Crystal Methamphetamine, Body Dysmorphia, and Shame: A Psychodynamic Case Report from the Trainee Perspective

Abstract

Shame is an affect common to many pathological as well as nonpathological states. It is rarely described in academic psychiatry, and the reasons are probably more sociocultural than physiologic or scientific. Whether identified as shame or termed something else altogether, it is often the target of effective therapies addressing anxiety, depression, substance abuse, personality conflicts, and even delusions. It is particularly common within lesbian, gay, bisexual, and transgender (LGBT) populations given the difficulties of confronting and accepting the self. Using a clinical case experienced by a psychiatry resident trainee as a framework, this paper explores the phenomenon of shame as a common pathway to several psychiatric diagnoses within the same patient. Psychodynamic aspects of the patient's relationships with family members, his interactions with the resident, and the resident's countertransferential reactions are explored as well.

KEYWORDS:

• clinical case discussion
• shame
• crystal methamphetamine abuse
• body dysmorphic disorder
• psychodynamics
• countertransference
• inpatient psychiatry

Shame is an affect shared by many pathological and nonpathological states. It is rarely described in academic psychiatry, and the reasons are probably more sociocultural than physiologic or scientific, given its classically moralistic connotations. Pallanti identified shame as very common but “much more structured in its abnormal expressions in anxiety disorders, particularly social phobia, obsessive-compulsive disorder, eating disorders, [and] body dysmorphic disorder” (2000). As such, it is often the target of effective therapies addressing anxiety, depression, substance abuse, personality conflicts, and even delusions.

The following clinical case, as experienced by a second-year psychiatry resident, explores the phenomenon of shame as a common pathway to several psychiatric diagnoses within the same patient. Psychodynamic aspects of the patient's relationships with family members, his interactions with the resident, and the resident's countertransferential reactions are explored. Commentary is inserted at intervals to provide analysis and context. The case has been disguised to preserve the confidentiality of the patient, staff, and others involved.

DK was a Caucasian male in his late twenties with little other known history or demographic information on initial presentation. At approximately 10:00 PM on a Friday night in Manhattan, police found DK wandering in a disorganized, paranoid state, shouting that he “did a lot of drugs.” Among various nonsensical statements, he reported having ingested two grams of crystal methamphetamine and requested help. There was little other information regarding his past at the time.

Upon arrival to the emergency department (ED), DK required physical and chemical restraint for bizarre, disorganized behavior and several attempts to elope. Over the initial 12 hours of observation, eight milligrams (a high dose) of intravenous lorazepam (a sedative) were administered, and his vital signs were monitored closely. The ED psychiatry resident consultant observed vague paranoia, perceptual disturbances including synesthesia, and an unreliable and a completely disorganized thought process; collateral history could not be gathered, and DK was admitted to the inpatient psychiatry unit while maintained on constant observation. Lab work revealed a urine drug screen positive for amphetamine, and thus DK was diagnosed with an amphetamine-induced psychosis. The initial treatment plan consisted of oral olanzapine (antipsychotic) five milligrams twice daily, as well as lorazepam doses as needed for instability of blood pressure or pulse.

Over the following 48 hours, the patient remained extremely disorganized, intrusive, and anxious; he was noted to respond to questions in nonsequiturs and showed extreme loosening of associations. Despite these findings, he was in behavioral control and remained redirectable with simple verbal commands. One notable theme during this overt psychosis was a preoccupation with death, as he often asked staff if he had died yet. He also described everything as “dream-like.” Another constant was his expression of a desire to stop using drugs. At this point, however, he lacked insight into his illness, was disoriented to place and time, and still could not provide reliable collateral contacts or information.

