Amy Elliott is a 34-year old Caucasian female. She was mandated to undergo a psychiatric evaluation due to the complexity and severity of the crimes she committed. Amy presented as calm, collected, and well-groomed during the initial interview. She began the interview smiling and very conversational with a very likable demeanor. As the interview progressed she became increasingly agitated as her husband unraveled the events leading up to her disappearance. Amy’s husband, Nick Dune, participated in the evaluation since Amy continues to insist that she “has done nothing wrong.” Nick seemed distressed at the beginning of our conversion and stated that he “felt relieved” at the end of the evaluation.

At the beginning of the interview, Amy stated that “she should not be in prison because she did not fake her own murder” (A. Dune, personal communication, 2016). She continued by claiming that her ex-boyfriend, Desi Collings, injured her badly when he abducted her, which made it look like she had been murdered. Nick jumped in, with extreme agitation, and yelled “you slit his throat!”.  Nick was asked to remain calm and start from the beginning at Amy’s childhood. Nick stated that:

Amy’s mom has always been really cold and calculating. She has always put Amy on a pedestal and they have never had a disagreement. She even made an imaginary character named amazing Amy that millions of people subscribe to. Amazing Amy is her mom’s fantasy and is nothing like the Amy that I know, for heaven’s sake it has made her family rich. (N. Dune, personal communication, 2016)

Amy replied angrily:

Nick you cheated on me. I should have killed myself so you would have ended up in prison instead of me, then you would have learned your lesson. If you leave me while I am in here I can assure you that you will never see our child. I have proof of child abuse and my mom will consult a lawyer. (A. Dune, personal communication 2016)

Amy’s and Nick’s relationship started out great and they both acknowledged being deeply in love with each other. Amy said that when they first started dating she tried to be Nick’s dream girl and referred to this persona as “Cool Girl.”  She describes,

Cool girl as a hot, sexy woman who is super intelligent, hilarious, and doesn’t mind doing guy stuff like watching football, drinking beer, eating lots of fast food, and farting. Nick didn’t love me, me. Nick loved a girl who doesn’t exist. (A. Dune, personal communication 2016)

Nick replied:

I am not surprised, you are great at making up stuff. You fabricated your dairy with stories of how I am abusive and your fake pregnancy to gain sympathy in your attempt to frame me for murder. I can’t believe you stole your pregnant friend’s urine and brought it to the clinic. I also found out that she setup her ex, Tommy O’Hara for raping her by mutilating her wrists and vagina, because she wanted to get out of the relationship. After she returned home from the fake abduction she went to my sperm clinic and got pregnant so I would have to stay with her. (N. Dune, personal communication 2016)

Then Nick was asked to disclose what he knows about Amy’s disappearance and fabricated homicide. He replied,

She found out I was having an affair, wrote a bunch of lies about me in her diary, cut herself and spread blood all over the kitchen, then broke a bunch of stuff in the living room to make it look like a struggle. On national TV I asked her to come home, and she wanted to be with me so she staged her abduction so she could come home. Amy made it look like her high school sweet heart Desi Collings was holding her hostage by injuring her own wrists and vagina. This way killing him would be justified and she could return to me. (N. Dune, personal communication 2016)

Nick was asked why he did not turn her in if he knew all of this, and he replied, “She got herself pregnant and I needed to stay in the relationship to protect my child from her” (N. Dune, personal communication 2016).

Past Psychiatric History

Amy’s psychiatric history was unremarkable. Amy has no history of psychiatric outpatient treatment, day treatment, or hospitalizations. Her husband, Nick, did indicate that he noticed “wired” behavior a couple of years before she plotted her abduction and false death, but for the most part she seemed fine.

Medical and Developmental History

Medical records showed no abnormal medical history. When Amy was born, her Apgar scores were all within normal range. Records obtained from her pediatrician and general practitioner document her as being physically healthy. Amy’s mother, MaryBeth, was hospitalized for postpartum depression after Amy was born. The hospital that treated her noted that she insisted on paying cash and tried to bribe the hospital to not document the admittance.

In regards to development, Amy demonstrated a typical developmental pattern. She exceeded her development milestones during each checkup for her age group. Her general practitioner noted that Amy seemed quiet or sad during a couple of visits but no pattern persisted. Amy denied any other significant medical history, hospitalizations, seizures, head injuries, nutritional deficiencies, lead exposure, blood sugar and thyroid problems.

