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Black Swan: Nina Sayers Case Study

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Daniel O'Neill

on 24 March 2014

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Transcript of Black Swan: Nina Sayers Case Study

Black Swan: Nina Sayers Case Study
Differential Diagnosis:
Other diagnosis which were considered were:
Post Traumatic Stress Disorder
Obsessive Compulsive Personality Disorder
Dissociative Identity Disorder
Anorexia Nervosa
Anorexia Athletica
Post Traumatic Stress Disorder (PTSD)
A. The person has been exposed to a traumatic event in which both of the following were present:
1)The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2)The persons response involved intense fear helplessness or horror

B. The traumatic event is re-experienced in one (or more) of the following ways:
1)Recurrent and intrusive recollections of the event, including images, thoughts or perceptions.
2)Recurrent distressing dreams of the event.
3)Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those on awakening or when intoxicated).
PTSD cont.
B. Cont.
4)Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5)Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C.Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness(not present before the trauma)as indicated by three (or more) of the following:
1)Efforts to avoid thoughts, feelings or conversations associated with the trauma.
2)Efforts to avoid activities, places or people that arouse recollection of the trauma.
3)Inability to recall an important aspect of the trauma.
4)Markedly diminished interest or participation in significant activities.
5)Feelings of detachment or estrangement from others.
6)Restricted range of affect(e.g. unable to have love feelings)
7)Sense of foreshortened future(e.g. does not expect to have a career, marriage, children, or a normal lifespan.

PTSD cont:
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two(or more) of the following:
1)Difficulty falling or staying asleep.
2)Irritability or outbursts of anger.
3)Difficulty concentrating.
5)Exaggerated startle response.
E.Duration of the disturbance(symptoms in criteria B,C, and D is more than 1 month
F.The disturbance causes clinically significant stress or impairment in social, occupational, or other important areas of functioning.
Obsessive Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four(or more) of the following:
1)Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2)Shows perfectionism that interferes with task completion
3)Is excessively devoted to work or productivity to the exclusion of leisure activities and friendships
4)Is overconscientious, scrupulous, and inflexible about matters of morality, ethics or values.
5)Is unable to discard worn out/worthless old objects even when they have no sentimental value
OCD Personality Disorder cont.
6)Is reluctant to delegate tasks or to work with others unless they submit to exactly her way of doing things
7)Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
8)Shows rigidity and stubbornness
DSM-IV-TR Diagnosis
Axis I: Schizophrenia/schizophreniform disorder
Axis II: Borderline personality disorder
Axis III: General Medical Conditions
Axis IV: Psychosocial factors and environmental stressors
Global assessment of functioning (Axis V)

Mental Status Examination
General Appearance:
Borderline personality disorder 301.83

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
(1) Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(2) A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation.
(3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
(4) Impulsivity in at least two areas that are potentially self-damaging (e.g.
sex, substance abuse,
reckless driving, binge eating
). Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.
(5) Recurrent
suicidal behavior, gestures, or threats,
or self-mutilating behavior.
(6) Affective instability due to a marked reactivity of mood (e.g. Intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
(7) Chronic feelings of emptiness
(8) Inappropriate, intense anger or difficulty controlling anger (e.g. Frequent displays of temper, constant anger, recurrent physical fights)
(9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

DSM-IV-TR: Axis I: Primary Diagnosis
Schizophrenia 295.90

Characteristic symptoms:
Two (or more of the following)
, each present for a significant portion of time during a 1-month period (or less if successfully treated):
(1) Delusions
(2) Hallucinations
(3) Disorganized speech (e.g. Frequent derailment or incoherence)
(4) Grossly disorganized or catatonic behavior
(5) Negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

DMS-5: *At least one of the symptoms in Criterion A must be (1), (2) or (3)
**Not applicable for DSM-5 diagnosis.

Social/occupational dysfunction:
for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level or interpersonal, academic, or occupational achievement).

Continuous signs of the disturbance persist for at least six months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in criterion A present in an attenuated form (e.g. Odd beliefs, unusual perceptual experiences).