A link between drug abuse and suicidal ideation has been well established in the literature (Borges & Loera, 2010; Richardson-Vejlgaard et al., 2009; Mino et al., 1999; Ganz & Sher, 2009). Some have suggested that all self-defeating practices (e.g., cigarette smoking, poor dietary habits) represent subtle suicidal acts, and this may represent an identifiable unconscious process from an analytic perspective, but direct correlations have only been revealed between depression and substance abuse (Ellis & Trumpower, 2008). Regarding crystal methamphetamine, one study (Yen & Shieh, 2005) found that up to 16% of surveyed users had experienced overt suicidal ideation in the preceding year of drug abuse. Darke et al. (2008) reviewed both physical and psychological problems associated with crystal amphetamine abuse, drawing special attention to propensities toward depression, anxiety, and suicidal behavior. These are beyond the well-documented phenomenon of crystal methamphetamine-induced psychosis, characterized by Nakatani (1998) as passing through three distinct stages: restlessness and insomnia, hallucinatory/paranoid state, and disturbance of consciousness. Each of these phases was observed in DK, and the last stage seemed to offer a glimpse into his unconscious preoccupations, including death and shame or regret over substance abuse.

It should be noted here that the resident psychiatrist who admitted DK from the ED while on call later directly cared for him on the inpatient unit until the time of discharge. In order to do this, he specifically admitted the patient to the floor on which he worked during the week because he found the patient interesting and perhaps vulnerable. The resident was consciously unaware of the reasons behind this, but they quickly became evident as the case progressed and with further reflection.

Without warning or prior contact, DK's mother visited the inpatient unit on the third day of his admission, and she provided the following collateral information. DK was born and raised in a New Jersey suburb and continued to live there with his mother while working full-time as an account executive for a large company near their home. He was the only child of a marriage that ended four years after his birth, and he divided the majority of his upbringing between two households.

Collateral information further revealed a complex psychiatric history including anxiety, body dysmorphic disorder (BDD), and insomnia, as well as crystal methamphetamine and alcohol dependence. Bipolar disorder had been considered in the past but was never formally diagnosed or treated. DK had been psychiatrically hospitalized once before for a similar, methamphetamine-induced psychosis and had attended two outpatient drug rehabilitation programs several years earlier, but he was never admitted to an inpatient rehabilitation program. He also had undergone trials with antidepressants (escitalopram, fluvoxamine, bupropion) and hypnotics (zolpidem) with little if any success in targeting his symptoms of anxiety or body dysmorphia. DK had no history of formal psychotherapy other than very brief, school-centered counseling trials. According to his mother, he had never evidenced suicidal behavior or attempts, although he was known to have episodes of rage directed at family members and ex-lovers, including violently beating one ex-boyfriend. He had two citations for driving under the influence (DUI) of alcohol but no other legal or criminal history. His family history was positive for bipolar illness in a maternal uncle as well as alcoholism in a number of relatives.

A chaotic upbringing and unstable life patterns emerged in the history, suggesting a conceptual framework with which to approach DK. The history of BDD was particularly striking to the resident, partially as a result of the perceived infrequency of the condition. For the resident, BDD immediately suggested an obsessional preoccupation with unmet physical beauty or perfection, but a full history had not yet been obtained. After investigating the disorder, the resident recognized a variety of subtle symptoms along a continuum of severity that applied to himself, particularly during adolescence. He attributed this particularly to his cultural upbringing (i.e., Hispanic in Miami) but noted DK and himself along a “body dysmorphia spectrum” of sorts.

A number of other commonalities between DK and the resident emerged. The two were of the same age and shared physical attributes such as dark eye and hair color, fair skin, and sharp features. The resident noted, however, that DK was meticulously groomed and shaven with so-called “clean-cut” features, consistent with BDD, but also suggestive to the resident of an “older version” of himself. The resident additionally observed that DK was of a suburban background decorated with occasional escapes into city life—he recalled a similar context for himself in Miami only a few years prior to this encounter. Upon reflection, the resident felt that he had “escaped” this existence and “liberated” himself from what he perceived as rigid constraints imposed by his family, Catholicism, and the Hispanic culture from which he originated. The resident was conflicted between a sympathetic desire for DK to individuate as well as paternal disappointment over how DK appeared to rebel via self-destructive binges.

