming a different person, and I was now taking care of him. That’s when I told him that he must see a doctor. And Fred did something I’d never seen him do: He burst into tears. Despite his emotional outpouring that evening, Fred managed to put off medical treatment for nearly a year. Eventually, however, the incidents caught up with him—for example, leaving his glasses in the mailbox or mowing only half the lawn—and he went for a neuropsychological exam. The results of a battery of tests revealed some significant problems, and the neuropsychologist, Dr. Schoenfeld, broke the news to us that he was suffering from a neurocognitive disorder. He explained to us that we would be facing a very difficult battle—that Fred would become less and less able to take care of himself. He also told us that very little could be done to stem the progress of Fred’s condition. Fred was going to have to rely on the support of his loved ones, particularly me, to see him through this. Neurocognitive disorders include a group of organic syndromes, marked by major problems in cognitive functioning, such as memory and learning, attention, visual perception, planning and decision making, language ability, or social awareness. Based on your reading of either the DSM-5 or your textbook, what form of neurocognitive disorder might Fred be displaying? Which of his symptoms suggest this diagnosis? Fred had already planned to retire, as his position in the company had been scaled down drastically after the contract debacle. The doctor’s diagnosis simply made it official in our minds. Within 3 months, he was thrown a retirement party by his coworkers, many of whom he had mentored. By then he was having trouble remembering people’s names, but that party meant a lot to him. He knew just how lucky he was to have so many caring friends and colleagues. He was still embarrassed about having lost that contract, but everybody tried their best to show him that they had nothing but gratitude for his years of service. He wasn’t walking too well by then, either, so I helped him to a chair, where he sat for most of the party, sometimes crying quietly to himself because he no longer had full control of his emotions. I think that was really his last great experience, the last time he had a really special night out. At the party, Fred gave a short talk to his coworkers, thanking them for the event. He had been worried about this speech for days. He feared attempting to reminisce or trying to be too specific, because he’d been having so much trouble remembering things. But he didn’t want to read a written speech, so he just kept it short. It broke my heart when I heard him say, “This is really a special night. I want to thank you all for this and for helping me out the way you’ve done the last few months. I’m not the kinda guy who talks a lot and makes big speeches to his friends. And that’s what you are—my friends. That’s why I’ve had a great time all these years. That’s why I’ve loved my job, and going to work in the morning. We’ve had a lot of good times, and I’ll miss you, my friends.” In 2012, more than 15 million family members and friends volunteered 17.5 billion hours to care for individuals with dementia, which can lead to a range of psychological problems for caregivers. What kinds of problems would you expect caregivers to develop? It was more than a retirement speech; it was a farewell speech. But, as painful as that was, the impromptu speech that he gave to me alone just 2 days later hurt even more. He was lucid that day. He was clear and organized and sharp as a tack, just like the old Fred. And he was hurting. Fred “Preparing for a Trip to Nowhere” I’m mad, I’m frustrated, I’m everything in between. It sure is embarrassing, Maggie, it sure is. Can you imagine what it’s like to have to think for 2 whole minutes before remembering our own grandchild’s name? A child I held in my arms when he was born, and said, “This boy is a perfect child.” I watched him grow and played ball with him, and I can see his face in front of me as if he was in the room with me, but when I reach for his name, there’s nothing there. Blank. How do I convince an 8-year-old child that his grandpa loves him and cares about him when I can’t even be bothered to know his name? I spend my whole life trying to be sharp, but I end up a failure. I’m a 69-year-old man who needs a woman to take care of him like he’s 90. What use am I? I provided for my family. I earned money. I did my job to help keep Wellstone Construction running. And now that’s all gone. All gone. I can’t do any of it anymore. Lying in bed or sitting in a chair all day. My wife and son provide for me. The company takes care of me. I’m a drain. No one will ever again think of trusting me with anything. Anything. “No, it would be too taxing for the poor guy.” That’s what they’ll say, but what