An Absence of Expectations About Dr. Johnson's Normal Life - Case Study Example

Alan Johnson (Don Cheadle) is a successful dentist with apparently fruitful life. He was well paid, was a successful dentist with reputation, a beautiful and caring wife, and children whom he loved. Despite all these he keeps meeting a therapist outside her clinic with several problems. He sometimes fails to communicate and he feels isolated, unfulfilled, and smothered despite having all than a man aspired to have. His hardworking job, family, and others make him not at ease, and he has apparently no one to share. After a long break of about 15 years since their time together in the Dental College, Dr. Johnson meets his roommate Charlie Fineman (Adam Sandler) who had a dental degree too. His personal tragedy was well published in newspaper, and so his friend, Dr. Johnson knows about it. Fineman lost his family on 9/11, and he could not cope up with that tragedy in the ensuing years. The therapist calls it posttraumatic stress disorder, but when Dr. Johnson discovers his college roommate on the streets of his neighborhood, he finds Charlie had changed. The two start spending time together, trying to relive their old days, with hard attempts to find meaning of life. During the course of these events Dr. Johnson finds Charlie to be in a complete mode of denial of the tragic incident related to his family, to be lost in a child-like existence, keeping himself constantly busy in listening to music, playing video games, watching movies, or trying amateur music at home. He is completely oblivious of his professional capabilities of a dentist; he appears disheveled; his rooms are scattered and disorganized; his home has a kitchen but no food; he is obsessive about shoes; he talks in small repetitive phrases; and he cannot tolerate the mention of his family. It is a horrible experience for him to even think about the 9/11 event and the demise of his family. On the contrary, when he hears about the death of his friend's father, he fails to demonstrate any empathy, and to the shock of Dr. Johnson, he keeps talking about having a late night breakfast. Alan finds himself beginning to enjoy life again in Charlie's child-like presence, but as he realizes the extent of the pain that ravages Charlie he starts to attempt to help Charlie face his past and return to the real world. With the cues from the movie, the characters played by Don Cheadle and Adam Sandler will be analyzed here to arrive at the respective psychiatric diagnoses and a treatment plan will be devised. Diagnosis and Treatment Planning Case Study Format Adam Sandler Character: Charlie Fineman I. Presenting Complaint A. What is the client saying about the presenting problem/complaint “I am okay.” “I don’t know, looks I am okay” “I don’t need a shrink” “I don’t like to think about them”, my family. “I don’t want to talk about those things that I don’t remember” “I don’t need to get some help” “ I have no one to share, you have got each other.” B. Subjective symptoms expressed Dr. Fineman developed these symptoms after a traumatic life event of loss of his family. He was afraid to think about his family, and he felt helpless even with the slightest thought about the family, although he persistently relived the event in the subconscious and took all measures in the conscious to avoid being reminded about it. These were obviously overwhelming to him to the extent that he was rendered nonfunctional as an adult, to the extent that he quit his practice as a dentist. There is evidence that he entered into a mode of strong denial of the catastrophe only in a vain attempt to cover up the re-experience of the traumatic event of loss and profound grief over his family in his daily thoughts and dreams. This led to his almost insane determination to evade anything that would bring his thoughts and grief about the event to his mind. There is also noted numbing of responsiveness in his social encounters with the present world and people and quite frequent incidents of states of hyperarousal. He cannot sleep at night, feels depressed, sometimes events of anxieties, and obvious cognitive difficulties failing to recognize even a past college friend and in-laws. He has developed poor concentration shifting from topic to topic. Sometimes he uses substances, and he has been addicted to video games, more to keep himself engaged. He was not able to deal with this experience and could not share this experience with anyone known due to the fact that this would induce the horror and anxiety that he is through. He was also feeling an element of guilt since he felt that he failed to be with his family due to his work when they were flying without them, and it was to him guilt for surviving. His communication was disjointed when it would be anything related even remotely to his family, and he was not able to process or rationalize the trauma that precipitated his experience of horror; even television news related to some terrorist activities somewhere else in the world rekindled his