DK's mother noted that a number of events occurred the year before DK began using crystal methamphetamine. At age 19, he declared his homosexuality, resulting in vehement rejection by his father. A series of subsequent paternal betrayals ensued, including ceasing financial support and a court designation of DK as an emancipated adult, somehow restricting DK's ability to secure financial aid for school. Although DK had hoped to attend college in Southern California at the time, he began community college courses instead, where he met others who regularly used cocaine, alcohol, and amphetamines.

DK's drug use was described as an eight-year-long repetitive pattern in the following sequence over a four- to six-week period per cycle: binging on cocaine, methamphetamine, and alcohol while engaging in impulsive spending and reckless sexual activity in New York City with strangers; feeling scared and paranoid while “crashing” and becoming depressed; returning home to a suburban environment in order to recover with the assistance of his mother; commencing work as soon as possible while remaining rather unmotivated but superficially responsible and in control; developing increasing ambitions and self-esteem while taking on various projects and outlets such as sports or new hobbies; becoming reminded and subsequently frustrated about being isolated in the suburbs with his mother and working in an understimulating position; losing considerable amounts of sleep and expending large amounts of energy watching pornography and seeking sexual outlets via the Internet; and losing control while repeating binge activities as previously described.

Of note, alcohol had been forbidden in DK's home for a period of time after his DUI charges several years earlier, but his mother re-introduced wine six months prior to this admission, and he gradually increased his use from two glasses per night to approximately two and a half bottles of wine per night by the time of his admission.

In addition to the aforementioned parallels, DK's living situation, physical attributes, and coming-out history were uncannily similar to those of a very close relative of the resident psychiatrist. This gay relative was of similar age, appearance, and demeanor to DK, raised in suburbia while living in the closet. This relative experienced a difficult transition within his community and family when coming out. The resident was supportive of his relative throughout this period while facing intense resistance and judgment by the shared family members. The relative was ultimately accepted by family and peers and the resident felt pride in his supportive role.

Drescher (2004, 2008) has written extensively on homosexuality and the process of coming out. He describes the common occurrence of hiding activities that are learned in childhood and persist into adulthood as a result of intolerance or judgment from peers, family, or society at large. These lead to concealment of important aspects of the lives of many lesbian, gay, bisexual, and transgender (LGBT) people.

Underlying such hiding behaviors is a strong and pervasive sense of shame, and internalized homophobia has been implicated as contributing to this shame. Allen and Oleson (1999) surveyed gay men and correlated internalized homophobia with high degrees of shame as well as with low self-esteem. In coping with a poor self-image, LGBT people often engage in self-destructive behaviors (e.g., drug use, self-induced debt, reckless behaviors), which McDermott et al. (2008) concluded was a form of self-punishment. The authors added that LGBT people often employ “modalities of shame-avoidance” that include minimization of homophobia and construction of “proud” identities. The relationship between homosexuality and narcissism conceptualized by Freud is long-standing (Drescher, 2010), and narcissistic conflicts may be intimately linked to shame revolving around feelings of attraction to the same sex. Compensatory narcissistic defenses may develop including self-aggrandizing or rage directed at others.

The association between narcissistic aggression and shame has been cleverly illustrated (Thomaes et al., 2008) in play studies in which “narcissistic” children reacted with hostility toward opponents only when defeated or humiliated.

Dissociation is regarded as one of the more complex hiding behaviors used by LGBT people. Psychoanalytic theories describe dissociation as a disorder of narcissistic self-regulation, resulting in a defensive split between the observing ego and self-experience. In his discussion of hiding practices, Drescher (2004) characterizes dissociation as a fairly common approach for avoiding anxiety-provoking knowledge about the self, leading to a “double life” of sorts. This is evident in DK in whom divergent perceptions of self directed him in different manners, depending on which portion of the self-destructive cycle he was in.