they’ll mean is, “He’ll just screw it up, like he screws everything up.” Consider Case 5, Major Depressive Disorder. Did Fred show any symptoms of clinical depression as his disorder unfolded? Did Margaret? Would any of the treatment techniques described in Case 5 be helpful to either of them? Sometimes, all of a sudden, I don’t know what time of day it is, or even what day of the week it is. I don’t even know what I had for breakfast this morning. If I want to go over there to pick up that book off that table, I have to ask you if you can help me walk. I can’t walk without leaning on someone. Otherwise, I’ll fall or have to stop and sit down. Why should I even want to get up in the morning? Being up isn’t all that different from being asleep, only a bit more confusing. Nothing in the world is more infuriating than knowing that you know the thing you can’t remember. Knowing that you’re not stupid, but that everything you once knew is being stripped away from you, little by little. God knows how long I’ll even know who you are, Maggie. How long will it be before it’s all just shapes and colors? How long before everyone else is making plans for me. Putting me in a home, putting me out to pasture, putting me to sleep. I feel like I’m preparing for a trip to nowhere. If you were to lose your memory and cognitive faculties, bit by bit, how would you feel? What fears and worries do you think you would experience? I don’t even know if I’ll mind that so much. When I don’t remember anything, it won’t be so hard. Probably then I won’t feel so stupid. I won’t realize how much I am forgetting. That’s what gets me—the forgetting. It gets me mad, but it gets me scared, too. I reach for a pen that I thought I was just writing with and I realize that it’s not there. I look for it and then I realize that I’m not writing anything. Now I can’t find the pen, and I don’t even remember why I’m looking for it, and nothing makes any damned sense. It’s like this dream that’s real upsetting because I don’t know what’s going on, but I know I should know. Oh, God! When this all started, you know, I didn’t believe it. A man can get used to a lot if he can convince himself that nothing is wrong. Every time I’d forget something, or lose something, or drive off the road, it bothered me for exactly 5 minutes. I’d be scared for 5 minutes and I’d admit to myself for those 5 minutes that there was a serious problem—that these things were happening more and more and that something was very wrong and that I should get this taken care of somehow. But after those 5 minutes, I would laugh it off and decide that everything was fine—everyone forgets things, everyone loses concentration driving, everyone misplaces things—and I’d be fine. I’d come home, and I wouldn’t think about it until the next thing happened. Then I’d be upset for another 5 minutes. Why would Fred and Margaret have tried to overlook his symptoms, even as they were worsening? I want you to put me away, Maggie—you know what I mean—let me go, if I ever don’t remember who you are. I don’t want to forget my beautiful wife, and if I don’t know who you are anymore, have them just inject me or give me whatever is necessary in order to get this life over with. Don’t worry about whether it’s the right thing, because it is. I’m afraid that you won’t do this, that you’ll let me go on when I’m not myself anymore. I don’t want you to have to see me and not know that I love you and need you with me. I don’t want you to doubt my love for you because of this damned disease. Please, Maggie, don’t let that happen. Please promise me. Margaret “A Long Goodbye” Unlike most of the other disorders in this casebook, Fred’s problem was organic, progressive, and largely irreversible. What role might psychological treatments play in disorders of this kind? I heard that speech from Fred several other times during the next 2 years. But of course I couldn’t make that promise. Eventually, he became less clear and less interested, and less able, and he stopped saying those things. The last 4 years really have been a long goodbye for us. As the years have passed, Fred has been less and less able to do for himself. He has been increasingly unsteady on his feet. Furthermore, he lost control of his motor functions and is now unable to feed or clothe himself, or to use the bathroom on his own. At first, this was very upsetting to Fred; he was still aware enough to feel that his incapacitation made him ridiculous in some way, and he often lashed out at me in anger—even accusing me at times of trying to drug him so that he couldn’t take care of himself. Later, he would tearfully apologize after these outbursts. About 4 years ago, I bought him a walker to make it easier for him to get around. But a year later, he fell while trying to walk across the hall to take a bath. He broke his hip and couldn’t