The patient is a 23-year-old veterinary assistant admitted for her first psychiatric hospitalization. She arrived late at night, referred by a local psychiatrist, saying, “I don’t really need to be here.”
Three months before admission, the patient learned that her mother had become pregnant. She began drinking heavily, ostensibly in order to sleep nights. While drinking she became involved in a series of “one-night stands.” Two weeks before admission, she began feeling panicky and having experiences in which she felt as if she were removed from her body and in a trance. During one of these episodes, she was stopped by the police while wandering on a bridge late at night. The next day, in response to hearing a voice repeatedly telling her to jump off a bridge, she ran to her supervisor and asked for help. Her supervisor, seeing her distraught and also noting scars from a recent wrist slashing, referred her to a psychiatrist, who then arranged for her immediate hospitalization.
At the time of the hospitalization, the patient appeared as a disheveled and frail, but appealing, waif. She was cooperative, coherent, and frightened. Although she did not feel hospitalization was needed, she welcomed the prospect of relief from her anxiety and depersonalization. She acknowledged that she had had feelings of loneliness and inadequacy and brief periods of depressed mood and anxiety since adolescence. Recently she had been having fantasies that she was stabbing herself or a little baby with a knife. She complained that she was “just an empty shell that is transparent to everyone.”
The patient’s parents divorced when she was 3, and for the next 5 years she lived with her maternal grandmother and her mother, who had a severe drinking problem. The patient had night terrors during which she would frequently end up sleeping with her mother. At 6 she went to a special boarding school for a year and a half, after which she was withdrawn by her mother, against the advice of the school. When she was 8, her maternal grandmother died; and she recalls trying to conceal her grief about this from her mother. She spent most of the next 2 years living with various relatives, including a period with her father, whom she had not seen since the divorce. When she was 9, her mother was hospitalized with a diagnosis of Schizophrenia. From age 10 through college, the patient lived with an aunt and uncle but had ongoing and frequent contacts with her mother. Her school record was consistently good.
Since adolescence she has dated regularly, having an active, but rarely pleasurable, sex life. Her relationships with men usually end abruptly after she becomes angry with them when they disappoint her in some apparently minor way. She then concludes that they were “no good to begin with.” She has had several roommates, but has had trouble establishing a stable living situation because of her jealousy about sharing her roommates with others and her manipulative efforts to keep them from seeing other people.
Since college she has worked steadily and well as a veterinary assistant. At the time of admission, she was working a night shift in a veterinary hospital and living alone.