As DK progressively gained insight and his mental status cleared, he was repeatedly interviewed by the resident psychiatrist, a third-year medical student, the unit's occupational therapist, and a social worker. He was polite, forthcoming, and patient with all staff and, with minimal facilitation, cooperated with psychiatric evaluation and concurred that he required further detoxification from substances, acknowledging a recent increase in both alcohol and amphetamine use. He identified work-related stress and having a limited social life as triggers that prompted his drug use. He described his mother as supportive and initially hoped to return to her home in order to resume work and outpatient substance abuse care. After speaking to the social worker and being offered more intensive care in the form of a 28-day inpatient rehab, he agreed to attempt it rather than return home. Of note, at this point DK signed for the release of his car, which he had left somewhere in New York City, to his mother, something that he described having had to do “many times before.”

On the fifth day of admission, the resident psychiatrist asked DK about his developmental history, which revealed a tumultuous and split upbringing resulting in a long-standing unstable self-image and social anxiety. DK recalled his interactions as awkward, frightening, and riddled with doubt and a sense of inadequacy. He also remembered being attracted to males beginning in preschool, shortly after his parents’ divorce. He described an early incident in which his mother warned that there would be a brief nudity scene in a film, and subsequently he felt “disappointed” when he realized it was a female rather than a male nude. He also recalled that at this age he would become irritable and angry if the class did not play together as a group, remembering feeling unaccepted if he were not involved in such group play.

DK spent childhood weekends at his father's house engaged in play and exercise with neighbors in an environment described as organized but strict. Weekdays he found himself in his mother's home, which he characterized as “the total opposite,” with his mother working excessively, a paucity of rules or structure, and the majority of his time spent watching TV alone. This dichotomy persisted until he was 19 and his father prohibited DK from visiting him and cut long-standing financial support (“he showed his love in a financial way, which was cut when I came out”).

DK watched considerable amounts of TV, especially sitcoms, throughout his early upbringing and continued to do so until the time of admission. He attributed his affinity for TV to its likable and accepted personalities, noting that he always wished avidly to be “good-looking and famous.” He noted suffering from “terrible acne” with the onset of puberty at age 13; he also noted an obsession with facial symmetry at this time and had his first major cosmetic surgery (pinning his ears back, or otoplasty) at age 11. At age 16 he had rhinoplasty and thereafter completed three sets of artificial cheek implants “because people on TV have nicer cheeks than I.” The last of these was performed two days prior to the current hospitalization in the context of his spending and substance abuse binge.

DK denied any instances of physical or sexual trauma or abuse.

In examining the relationship between BDD and shame, the literature reveals a number of findings. The prevalence of the condition is fairly high, with a range between 2.3% and 13% in nonclinical samples. Intrinsic to the condition is a high degree of humiliation and shame over cosmetic or physical matters, leading to underreporting as many patients choose not to approach clinicians (Grant et al., 2001). Features include obsessive compulsive disorder (OCD)-like rituals, such as excessive mirror-checking, consultation with others regarding appearances, hair/eyebrow-plucking, grooming, tanning, changing clothes, and attempts at hiding perceived defects with makeup or accessory items and clothing. Phillips has studied BDD extensively, and in regards to suicidality, she found a lifetime rate of suicidal ideation of 78–81% in these patients (Phillips et al., 2005). Attempted suicide in this population was as high as 26%, and the relative risk of suicide was 6–23 times that of the general population (Phillips et al., 2007). Other studies (Gunstad & Phillips, 2003) identified Axis I comorbidities that further increase the risk for suicide in this group, including major depressive disorder, eating disorders, and substance abuse disorders.