leave his bed for 4 months. Fred became more and more depressed and began spending days staring at the wall or the bed sheets, refusing to talk even when I tried to speak to him. After his hip had healed, he still remained in bed, refusing to try to walk. He even began hearing voices and seeing people who weren’t really in the room. Sometimes he would believe that long-gone relatives were in front of him and talking to him. Eventually, it seemed like it was just too taxing for him to try to distinguish the real from the imagined, and Fred began to treat everyone and everything around him with indifference or doubt. He treated real people who were talking to him as though they might be figments of his imagination and just turned away. What role might psychotherapists play in helping close relatives cope with the deterioration of a loved one? What therapy approaches described throughout this casebook might be particularly helpful to such relatives? Our son, Mark, visited regularly, at least once every other weekend, from his New Hampshire home. Even so, Mark was always surprised by the speed of his deterioration. After breaking his hip, Fred, who had always looked so forward to Mark’s visits, often failed to get out of bed to greet our son, sometimes sleeping through the entire visit. Mark noticed that his father appeared to get less pleasure from the visits. He tried to prepare himself for the ravages of Fred’s condition, but as his father deteriorated more and more, he became very shaken. During one visit, Fred looked Mark in the eye, then turned to me and asked, “Who is this, Maggie? Who’s he? Is that your brother Jimmy? What’s he doin’ here?” Mark faced his father and said in a quiet voice, “Dad, it’s me. Your son, Mark. And I love you.” As he said this, however, Fred fell asleep, and Mark left the room feeling dejected. Later, after Mark and I ate lunch, Fred awoke again, and called out. When Mark entered the room and stood over his father’s bed, Fred touched his hand to Mark’s face and after a minute said, quietly and hoarsely, “Son . . .” And they held hands without saying a word for an hour. I almost couldn’t bear it. Also, about 3 years ago, Fred started having violent nightmares, and he would sometimes wake me with his screaming. During and after some of the nightmares, he seemed like a completely different person, with a crazed passion behind his frightened eyes. He was growing more and more convinced that I was plotting against him. During one of our visits to the neuropsychologist, he complained, “She’s stealing things from me. She steals my clothes so that she can make me feel foolish when I can’t find them. I was eating a banana, and she wanted the banana. I put it down and turned my back for a minute, and that banana was gone. She’s taking my food. This is all her fault. I know it is.” People with a disorder such as Fred’s often become angry, suspicious, and accusatory. What are some of the potential reasons for such reactions and personality changes? It’s now been 8 years of taking care of him. At this point, I have to feed him and help him use the bathroom. I bathe him and I take him to the doctor. Thanks to his retirement package, we’re okay financially. Still, I need to spend every penny we have on Fred’s care. I can’t work myself, since I have to be with him. The worst part is when he looks at me and I know he doesn’t know who I am, yells at me as if I’m an enemy, and accuses me of stealing his things. At other times, however, he looks at me and his eyes say, “Thanks, Maggie,” and I know he hasn’t forgotten—even if he’s remembering for only a moment. Fred’s decline seemed to reach a new level beginning around 6 months ago. Since then, he has been completely incontinent and barely able to speak. He has also been unable to leave our bedroom. He hasn’t shown any recognition of Mark during his visits, and has barely even acknowledged me. About 3 weeks ago, he developed a cold that would not go away, and last week I took him to the hospital. He’s still there, with a respiratory infection, using a ventilator to breathe. He is in such a weakened condition that doctors are not sure that he will live out the week. I suspect that Mark and I each privately hope that the doctors’ prognoses are accurate and Fred will die within the week. Neither of us has dared express this to the other, but I think we will both be relieved when Fred is gone—that is, the bedridden Fred whose true spirit has already left us. When he is gone, we will all finally be delivered from this long ordeal. And Mark and I will be able to remember our beloved Fred again as he once was—strong of mind and body. After a long ordeal such as Fred’s, it is common for close relatives to find themselves almost wishing for or looking forward to the person’s death. What factors might explain such feelings and reactions?"