Family and Social History

Amy grew up in a privileged upper-class family with her mother MarryBeth and father Randy Elliott. Amy’s parents have always idolized her but show very little affection towards her. Randy and MarryBeth have never had a close relationship and can be verbally hostile towards one another. They stay together to support Amy and do not want to go through the embarrassment of a divorce. Throughout Amy’s school years she has always had a lot of friends; however, the durations of her friendships only lasted six months to one year. When Amy was young, MarryBeth created a fictional character based on her called “Amazing Amy.” Her mother has made a lot of money from writing about this fictional idealization of her daughter. The Elliott’s all have a history of short and empty relationships with friends. Amy has a long history of manipulating people to get what she wants.

Amy’s manipulation of her husband, Nick Dune, has still not been proven in a court of law. After Amy was detained a month ago, Nick reported the murder of Desi Collings to authorities. Her trial will be comprehensive including falsifying her own homicide and for the murder of Desi Collings. Investigators also have a statement from her previous boyfriend Tommy O’Hara, confirming that he was set up for allegedly raping Amy.

School and Employment History

Amy did work until she graduated from college. Her parents gave her everything she wanted since they were making a lot of money off of the “Amazing Amy” series. Amy attended prep school in Columbus, NY where she received a 4.0 GPA. After prep school she obtained a psychology degree at Harvard. Amy only had one job where she worked as a writer in New York, NY and was very successful until she was laid off. Her supervisor, Jane Pufal claimed that Amy was trying to take her position by fabricating stories about her to the company president. Amy has been out of work for two years since she is unable to get a letter of recommendation from her previous employer. A couple of professors at Harvard have come forward with allegations against Amy for bribery. Her professors claim that Amy offered them large sums of money to maintain her 4.0 GPA at Harvard. One of her professors stated, “I did not accept the money, but gave her A’s because the dean idolized her for unknown reasons. I felt my job was at risk if I did not give her good grades” (Professor, personal communication, 2016).

Assessment and Diagnosis

Amy Elliott is a 34-year old Caucasian female presenting with personality and legal concerns. Based on this diagnostic interview and outside records, Amy Elliott meets diagnostic criteria for antisocial personality disorder (APD), malingering, and delusional disorder with grandiose type. Amy displays more than three of the required characteristics listed in criterion A of APD, including multiple acts of breaking the law, deceiving others for personal gain, aggressiveness, disregard for the safety of herself and others, and lack of remorse (American Psychological Association, 2013). She is over the age of 18, meeting criterion B and there is no history of schizophrenia or bipolar disorder, which meets criterion D of APD.

Amy also meets criteria for malingering by fabricating physical symptoms to avoid criminal conviction. There is also a marked discrepancy between Amy’s claim of being abducted and case evidence. She has not cooperated with her evaluation by withholding information and lying.

Amy also meets criteria for delusional disorder with grandiose subtype. She meets criteria A with having the presence of a delusion of being superior and above the law for more than one month. This is the central theme of her delusion that supports a grandiose subtype. She does not present adequate symptoms to be diagnosed with schizophrenia; therefore, she also meets criteria B. Criteria C is met in that her functioning is not markedly impaired, and her behavior is not obviously bizarre or odd. She presents herself as very intelligent and sociable. Amy is not taking any prescribed or illegal drugs, and her condition is not better explained by body dysmorphic disorder or obsessive-compulsive disorder, so she also meets criteria E.

301.7 (F60.2) Antisocial Personality Disorder

V65.2 (Z76.5) Malingering

297.1 (F22) Delusional Disorder, Grandiose type

Treatment Recommendations

Treatment for APD is challenging and extensive. Although Amy is facing life in prison, mental health treatment is needed so that Amy is able to stay in compliance with the state’s prison system. It is recommended that Amy completes all five phases of Erickson’s Psychosocial treatment. Phase one involves developing self-value so that she is not dependent on external achievements to feel valuable. The second phase consists of developing a sense of autonomy, so that she breaks the cycle of being dependent on feeling superior to others. Phase three is the development of individual pride. This will teach Amy how to be accountable for her actions and cultivate a sense of belonging. The fourth phase involves the development of her identity. In this phase she will be taught to eliminate the identity diffusion she experiences which is the source of her threatening/aggressive behavior.

The goal of the final phase is to develop intimacy. When someone has the capacity for intimacy they are less likely to cause harm and take advantage of others. Clark (2011) concluded that the “Reconstructive model of therapy of a psychotic homicidal person has been expanded to the treatment for non-psychotic offenders, and non-clinical populations. Since this model makes use of treating the unresolved stages of Erickson‘s Psychosocial Stages” (p. 140). Refer to Clark (2011) for more detail regarding Erickson’s Psychosocial Stages treatment (p.136). Once this treatment is complete, Amy’s malingering tendencies will also subside.