BDD is characterized with negative thinking at a delusional order. Phillips postulates that as a result of obsessive and intrusive feelings of anxiety and shame regarding appearance, these patients become overwhelmingly distressed and find no relief from recognizing that the thoughts are either inaccurate or senseless. In a study examining self-esteem and BDD, Phillips et al. (2004) found a high correlation between low self-esteem and severity of BDD but felt the relationship was largely mediated by depressive symptoms. Therefore, they could not conclude whether poor self-esteem predisposes to BDD and/or is a consequence of the disorder.

The true etiology of BDD in general remains elusive, but some studies have associated early abuse with the development of the disorder. Didie et al. (2006) explored the incidence of childhood maltreatment in this group and found that more than three-fourths of BDD patients experienced emotional neglect (68%), emotional abuse (56%), physical abuse (35%), physical neglect (33%), and/or sexual abuse (28%). DK's history offers no physical or sexual trauma, but surviving a divorce and subsequently enduring split upbringings with rigid expectations from his father and a passive approach by his mother suggest emotional abuse and neglect, respectively.

Considering these family relations, DK's case thus far reveals relevant, psychodynamic tension. Betrayal by his father appeared to be sophisticated and complex, with severe legal and financial acts hindering DK's ability to attend college or truly emancipate himself. DK's mother practiced maladaptive enabling patterns such as reintroduction of alcohol into the home, a general lack of structure or limit-setting and repetitive coddling of DK after each binge. Given these failures and no mention of other social support since her divorce, DK's mother appeared to depend strongly and solely on his reliable cycle of self-destruction (at one point she even admitted to scheduling events around DK's pattern).

The resident psychiatrist noted several countertransferential reactions at this point. He recalled feeling anger upon learning about the sociopathic aspects of DK's father's strangulation and thus empathized with DK's aggressive rage and distrust toward others. The resident also felt disappointment in DK's mother, who appeared incompetent, unstable, and disinterested in “truly” helping her son. The resident felt DK could only be helped by severing the codependent cycle.

The resident confronted DK regarding the cyclical nature of his drug use and an overall pattern of instability. The patient seemed to show a degree of insight into his need to fill a “hole” or “void” with drugs, material items, casual and unprotected sex, and other thrill-seeking behavior that he identified as “self-defeating.” He also admitted to not liking himself much and endorsed chronic feelings of boredom and emptiness. Although he denied overt suicidal ideation or acts, he did recognize the cycle as representative of “some subconscious death wish, like a suicidal act of the subconscious.” In addition to stopping his drug use, DK hoped to end each of the components of the cycle but lacked knowledge as to how to accomplish this.

Intensive and individual psychodynamic therapy was recommended by the resident, and DK superficially accepted this, reporting that he needed to “talk about relationships and the drug use.” He reported little success in the past with relationships of all types. He characterized himself as “an extrovert” but added that he was not able to speak about his feelings or emotions out of fear of intimacy with others. He described an inability to trust people but found that he liked “opening up and talking like crazy” when intoxicated in binges. DK described an unhealthy codependency with his mother and no other real support or friends. He was not open about his sexuality or drug use with coworkers, and lost meaningful contact with his father.

During his five-day hospitalization, DK fully recovered his perceptual abilities and eventually engaged in group activities on the unit despite expressing some discomfort due to “the clientele” being “different” from what he was familiar with. His oral olanzapine dose was reduced to 5mg at bedtime, and aftercare plans were drafted. He expressed concordance with the staff that he would attempt both an inpatient rehabilitation program and subsequent outpatient intensive psychotherapy.

If conceptualized as the ultimate hiding behavior against severe shame, suicidality should almost be expected in patients with such a high degree of humiliation. DK's case is characterized by a diagnosis of BDD and further compounded by insomnia, anxiety, and severe substance dependence. His flirtation with an unconscious death wish as expressed above is understandable and helpful in ultimately addressing his pathological behavior.

Interactions between DK and the resident psychiatrist began to reveal a patient with an impressionable personality style as well as a provider with a paternalistic bent; these profiles were further solidified in the remainder of the vignette.