*Due to the lack of information regarding time frame in the movie we are unable to ascertain if the character has presented with symptoms for at least six months.

Schizoaffective and Mood Disorder exclusion:
Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during the active-phase symptoms; their total duration has been brief relative to the duration of the active and residual periods.


Substance/general medical condition exclusion:
the disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.


Relationship to a Pervasive Developmental Disorder:
If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Axis I: Secondary Diagnosis
Schizophreniform Disorder 295.40

Criteria A, D, and E of Schizophrenia are met.
An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as “Provisional”).

Specify if:

Without Good Prognostic Features
With Good Prognostic Features:
as evidenced by two (or more) of the following:
Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior of functioning.
Confusion or preplexity at the height of the psychotic episode.
Good premorbid social and occupational functioning.
Absence of blunted or flat affect.

DSM-5 criteria: criteria A, C and D of Schizophrenia (DSM-5 criteria) are met.
Axis V: Global Assessment of Functioning (GAF)
Score: 21
Behavior considerably influenced by delusions or hallucinations
Axis IV: Psychosocial and Environmental Problems
Problems with primary support group -
e.g., death of family member; health problems in family; disruption of family by separation, divorce, or estrangement; removal from the home; remarriage of parent; sexual or physical abuse;
parental overprotection
; neglect of child; inadequate discipline; discord with siblings; birth of a sibling.

Problems related to the social environment
- e.g., death or loss of a friend;
inadequate social support;
living alone; difficulty with acculturation; discrimination; adjustment to life-cycle transition (such as retirement).

Occupational problems
- e.g., unemployment; threat of job loss;
stressful work schedule;
difficult work conditions; job dissatisfaction; job change; discord with boss or co-workers.

Other criteria not satisfied:
Educational problems, Housing problems, Economic problems, Problems with access to health care, Problems related to interaction with legal system/crime, other psychosocial and environmental problems.
Differential Diagnoses
Average height; normal build for ballet industry but seamstress notes
"you lost weight"
; clean; neatly dressed; serious "focused" facial expression;
Psychomotor Behavior:
Excellent posture, co-ordination.
Abnormal movements: scratches her back when stressed
Mood and Affect
Congruent mood (happy when given the part, sad when she knows she is dying); normal/stable affect; observed feelings: sadness, anger, worry, happiness, distress
MSE continued...
Ordinary speed, soft, clear, responds only to questions
Lack of insight into illness; Lacks judgement- inability to come to appropriate conclusions (stabs Lily); Impulsive behavior in some instances (substance abuse, intimacy and stealing)
Thought Patterns
Thought content:
Persecutory delusions- singled out for attack
Hallucinations- auditory and visual, mainly visual
Persecutory delusions

Nina believes she is trying to take her role as the swan queen
-Non-bizarre delusion
-No reason to be suspicious of her
-Lily tried to befriend her; looked up to Nina
Predominantly visual
Auditory: "sweet girl"
Nina's BPD symptoms
2. Intense interpersonal relationship with her mother
Does everything to please mother e.g. cake scene
Allows mother to help her get dressed/undressed
Symptom progression: cares less about mother; disobeys her, e.g. goes out with Lily; when mother asks Nina to take of her shirt, "NO!".
BPD Symptoms cont....
Drugs, "it only lasts a few hours right?"
"He picked me, mommy! I'm the new swan queen!"
Mother: [raises voice] What else have you been doing?
Nina: Oh, you want to know their names? [laughs]
Mother: You need to sleep this off.
Nina: No, there were two. There was Tom, there was Jerry.
5. Recurrent self-mutilating behaviour
Back scratching
Paintings (1.32-1.42)
3. Identity disturbance
Becoming the "black swan"
4. Impulsivity
8. Inappropriate intense anger
catches mother's hand in door
aggressively grips mother's injured hand
Sees herself
Lesbian scene with Lily
Dark swan prince

Fatally wounding Lily

Patient identification
Nina Sayers



she is in her mid twentys

Marital status:

Ballet dancer

Personality and emotional traits:

Patient identification
- Dependent

- Introverted, shy and insecure

- Low self-esteem

- Very critical and overachieving

- Difficulty in interpersonal relationships

- Obsessive

-Rigid personality

- Social anxiety and agressive behaviours

- Sexual disinterest

Main symptoms
Dissociative Identity Disorder:
- Persecutory delusions

- Visual hallucinations

- Auditory hallucinations

A.The presence of two or more distinct identities or personality states (each with it's own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person's behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfullness.
D. The disturbance is not due to direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or general medical condition (e.g., complex partial seizures).
Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth leading to body weight of less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue body weight or shape on self-evaluation, or denial of the seriousness of th current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, adminisatration
Psychotic Disorder due to a general medical condition, a delerium, or a dementia
Substance-Induced Psychotic Disorder/Delerium/persisting Dementia
Substance-Related Disorders
Mood Disorder w/Psychotic features
Schizoaffective Disorder
Depressive Disorder not otherwise specified
Mood Disorder with Catatonic features
Delusional Disorder
Psychotic Disorder not otherwise specified
Pervasive Developmental Disorders
Childhood presentations combining disorganised speech (from a Communication Disorder) and disorganised behaviour (from ADHD)
Schizotypal, Schizoid or Paranoid Personality Disorder
Schizophreniform Disorder
Differential Diagnosis
Mood Disorders
Histrionic Personality Disorders
Schizotypal Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
Antisocial Personality Disorder
Dependent Personality Disorder
Secondary symptoms
In DSM-5 non suicidal self injury (BPD symptom) is also considered as distinct disorder.
- Child behavior

- Excessive exercise

- Obsessive behavior with
-calories and weight
- scratching

- Constant worrying

- Anxious or racing thoughts

- Nauseas

Personal Development
The academy holds an audition or Swan Lake. Nina is offered the main role
Nina's life revolves around ballet
We are presented with Lily, Nina's understudy who seems to embody the Black Swan with passion and spontaneity
Nina becomes suspicious of Lily and becomes increasingly paranoid that she is trying to steal the role from her
As the opening night draws closer, Nina becomes more uncontrolled, spontaneous and sexual - Nightclub
Anorexia Athletica (Sundgot-Borgen,1993,1996)
Her ongoing paranoia results in stabbing Lily with a piece of broken glass, after a struggle.
On the opening night, Nina's transformation as the black swan is complete
Unstable relationships with others
Although Nina believed she stabbed Lily, she actually stabbed herself. Despite that, she goes out and finishes her performance.
1. Weight loss (>5% of expected body weight)
2. Delayed puberty(no menstrual bleeding at age 16).
3. Menstrual dysfunction (primary, secondary amenorrhoea, oigomenorrhoea).
4. Gastrointestinal complaints

5. Absence of medical illness or affective disorder explaining weight reduction.
6. Disturbance in body image.
7.Excessive fear of becoming obese
8. Restriction of caloric intake
9. Use of purging methods (self-induced vomiting, laxatives, diuretics)
10. Binge eating
11. Compulsive exercise.
Impulsive behavior
" I felt it... Perfect... I was perfect."
Medical History
Nina violently scratches her back
Patient complaints
Problematic behaviours
Certain medical conditions fit her symptoms, such as
However, it's never stated that she has a medical condition regarding her scratching
Nina Sayers
Example of Dermatitis
Family Psychiatric History
Erica Sayers:
Predisposing factors
Precipitating Factors
Protective Factors
Maintaining Factors
Borderline Personality Disorder
Clinical Formulation
If Nina doesn't answer her phone, she keeps calling until she answers.
Sits in the dark waiting for Nina
Becomes distressed quickly if things don't go her way
However, it is never explicitly stated that Erica Sayers has any mental disorders of medical conditions
Obsessive Behavior
Family dynamics
We only see Nina's mother. She treats Nina as if she is still a child.
This is reciprocated by Nina - " He picked me
We are led to believe that Nina's mother was also a ballet dancer, but had to give up her dream in order to have Nina.
Erica Sayers is very controlling of Nina. She helps her with everything, from undressing to cutting her nails.
Erica is also possessive and doesn't tolerate outsiders.
"Can I help you? (Pause) I'm sorry she's not in"
Father/Father figure is nonexistent in the family dynamic. We assume Erica is a single parent
Getting to play the lead in Swan Lake
Kissing the director before landing the lead
Exposure to high stress.
Drug misuse.
Abnormal Behaviors
Obsessive behavior