CASE OF SUZANNE CASE 20

"You Decide: The Case of Suzanne

This case is "

"You Decide: The Case of Suzanne

This case is presented in the voices of Suzanne and her mother, Sherry. Throughout the case, you will be asked to consider a number of issues and to arrive at various decisions, including diagnostic and treatment decisions. Appendix C reveals Suzanne’s probable diagnosis, the DSM-5 criteria, clinical information, and possible treatment directions.

Suzanne A Sign of Things to Come

I don’t know when I started doing it. I guess I’ve always hated school and I’ve always been really nervous about things. A lot of the time, even before college, I used to play with my hair a lot and pull on it; the more nervous I became, the tighter I pulled. But I didn’t think there was anything unusual about it. You know, everyone has nervous habits that they turn to when they get stressed out, right?

My parents were . . . let’s say “difficult.” They were always making me feel like I didn’t do well enough. “Couldn’t you have gotten an A? Couldn’t you play basketball or soccer? Couldn’t you have won the game? What could you have done to prepare for the test better? What can we learn from this? Why don’t you have a boyfriend? Maybe if you dressed differently? You know, we just want you to be happy.”

Many loving parents are described as being “overconcerned” about their children, or “overcontrolling” or “overinvolved.” Where do such patterns of behavior come from? What can parents do to avoid crossing the line in their efforts to guide and protect their maturing children?

I guess this whole thing really started a long time ago. When I was in seventh grade, I used to pluck out my eyelashes. I can’t remember how it started, but I remember that it used to relax me when I was tense. I also got the idea in my head that my eyelashes and my eyes were really irritated. I thought that maybe I had some dirt caught in there, and it was stuck between my eyelashes. So I would loosen it and stop the irritation by pulling the eyelash out. I actually remember thinking that there were microscopic bacteria—like I had seen in a science film—living on the end of the eyelash, wiggling around under my skin, and the bad eyelashes needed to be pulled out. The little pain of pulling the lash out was something I actually looked forward to, like when you have a hanging fingernail that hurts and you need to pull it out: a second of pain and instant relief. Once I started noticing that I was doing it, I would be really nervous right before I would pull it, and I would think that maybe I shouldn’t pull this one. Then, when I was pulling it out, I imagined I could feel the irritating part coming out. After it was over, I felt relieved, all the nervousness gone. I would look at the lash I had pulled, almost trying to see the little bacteria wiggling like a worm on a fishhook.

Soon, my eyelids were running out of hair, but no one seemed to notice, so I thought it wasn’t a big deal. Maybe I wasn’t really plucking them all out, I thought. Maybe I was just plucking out the bad ones, and the eyelashes now looked exactly the way they were supposed to. Maybe, I thought, I’m just sensitive to the way it looks because I keep thinking about it so much. Of course, I couldn’t help but notice that I wasn’t able to pluck any long eyelashes anymore, only little stubby ones. Also, my eyelids were hurting all the time.

One night at dinner, my mom just turned to me after we’d been sitting together the whole dinner, and screamed out, “What happened to your eyelashes?” That was so embarrassing! I wanted my parents to just go away. They wouldn’t understand why I had to do it. I just wanted to crawl into a hole and die. I promised my mom that I would stop, but it was easier said than done. I’d catch myself—or should I say Mom would catch me—doing it, reaching for the eyelashes even when there wasn’t anything there. Eventually, my embarrassment became so great that it helped me to stop. Whenever I would reach for my eyelashes, I was able to catch myself before I touched them.

My lashes grew back, and the eyelids weren’t as irritated all the time. After about 6 months, I didn’t even have to think about it anymore. When I did think back on my behavior, I couldn’t believe that I had plucked out every eyelash. It didn’t make sense anymore, and it seemed so unnatural. I was glad I had stopped, but I didn’t want to think about it too much because I didn’t want to consider the possibility that I wasn’t “normal.”

After my victory over eyelash plucking, I found myself trying to cope with school and other stresses in other ways. Throughout high school, I bit my nails and often stayed up all night worrying myself to the point of tears, and walking around with a headache, half asleep, during the day. During my junior and senior years, I was always concerned about whether I would get into a good college. Then, after I was accepted, there were all these preparations to make, while at the same time trying to finish my senior year in good standing. And then I had to get ready to move away from home. All the while, in the back of my mind, I was worried that there was something different about me from everyone else. I really didn’t get along that well with most people; I just got too nervous around them, and relationships with boys never seemed to go anywhere.

Suzanne Entering the Big Leagues

When I first got to college, I was really scared. I’d never been away from home for more than a couple of weeks, and never so far from my parents. Even though I couldn’t wait to get away from them, I didn’t know how I was going to get through life without them telling me how to do everything and how to get by in the real world. My next-door neighbor in the dorm suite, Jon, was a big help. He was from New York, so he was independent and sure of himself. He taught me how to take care of things like bills and spending money, how to get through classes, and how to get food for myself. It was really a lot of fun; we made a little family out of our suite. Jon and I spent tons of time together and I was happy that I had wound up with him; it seemed like a stroke of luck.