On the fourth day of care, referral to inpatient rehabilitation was being arranged for DK when his mother learned of this plan through conversation with DK. She phoned the resident psychiatrist and expressed intense outrage over this. She felt that DK required a prompt return to work, home, and outpatient drug treatment, with “perhaps a psychiatrist that can prescribe a medication.” Although informed of the treatment team's formal recommendation for inpatient rehabilitation with the aim of initiating a serious period of sobriety for DK, she countered with a number of rationalizations against this, including lack of insurance coverage, lack of any empirical evidence that rehabs “cured” amphetamine dependence, and the prediction that DK would only “leave prematurely, quit his job, and then move to Southern California to live a fantasy life of Hollywood and drugs.” The resident psychiatrist acknowledged her concerns but maintained his original recommendations. The mother was informed that, as an adult, DK would be asked to make this ultimate decision himself. Although at that point she expressed unwillingness to directly influence her son, DK opted for his mother's plan after speaking to her.

The resident psychiatrist discussed DK's case from an interpersonal perspective in daily interdisciplinary clinical rounds. The amount of time the resident spent working with DK was longer than customary for any given patient, and although psychodynamic perspectives were not routinely elaborated in these rounds, this case was a remarkable exception. The resident recognized having taken a more directive and insight-oriented role than usual, as evidenced by his confrontations of DK's self-defeating cycle and maladaptive relationships. As a result of the altered aftercare plans, for example, DK was encouraged by the resident to think of his own mother as possessing her own “void” of sorts stemming from her divorce, and to consider the possibility that DK filled this emptiness through constant returning to and dependence on her. In light of these interpretations, the resident suggested DK emancipate himself from his mother's influence and consider living elsewhere. The resident became quickly aware of this paternalism and expressed it to supervisors who, acknowledging the strains of managed care in an acute inpatient setting, counseled the resident to maintain a strictly clinical perspective throughout with a focus on rapid transition to aftercare.

It should be noted that during interactions with DK, staff noted a child-like, shy, and impressionable quality to his demeanor. Whenever asked questions of his past or symptoms, he employed laughter and self-deprecating humor as an overt defense, as well as a thin veil of incompetence most often expressed in the form of empty “I don't know” statements, despite revealing fair amounts of insight when pressed further. He appeared uncomfortable and evasive at various points, particularly nonconfrontational, and especially so when exploring topics such as shame, body image, sexuality, and relationships.

Addressing DK's best interests resulted in competition between his mother's suggestions (i.e., outpatient rehab, antidepressant trial, and return home with her) and the treatment team's (i.e., inpatient rehab, intensive psychodynamic psychotherapy, and move away from mother). This tension essentially reduced DK to a transactional, narcissistic extension of two contending selves, in each end offering to enact subconscious wishes and fantasies. This was best exemplified by the resident's personal awareness of his own countertransferential reactions, specifically noting a rescue fantasy regarding DK and a punitive or retaliatory fantasy directed at DK's mother and father. These reactions conjured the resident's own experiences with his relative's coming out and disapproving family members. Upon DK's discharge, the resident additionally felt defeated, incompetent, and disillusioned, suggestive of a projective identification process between patient and provider.

Much can be said about the dynamic exchanges presented here. The above implies some degree of narcissistic injury experienced by the resident. He continued to reflect on the case for weeks and clearly felt the need to re-examine perceived failures in the care of DK. The most direct manifestation of this is this paper. Composition of the vignette represents a narcissistic extension of the resident's self, utilizing DK as a medium for expression of unresolved conflicts.

Regardless of these unconscious motivators, or perhaps as a result of them, the resident emerged with awareness not only of personal psychodynamic forces affecting his interactions but also of the pivotal role of self-image and shame in a number of pathological states.

Xavier Jimenez is PGY-2 Psychiatry Resident in training and Scot McAfee is formar Residency Training Program Director.