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Brent Ball

on 8 March 2014

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Transcript of IDENTITY

Diagnosis and Assessment Cont'd...
V Codes:
V15.49(Z91.49) Other Personal History of Psychological Trauma

Strength Based Assessment:
Intelligent, Able to live life without help from others up until crimes, Identities are reflection of Malcolm’s personality, and several Identities are represented by the moral and kind aspects of Malcolm’s personality.
Treatment Phase Two: Middle Stage
Goal: Confronting Malcolm's traumatic past, while meshing together the different identities, without singling any out.
Treatment Plan
Psychotherapy integrated with CBT:

The problems we will focus on are psychological in nature (Dissociative Identity) and can vary in terms of their causes, influences, triggers, and potential resolutions. Cognitive Behavior Therapy will be used to challenge Malcolm's maladaptive thinking, his patterns and beliefs, and replace them with "realistic" thoughts in an attempt to merge the fractured parts of Malcolm's personality.
Without focusing on the identities as separate entities.
Treatment Phase One: Early Stage
Goal: Educate Malcolm on his disorder and improve his overall level of functioning
Treatment Phase Three: Final Stage
Develop coping skills
Improving understanding of self
Malcolm will be institutionalized so his quality of life will be based on his surroundings, but his ability to focus on current problems or issues and not on his past trauma will improve his overall functioning
Realization that all of his identities are part of who he is and while DID may always exist, Malcolm can understand he is one person, with one personality.
Refer to a different Psychiatrist due to medication issue.

Diagnosis and Treatment Plan
For Malcolm Rivers

Paris Nevada
Robert Maine
Timmy York
George York
Larry Washington
Caroline Suzanne
Ten Strangers find themselves stranded at a Nevada Motel during a severe storm, only to find out each of them has a connection to each other as one by one they are murdered.
We the audience learn that each character is a different identity inside the mind of Malcolm Rivers, an accused murderer on trial for six homicides at an apartment complex.
In an attempt to eliminate the murderous identity Malcolm's psychiatrist, Dr. Mallick, attempts to make contact with the personality of Ed, to find and kill the identity responsible for the murders.
Case Conceptualization
Malcolm Rivers, a 43 year old Caucasian Male, has been court mandated, on the account of him committing crimes, he claims he was unaware of committing, and with him is a journal, that he has been writing in.

Abandoned by his mother at a Motel, at a young age.

Mother was a prostitute, and in his journal Malcolm writes as a prostitute named Paris in some of his entries.

Was physically abused by his mother as reported

Has little recollection of his mother, only states that she was a “whore”

Journal entries are written in different points of view and all the entries have different handwriting according to different identities.

Different identities include, an ex-cop turned limousine driver named Ed, the prostitute mentioned above, named Paris, Two criminals (one posing as a police officer), a drifter, a movie star, a just eloped couple, a father and his son Timmy.

Case Conceptualization Cont'd...

In some cases the journal entries respond to each other, asking how did you get my book and why are you writing in it.

Malcolm often shifts from identity to identity, not remembering the previous one or where he is.

Malcolm has no family members he speaks with

Can be in a catatonic state when shifting identities

When Malcolm is portraying any of his identities he is completely convinced that he is someone other than Malcolm Rivers, not acknowledging the existence of Malcolm Rivers at all.

Every identity has the same birthday, and all identities have a U.S. state in their name.

The crimes were committed on Malcolm River’s birthday

No drug use or any other substance reported

Unable to function as one identity for any extended time, due to the shifting from identity to identity

Mental Status Exam
Overweight, pale skin tone, no hair on head, shaving kept up
Affect and Mood:
Confused, Anxious, Mood changes with identities from happy to in disarray. Affect varied with each identity shift.
Attitude Towards Interviewer:
Attempts to convince Interviewer he is not Malcolm Rivers, aggravated, hostile
Behavior and Psychomotor Activity:
Agitated, fidgeting in seat, at other times motionless
Perceptual Disturbances:
Shifting from identity to identity, not presently in reality
Speech and Thought:
Panicked speech, racing thoughts that appear spontaneous based on identity shifts and unorganized, at other times catatonic
Orientation and Consciousness:
Does not have have a grasp on reality, believes he is somewhere else than where he is. Blackouts, and catatonic
Does not remember shifting between identities, does not remember who he is himself, does not remember committing any crimes
Some identity states appear highly intelligent, while others not so much
Reliability, Judgement, and Insight:
Non-existent with no consistency. Client lacks consistent judgement, and is unaware of his problems

Diagnosis and Assessment
300.14(F44.81) Dissociative Identity Disorder

Diagnostic Criteria:

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important, personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
E. The symptoms are not attributable to the physiological effects of a substance or another medical condition.
Establishing safety, stabilization, and symptom
reduction, for daily life functioning through establishing the counselor, client relationship with Malcolm.
It is vital to educate Malcolm on the Disorder that he has, through a psycho-educational process so that Malcolm can also be aware of his confusion and lapse in memory. Once Malcolm is aware, steps to keep Malcolm safe through acknowledging symptoms of identity shifts are administered.
Once symptoms are pinpointed we can work on focusing on the trauma in the second stage.
Collaborate with Malcolm's psychiatrist to find out
any medication Malcolm, may be taking.
Bringing forth the reality that Malcolm has experienced a trauma and it is in the past.
CBT, process of re-framing Malcolm's behavioral responses to the traumatic event.
Focusing on the person Malcolm is and helping him identify himself, as Malcolm Rivers. Focusing also on the strengths of Malcolm's personality.
Goal: Rehabilitation for overall life adaption
and coping
Final Thoughts...
The overall goal is to get Malcolm functioning enough to understand his disorder and find some meaning for his life while he is incarcerated.
There is no medication that can alter the identity shifts of DID
It is cautioned that alternate identities should not be addressed one by one, or as individual parts, so not to reinforce any of the separate identities. Which Dr. Mallick does in the film, and it costs him dearly.
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, American Psychiatric Association, Washington, DC, 2013.
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