Entering college is a major life stress that seems to trigger or exacerbate psychological difficulties for many persons. Why might this be such a difficult period in life?

Then one day he kissed me. Gosh, it seems so simple just to say it like that: “He kissed me.” But that was how it happened. And I didn’t think twice; I just kissed him back, even though I had never really kissed a boy before. Not like that. We moved on from there and had sex. I had always wondered what that would be like. How would it feel? But it felt wonderful—so right, so natural. I was so very happy with Jon, and I was feeling things that I had never felt for anyone.

One day, after we had been going together for about a month, Jon suddenly told me he thought we shouldn’t be doing what we were doing anymore. He said it just like that, and just like that it was all over. He talked about expanding our horizons, exploring other relationships, and other such things. None of it made much sense or comforted me. I was totally devastated. And I was shocked by the suddenness with which the relationship ended. That alone would have been enough to crush me, but there was more. Jon wouldn’t even talk to me or hang out with me anymore. It was a nightmare. I knew he was having girls come over and he was sleeping with them—each of them was a reminder of how undesirable I was, of my failure at love, of my loss. I felt terrible about myself because Jon didn’t love me like I loved him, and terrible because I had loved him in the first place. I was so depressed that I started failing two of my classes.

I think it was around this time, about midway through that first semester, that I first became aware that I was pulling my hair out. I say “first became aware,” because I have no idea how long I’d actually been doing it. I just suddenly noticed, while in the middle of pulling my hair one time, that there were already a few strands of blond hair on the floor. This time it wasn’t my eyelashes, but actual hair from my scalp.

Everyone has certain habits that they exhibit when they are under stress. Only occasionally do such habits blossom into a disorder such as Suzanne’s. Are there ways of distinguishing innocent bad habits from signs of problems to come?

I realized immediately that the hair pulling was the same kind of thing that my eyelashes had been. I didn’t feel so much the itchy, irritated feeling, but I would feel very uncomfortable. If I tried not to do it, I’d get really nervous and tense. I’d get this cramped, tight feeling in my stomach, and I’d worry that something bad was going to happen. By pulling out a hair, I would feel instant relief. When the hair came out, the knot in my stomach would pass and my heart would stop pumping so heavily. I could lean back in my chair or bed, and breathe much more easily. Unfortunately, this feeling of relief wouldn’t last for long. In fact, as I said, the hair pulling would happen so often that I usually didn’t know I was doing it—I would sometimes simply catch myself in the act.

Recalling the eyelash thing, I’d say to myself, “Remember that was just a phase. You didn’t have any trouble stopping,” and I’d feel reassured. But of course I had had trouble stopping the eyelash plucking; it had just faded from my memory. As I paid more attention to my hair pulling, I observed that I tended to pull it from my right temple, on the side of my head, with my right hand. But I honestly couldn’t be sure that that was the only hand I ever used.

Based on your reading of either the DSM-5 or your textbook, what disorder might Suzanne be displaying? Which of her symptoms suggest this disorder?

A month or two after I first noticed what I was doing, I was in the shower and felt a little patch of skin exposed around my favorite plucking spot. I think I was running the shampoo through my hair and I was rubbing it through my scalp. When I felt the patch where there was less hair, I panicked immediately. I could feel my face turn bright red, and I think I was more embarrassed than anything else, even though I was alone. I thought, here I am doing this bizarre and perverse thing that no one else does, and now I must look like a freak. It occurred to me that everyone must know, and I just wanted to run and hide. In those first few moments of shock, I started breathing heavily, and I silently promised myself that I would never do this horrible thing again, that I was immature and stupid and disgusting, and I had to stop. I rinsed out my hair, toweled it off, then, terrified, I moved to the mirror to see just how bad I looked. Peeking from between squinted eyelids, I couldn’t see a difference at first. Then I opened my eyes wide, and saw that there was definitely a bald patch, although not as bad as it had felt to my fingers in the shower.