Ballet- practices at home, practices at academy
Uncontrollable anger
Towards her mother- nearly breaks her mother's hand
Washing/Cleanliness- washing hands, baths
Experiences 22 hallucinations throughout the movie
Bodily horror- ripping skin, feathers
Often sees a confident evil version of herself in public or in mirrors
Sexual- imagines a sexual encounter with Lily
Nina is preoccupied with the idea that Lily is trying to steal her role. After going partying together, Nina sleeps in and is therefore late for rehearsal.
"She's after me! She's trying to replace me" to Thomas (mentor)
Intense jealousy and obsession lead her into a downward spiral of paranoia
Abnormal Behaviors: Out of character
Nina starts keeping things from her mother
She throws out all her toys
At the beginning, Nina seems to be sexually repressed. She becomes more sexual- has intimate encounters and sexual fantasies about Lily.

- when talking with Lily in dance hall

Alcohol/substance use

-when she goes out with Lily -> fights with her mother that night
-interferes with her ability to perform the next day
Development history of present disorders
Nina is given the main role in Swan Lake which brings great levels of stress
She is obsessive about perfecting her role. She becomes jealous of Lily- Hallucinations about becoming the black swan
She becomes increasingly paranoid- development of delusions
Her interpersonal relationships (Erica & Lily) suffer. Dysfunction at work- her paranoia with Lily hinders her ability to perform
She becomes impulsive- intimacy, substance abuse (cigarette, alcohol & drugs) and stealing (from Beth)
Self-mutilating behavior- constantly scratching her back (Erica
"It's all this pressure... I knew it'd be too much, I knew it"
Inappropriate intense anger- with her mother (on different occasions)
Stress related paranoid ideation (Nina starts crying
"I just had a hard day"
Social/occupational dysfunction
Interpersonal relations

Animosity with colleagues, i.e. Lily
Late for rehearsal
-first apparent friend: kind, supportive
"I think you're going to be amazing"
-relationship declines due to delusions

Relationship with mother breaks down

Smoking with Lily in dance hall
Nina: "It's called privacy, I'm not 12 anymore!"
Nina: [crying] Lily! You made her my alternate?
Thomas Leroy: Well there's always an alternate. Lily is the best choice.
Nina: No, but she wants my role.
Thomas Leroy: Every dancer in the world wants your role.
Nina: No, this is different. She's after me. She's trying to replace me!
Thomas Leroy: Nobody's after you.
Nina: [crying harder] No, please believe me!
Mother: "Shh, it's okay. I'm here. You were scratching all night."
Mother: "you can't handle this!"
Nina: "I can't? I'm the swan queen, you're the one who never left the corps!"
Nina: "why didn't you wake me?"
Steals from Beth
Genetic Vulnerability
Authoritarian parenting style (High warmth, high control)
Single parent
Good premorbid adjustment.Peer-group support
Things for us to consider:
Extremely paranoid about Lily and her intentions
"Sweet girl"
: What happened to my sweet girl?"
: She's gone!"
Nina Sayers meets the DSM criteria for schizophrenia/schizophreniform disorder which in her diagnosis is co morbid with borderline personality disorder.
Nina also meets the criteria for anorexia athletica but this is not in the DSM as of yet.
Do you agree with us putting in both Schizophrenia and Schizophreniform as diagnosis based on timescale?
Do you agree with our BPD diagnosis?
Is there any other diagnosis you think should have been attributed to Nina?
Are you upset there was no video of the lesbian scene?

Focus on Erica Sayers as she is the on family
we are presented with
1. Patient Identification
2. Main and secondary symptoms
3. Developmental History
4. Personal and family history
5. Mental status examination
6. DSM IV-TR diagnosis
7. Differential diagnosis
8. Clinical Formulation
Full transcript