stress. This continual experience of stress led him to embrace different avoidance techniques such as movies, video games, substances, music through headphones in an attempt to avoid experiencing it. He even avoided people, company, children, and women of his age since they reminded him of his family. The feelings would be so overpowering that despite his partial ability to cope with this stress cognitively, sometimes everything will be blocked. The trauma is now being simulated by physical and mental reminders such as sight, smell, or sound. These are presently initialing new fear responses independent of the original event, and he has developed a pattern of avoiding both the stimuli. Secondary gains from the external world monetary compensation and finance management through his attorney, increased attention or sympathy from a friend in the restaurant or in-laws, and satisfaction of dependency needs from his college roommate, all seemed to have reinforced his fear, anxiety, and stress and led to its persistence (Sadock and Sadock, 2007). C. History of the problem Following exposure to the traumatic experience of 9/11, where his family of a beautiful wife and three children were in a flight to Los Angeles, which hit one of the twin towers of the World Trade Centre, Dr. Fineman lost both of his parents in his early childhood. The other details of his developmental years are not relevant to this movie. He had a beautiful wife and three daughters who were "very female" and "adored" him, and he was the only man, the "attaboy", the "Mr. Man" in his family. They had a full and complete life with his wife who never used to "judge" him or "nag" for any reasons. When he used to come back from work, she used to "take his shoes off." For seeing her sister and her boyfriend, his wife and the kids wanted to go to Los Angeles, and the children wanted to Visit Disneyland. Dr. Fineman could not go with them. They were in one of the flights that hit World Trade Center on 9/11, and this shock came to him when he was on his way to airport on the radio, and in the airport, he saw the television footage. The stress had further been accentuated by the memory of his wife and the daughters who lost their lives, and he was feeling like everything was "burning." After this loss his singleness in the backdrop of adulthood and recurrent exposure to precipitating situations lead to social withdrawal. Although he was not directly involved in the incidence, due to the intense bond that he shared with his loving and all-engrossing family, he was actually in the close proximity to the precipitating event; he was feeling the "burn" that his family suffered. Continuous re-experience, reliving, and re-projection in the real world actually continued to expose him to the incident leading to high severity, duration, and proximity to the situation. This indicated that the his subjective meaning of this incident determined the intensity of the traumatogenicity in case of Dr. Fineman, and there could be a possibility that this 9/11 loss was resonating with his childhood trauma of losing both the parents. He was not being able to regulate his affects following the current incident 5 years back. He was employing defenses such as denial, dissociation, guilt, projective disavowal, and guilt of not being there as a defense against helplessness. He is thinking himself to be a victim. While his feelings are actually so intense, he is not able to identify people such as Dr. Johnson who was his college roommate. He is not able to verbalize his feelings and his mental state, and is not able to soothe himself whenever he is under this gripping stress, while his ego is trying to master and reduce the anxiety through reliving, and inability to do so successfully is pushing him harder to take resource to different means of engaging himself in different activities which otherwise he would not do (Palyo and Beck 2005), as his dentist friend Dr. Johnson, apparently not in stress or anxiety, who is leading an apparently normal life with a family in the real world would not do. D. Any previous treatment for this complaint/problem None, at least as evident from the movie. E. Clinical observations during session There are only few scenes involving session. Therapy sessions involved the therapist played by Liv Tyler and Fineman played by Sandler. However, a trained observer will have a host of clinical observations about Fineman throughout the movie, and consequently, there are multiple clinical observations. Dr. Fineman used to live in a large settlement with his wife and three daughters. He left it and his established dental practice and embraced a lonely world of his own, drifting away from the regular and boring life of similar dentists such as his roommate Dr. Johnson. He now wanders alone in his scooter on the roads of the city and has been noticed by his close friend, a dentist, and old college roommate Dr. Johnson. This all occurred to him following the 9/11 catastrophe to his family. Initially he fails to recognize his friend but