Good, I thought, with a feeling of relief. It seems silly in retrospect, but I remember thinking that if I just combed my hair over a certain way, everything would look fine. It relieved me enough that I went right back to my routine. Time and again, I’d catch myself plucking hair from the same spot. Eventually, I could no longer pretend that I didn’t have a noticeable bald patch. I invented newer, more elaborate hairstyles to cover it, while always thinking to myself, “Oh, I’m never going to do this again,” or “I’m phasing it out.” The truth was I hadn’t slowed down a bit. It was probably becoming apparent to the people around me that there was something peculiar going on with my hair. But I kept on going.

Suzanne’s disorder is listed with the obsessive-compulsive and related disorders in the DSM-5, but it is considered a separate disorder from obsessive-compulsive disorder. Yet some clinicians believe that problems like hers are really a kind of compulsion. How are her symptoms similar to those displayed by the individual in Case 2, Obsessive-Compulsive Disorder? How are they different?

When I went home for the winter break, I was terrified. I didn’t want to risk my parents seeing this ugly bald spot on their “perfect” little daughter. For the entire month before winter break, I kept thinking, “Okay, stop pulling the hair. It needs to grow back.” Then I’d think, when the urge had its grip on me, “Well, break is still 3 weeks away.” And so I’d pull out the hair. And pull. And pull. And 3 weeks became 2, and 2 became 1, and the problem was as bad as ever when I had to fly home. I bit my nails the whole flight home, trying not to give in to the urge to pull my hair. I also didn’t want to mess up the deceptive hairdo I had worked on so hard. Of course, there was Mom at the terminal waiting area, screaming, “Oh, my God! What kind of a hairstyle is that? You look terrible!” I told her to mind her own business and leave my hairdo alone. It was all I could do to stop her from touching it.

I was only kidding myself that I could keep this a secret for 4 weeks. Within 1 week, Mom noticed the bald spot that I’d tried so hard to hide. In her typical way, she made me feel as if I had cut off an arm, and I turned bright red and cried. I didn’t want to talk to her about it, both because she was horrible and because I didn’t want to face it myself. So I left the room and said, “I won’t talk about this now.” But I knew that the damage had been done, and later I went down and told her that, as she could see, I had been pulling out my hair. I explained that I didn’t know why, but I was going into therapy (to get her off my back) and I wanted to deal with it on my own. And then I refused to discuss it further. I was surprised at how well I had handled my mother, but I knew that I had yet to handle my hair problem.

I went back to school, and continued to pull my hair out. My hair looked so bad I wasn’t even trying to date. It wasn’t until 2 more years passed that I decided to actually try the therapy that I’d told my mom about. I’ve been in counseling for 8 months now. I’ve come to appreciate that I have a lot of anxiety issues and problems with myself and my parents, and that’s probably why I do this—at least in part. At the same time, my therapist has explained that many people have this disorder. I couldn’t believe that at first; I really thought I was the only one.

How might the treatment approaches used in Cases 2 and 5 be applied to Suzanne? Which aspects of these approaches would not be appropriate for her? Should additional interventions be applied?

I’m going to graduate this coming spring, and I’m doing very well at school and in basketball. Mom and Dad are so happy! I haven’t pulled any hair out in, I think, close to 4 months, and I’m not feeling the urge much anymore, which is great. I feel better about the way I look. I’ve also started seeing a really nice guy named Mark. It’s going great, although, after the disaster with Jon, I’m trying to take it slow. All in all, things are pretty good, but I do wonder whether I am prone to pulling my hair. Will I revert to this whenever I face a crisis? That worries me, and for now that’s why I am continuing to attend therapy.

A Mother’s View “You’ve Got to Stop This”

I think Suzanne was about 13 when I first noticed the problem with her eyelashes. We were sitting at the dinner table—this was about, oh, 8 years ago—and talking about her cheerleading practice. She was excited that she’d been picked to be the top of the pyramid. Tom and I were also happy about that. We’d been encouraging Suzie to try out for this cheerleading team because she had seemed unhappy. Sometimes she’d cry, and when we’d ask her what was wrong, she’d say, “I don’t know,” or “School is really hard.” Tom and I talked about it and thought she might want to get involved in an extracurricular activity. We gently tried to get her to go out for a sport, like basketball, which she was so good at, but she insisted she didn’t like playing sports. Finally, in desperation, I suggested that since she really liked gymnastics, she might want to try cheerleading. Suzie loved the idea. Apparently, she had thought about cheerleading, but she had been afraid to ask us if she could be a part of the team. She was concerned that we’d be disappointed; she thought we might look down on it compared with basketball, soccer, or field hockey. Can you imagine that?