Treatment for Amy’s delusion disorder should be conducted using cognitive behavior therapy (CBT). Her CBT exercises should be geared towards the treatment of her delusions, which are stated above. Treatment using CBT is well documented and effective in treating many mental health disorders, however to treat delusion disorder the therapist must have a specialty in treating delusions with CBT.  The article Delusions and Delusional Disorders (1999) emphasizes:

In cases where the patient is too suspicious to reveal the thoughts, by peculiar or threatening behavior. Cognitive therapists do not challenge the belief or immediately try to change it. Instead they show sympathetic interest and offer to help with the resulting depression, anxiety, and frustration. Meanwhile they are learning how long the delusion has been present, how and when it comes and goes, and which experiences are supporting a delusional system. The patient may be asked to keep a daily log of these experiences. The therapist tries to understand what the delusion means to the patient, what concerns it reflects, what problems it solves, and how it interferes with the patient’s life. Therapists must also ask about hostile plans and do what they can to prevent the patient from carrying them out. (para. 10)

The combination of Erickson’s psychosocial stages treatment and CBT will provide adequate treatment for Amy’s Diagnosis. It is important that Amy completes Erickson’s Psychosocial Stages treatment prior to starting CBT. She needs to establish a sense of self before cognitive restructuring can occur. This will also help her to be accountable in CBT treatment.

Differential

Amy’s diagnosis demonstrations traits in both narcissistic and borderline personality disorders. Her diagnosis did not meet sufficient criteria for either of the above disorders. Narcissistic personality disorder (NPD) was ruled out because she does not present the need to be associated with other high status. This is supported by the fact that most of her relationships have been with regular people. She does see herself as special but does not seek recognition from others. APD better defined her condition, although there is high comorbidity with NPD. Borderline personality disorder (BPD) was also considered and ruled out, mainly because childhood abandonment and trauma were not present in her evaluation. Her parents may have partially rejected her, however they did not completely disregard or leave her. Amy does have a history of unstable relationships and impulsivity, however this is driven by the satisfaction she obtains from deceiving and manipulating others for her own benefit. Although, she did take drastic measures to avoid losing her husband, she does not meet necessary criteria to be formally diagnosed with BPD.

Contributing Factors

There are many contributing factors to consider when diagnosing a personality disorder. An early contributing factor was that Amy’s mother, MarryBeth, struggled with postpartum depression after Amy was born. Goodman (as cited in Jaffee, Strait, and Odgers, 2012) claimed that maternal depression is linked to ABD in that, “Children whose mothers are currently depressed or have a lifetime history of depression are at elevated risk for antisocial behavior” (p. 282). Amy’s APD symptoms could have started when she was an infant.

Amy’s parents also failed to embrace the real Amy and created an idealization of her call ‘Amazing Amy’. She may have internalized this fabricated persona of perfection as a character rejection by her parents. The results of Jevtic (2011) study confirmed that, “parents who actively reject their children have statistically dominant influence in formation of social behavior disorders” (p. 30). The ‘Amazing Amy’ persona also likely contributed to Amy’s delusional state. While actualizing this persona Amy likely felt that she was gifted and perfect, while everyone else is flawed and weak. Feeling gifted has been linked to violence, according to Ullrich, Keers, and Coid (2014) “we identified a further pathway between having special gifts/powers and serious violence. This same delusion, when associated with elation or anger, showed a direct pathway to serious violence irrespective of affect due to the belief.” (p. 1779). This gifted belief of Amy’s was the primary factor in her delusional state additionally contributing to her lack of regard for others, and ability to commit murder

Amy’s parents also showed a lot of hostility and inflexibility towards each other when she was a child. Snyder (as cited in Jaffee et al., 2012) stated that “there is a developmental progression by which antisocial behavior emerges in childhood through hostile and coercive interactions among family members” (p. 286). In addition, Jevtic (2011) confirmed in his study “that parents who are rigid and inflexible in their attitudes have a dominant influence in formation of social behavior disorders” (p. 33). Lack of cohesion between parents is a common factor contributing to the onset of APD in children.

.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Clarke, R. M. (2011). Antisocial behavior: Causes, correlations and treatments. New York, NY: Nova Science Publishers, Inc.

Delusions and Delusional Disorders–Part II. (1999). Harvard Mental Health Letter, 15(8), 1.

Jaffee, S. R., Strait, L. B., and Odgers, C. L. (2012). From correlates to causes: Can quasi-experimental studies and statistical innovations bring us closer to identifying the causes of antisocial behavior? Psychological Bulletin, (2), 272. doi:10.1037/a0026020

Jevtic, B. b. (2011). Causes of antisocial behavior of adolescents. Problems Of Education In The 21St Century, 38,24-36.

Ullrich, S., Keers, R., and Coid, J. W. (2014). Delusions, anger, and serious violence: New findings from the MacArthur Violence Risk Assessment Study. Schizophrenia Bulletin, 40(5), 1174-1181. doi:10.1093/schbul/sbt126