after few encounters, the old memories re-emerge, and he was able to recognize his friend. He has regressed to a state of denial, where he keeps himself busy with many other things other than dentistry, which are old Mel Brooks movies late night, video games, music, and musical instruments. He gets so excited about the memories of his family that he avoids social contacts which haunt him to remember his past days get back there like all others, and this was perhaps one of the reasons that he allowed Dr. Johnson, his former roommate to come closer. He was seeing Dr. Johnson about 15 years after their college days, and Dr. Johnson never knew his wife and children since they lost touch early on. Unlike others spending time together would not bring these severely hurting memories back, so he could be a safe companion and would allow “just let him be what he is.” These all point to avoidance of fear to remember the terrible past trauma that creates profound stress in him. This is important for him to survive since the memories of his family life bring back the severe pain and trauma and the sense of “burn” that his family might have suffered during this incident. The intensity of this emotion can be felt by the bare walls of his apartment where no memories from the past remained, and his cluttered rooms display severe stoicism and loss of interest about a life that he was used to. The hobby of collecting records, their boxes, and advertising paraphernalia almost displays obsession when the hallway displays plenty of them. Last time when he saw his wife is in their kitchen, and that vision keeps repeatedly coming in, and to get rid of that anxiety, he remodels his kitchen over and over again. This stress that he was going through leads to hostility in his behavior with people who had ever had suggested him to visit a therapist to “fix his life up.” No one had been an exception to that, his in-laws, a cursory acquaintance in record shop, his friend, Dr. Johnson, leading to restaurant spat, vandalism in his clinic, and even at places where these two were trying to relive their old young days of college life, and to the state counsel who used photographs of his wife and daughter to prove his point in the court of law. These aggressive behaviors came on all of a sudden giving the other party no scope to reconcile or convince him. Most of the cases, these turned up to be physical aggression but it could be understood that these were expressions of his fear and helplessness over the traumatizing life situation, where he had intense feelings but had hardly anything to do. Within these, when the two friends were trying to understand each other over again, the best way was to nurture the memories of college life. There amorous trips to night clubs, Chinese restaurants, records shops, and late night movie marathons brought almost pediatric pleasure sensations to both of them, with joint rides on scooter, discussing “girls”, life, and getting to enjoy things which men of their age would not do. This lead to a respite from this cruel world of reality, which does not bother about “friends who would like to know about what is happening in each others’ lives.” Thus the basic findings are fear, stress and pain due to trauma; loneliness; and inability to communicate. There are suggestions of his mental status throughout the movie. There are situations of painful re-experiencing moments of the even in focus, the 9/11 plane crash. The recurrent thought pattern leads to coping strategy of avoidance and forceful denial and constant hyperarousal to present events which he can mentally connect to his past life with his wife and daughters. There is a feeling of guilt since he was not able to be there as well as the reason he survived. There are feelings of rejection and humiliation, he could not do anything but observe, get the news through radio, and see the crash in television report. Extreme delusion, illusion and hallucination all occurred in the scenes involving his daughters and wife and their life. There are aggressive and violent materials in his behavior; he cannot contain and control impulse, and he is depressed. His memory has been impaired and his attention has been compromised. He has difficulty going to sleep, and in his past life he used to sleep walk. He has recurrent and intrusive distressing recollection of the event which included images, thoughts, and perceptions. He was acting as of he was feeling as if the event was recurring, he was constantly reliving that experience. He was having delusions and dissociative flashback episodes. He displayed intense psychological distress at exposure to internal and external cues that symbolized or resembled an aspect of this event which was also associated with physiological reactivity. There are other significant observations. He made all efforts to avoid thoughts, feelings, and conversations associated with the traumatic event involving his family. He attempted to avoid activities, places, and people who possibly would arouse recollection of the trauma (Nemeroff et al., 2006). In this when he does not want to remember the trauma, he was perhaps unable to remember important details of that event. He was a dentist, but he was interested in many significant activities. His visits to his friend, Dr. Johnson's clinic and exposure to dental instruments and chair did not around any professional interest, and this indicates his markedly diminished interest in participation in significant activities, whereas he is significantly interested in video games, collection of records, music and musical instruments, late night movie marathons without being concerned about his friend's significant professional work next morning, mock jam sessions and childish pleasures out of it. While these were respites from a boring noncommunicative life for Dr. Johnson, for Dr. Fineman these were avoidance techniques to cope up with the re-experience phenomena leading to a "lot of pain" "in the sea of sadness." There are plenty of evidences that he felt detachment and estrangement from others. A visit to Dr, Johnson's home where in response to his daughter's "Good morning Dr. Fineman" he just walks away from her without a response keeping the girl shocked. This indicates markedly diminished attachment and estrangement from others. When Dr. Johnson tells him about his father's death, he responds by saying "you want to go and get some breakfast." When Johnson repeats "Charlie, my father just died", he responds by saying "ah, there is store that opens next block" or "lets go get some Chinese, Come on, don’t get such a pussy." This indicates severely restricted range of affect pointing towards his inability to have loving and empathic feelings. In all his activities, he demonstrates an absence of expectations about his career, marriage, children, or a normal life, which can be termed as a sense of foreshortened future. II. Social and Family History A. Family of Origin 1. Parents Living or deceased/married or Divorced/when Both parents expired when he was in the grade school 2. Siblings No reference 3. Extended Family Only in-laws, none other reported 4. History of psych or medical disorders in the family None reported 5. Developmental History Nothing significant B. Current Family 1. Married or Divorced Married, wife deceased in a terror plane crash 2. Children/Ages Three children, all deceased in the same plane crash. 3. History of psych or medical disorders in family None. 4. Any current marital and/or family dysfunction a. domestic violence: None b. child or elder abuse: None c. sexual abuse: None d. extramarital relationships: None C. Vocational/Educational History 1. Current Occupation and job if any None 2. Disability? State, Federal or Military None 3. Academic history and highest grade achieved Dental post grad 4. Certifications, licenses, special skills etc. Licensed to practice dentistry in the United States, can play guitar and drums D. Socialization 1. Discusses friends and interactions 2. Social outlets: Church, Clubs, Hobbies involving others etc. III. Mental Status Exam A. Follow one of the outlines passed out in class B. Include dual dx. Information IV. Staffing V. Treatment Plan A. Treatment Problems PTSD with difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (McFarland 2005). B. Treatment Goals/Objectives (related to presenting complaint/problem) Support, encouragement to discuss the event, and education about a variety of coping mechanisms C. Planned Treatment Modalities (Individual, Group, Family, Marital) 1. Modality, Frequency, Estimated Duration Patient experienced a traumatic event in the past and now has PTSD, the emphasis should be on education about the disorder and its treatment, both pharmacological and psychotherapeutic. 2. Referral for Psychiatric/Neurological/Medical evaluation To be done 3. Psychological or Neuropsychological testing indicated None 4. Other social service resource needed and referrals made Additional support for the patient and the family can be obtained through local and national support groups for patients with PTSD VI. DSM-IV-TR Diagnosis A. Axis I Clinical Disorder(s) any other disorder that may be the focus of clinical attention None B. Axis II Personality Disorder(s) Mental Retardation None C. Axis III General Medical Condition None D. Axis IV Psychosocial and /o Environmental Problems/Stressors Posttraumatic Stress Disorder E. Axis V Global Assessment of Functioning (GAF) 0-100 50 Reference McFarland BH. (2005). Introduction: Disaster dangers and decisions. Community Ment Health J. 2005;41:631-632. Nemeroff CB, Bremner JD, Foa EB, Mayberg HS, North CS, Stein MB. (2006) Posttraumatic stress disorder: A state-of-the-science review. J Psychiatr Res. 2006;40: 1-21. Palyo SA, Beck JG. (2005) Post-traumatic stress disorder symptoms, pain, and perceived life control: Associations with psychosocial and physical functioning. Pain.;117:121-127 Sadock, BJ and Sadock, VA, (2007). Posttraumatic Stress Disorder and Acute Stress Disorder in Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition 612-622 Read More