Are the family, school, and social pressures described by Suzanne particularly unusual? Why might they have led to dysfunction in Suzanne’s case, but not in the lives of other persons?

Anyway, the eyelashes. . . . She was telling us about this pyramid thing at the table, and I wanted to give my little girl a big hug. When I leaned in, I thought something looked peculiar about her face. At first, it seemed like she looked really sad, and her eyes were bigger than usual. I hugged her and told her that I was so proud of my little girl. Tom looked up from the paper and said he thought it was just great. Later, during dessert, when I was passing out the ice cream, I looked at her again. We were talking about her test the next day in social studies and how much studying she should do after dinner. At one point, she looked up, and that’s when I noticed it.

“What happened to your eyelashes?” I exclaimed, before I could stop myself. Suzie tried to turn her head away and look outside the room, in the opposite direction. She muttered, “I don’t know.” But I said, “Tom, look at this! She doesn’t have any eyelashes.”

He looked over, leaned in, and said, “You’re right, Sherry. What’s going on here, Suze?” Suzie took a deep breath and just said she sometimes plucked her eyelashes out. She didn’t know why she did it. She said she just did—they itched her, maybe. I figured it was some sort of nervous habit, and I told her she had to stop. I told her it wasn’t normal. She got upset, but finally promised she would try to stop doing it. I tried to give her some more incentive. “You’re so beautiful,” I told her, “but you look terrible without your eyelashes. You could look so much better. You’ve got to stop this, okay?”

On the surface, Suzanne and her mother had a close and loving relationship, but they also had some serious problems in their interactions. What were some of these problems, and how might they have contributed to Suzanne’s disorder?

For a while after that, I’d see her rubbing her eyelids where the lashes used to be. Tom and I tried to help out by stopping her whenever we saw her playing with her eyelids or eyelashes. After a while, and with some effort, it seemed to pay off. Her eyelashes eventually grew back, and she didn’t seem to be plucking them anymore. Tom and I forgot all about it after a few years.

When Suzanne went off to college in Florida, the last thing on my mind was the way she had plucked out her eyelashes at the age of 13. Tom and I had been hoping she would go to a good school, with a strong girls’ basketball team, but she didn’t do very well on her SATs, and never did well enough in basketball to interest the scouts from the big schools. Anyway, the school she went to was fine, and we were proud that Suzie was going to college.

She never called us when she first went away. I guess it was the excitement of being somewhere new. Anyway, girls are like that at that age. When we would call her to see how she was doing in her classes, she never seemed to want to talk—she would talk very softly, say things were fine, and yes, she was making friends. She would then rush off the phone; once, I was sure that she was holding back tears.

When she came home for her first winter break, she had the most ridiculous hairdo I’d ever seen: a weird type of beehive combed over from the left. It was just horrible. I asked her why she did that to her hair, and she just said she liked it that way. After she’d been home a few days, she literally let her hair down, and when she tilted her head back once, right before she quickly brushed the hair back over, I saw it—her scalp! A horrifying, huge bald spot. I asked her what was wrong. “Are you sick?” But she just got really serious and said she didn’t want to talk about it. Then she left the room.

Later, she admitted that she had started pulling her hair out. She said she didn’t know why she did it, but she was going into therapy, for that and for a lot of other things. She explained that it was somehow connected to the eyelash thing from years ago, and I thought. “Of course, it all makes sense now.” This is really strange, but she told me that it wasn’t my problem, and I should just let her try to work on it herself.

What defense mechanisms did Suzanne and her mother seem to use in order to cope with her eyelash problem and, later, her hair-pulling problem? How did such mechanisms help Suzanne? How did they hurt her?

After that, once she was back at school, whenever I would ask her on the phone how she was doing with the hair problem, she would mumble a short answer like “Fine.” Sometimes she wouldn’t come home at all on vacations. But I guess now that she’s a senior, she’s made things right and put it all behind her. She was home just last month and she certainly seemed to have a full head of lovely blond hair. We had a great visit and she’s looking forward to graduating. And guess who’s the starting guard on the girls’ basketball team?"