A Case Study of: Norma Jeane Mortenson (Marilyn Monroe) Rachel Miller and Sarah Brothwell Wednesday November 12th 2014.

A Case Study of: Norma Jeane

Mortenson (Marilyn Monroe)

Rachel Miller and Sarah Brothwell Wednesday November 12th 2014

The Case Background● Historic Public Figure found her story interesting after

watching the documentary Love, Marilyn, which showed the complexity of her life through journals and poems that she had written.

● Overall, she survived an abusive, and neglectful childhood, and developed the persona Marilyn Monroe to mask her own insecurities.

● Marilyn Monroe has captivated the hearts of Americans since

her rise to fame in the early 1950’s. Her willpower to establish herself as a serious actress while struggling with deep internal conflict has been astonishing and inspiring.

Assessment: Identifying InformationAge- 36Gender- FemaleSocio-cultural- White European descent, father unknown, lower middle class Education- Dropped out of high school at age 15. Took various classes like dramatic, dance, singing, and horseback lessons. Studied acting with Lee Strasberg at the Actors’ Studio in New YorkEmployment- Model, actress, singer, movie producer

(Buchtal, Hobby & Garbus, 2012)

Assessment: Medical History

Personal Medical History● Insomnia (took barbiturates to fall asleep)● 2 Miscarriages ● Pre-performance anxiety that sometimes made

her physically ill● Chronic gynecological problems, that often would

be the reason for missing work● Good physical health, exercised regularly

(Buchtal, Hobby & Garbus, 2012)

Family Medical History ● Father unknown● Mother (Gladys Monroe Baker) had severe

psychological issues and was institutionalized many times. She was diagnosed with paranoid schizophrenia

● Her grandmother was also committed to a psychiatric institute

● Uncle reportedly committed suicide

(Monroe, 2014)

Psychological Assessment

–Mental Status- Appearance- She created the Marilyn Monroe persona (i.e. the way she walked, talked and her overall appearance) to mask her insecurities. Marilyn was described as self-absorbed and would often spend hours perfecting her her hair, makeup and clothing Mood (season) -More often depressed. Significant lability in mood (from elevated to depressed). Possibly only elevated when in persona Affect (weather)- Positive: determined, active alert, enthusiastic, inspired, proud, strong cheerful, happy, energetic. Negative: irritable, ashamed, sad, timid, alone, sheepish, nervous, hostile, distressed and lonely

(Buchtal, Hobby & Garbus, 2012)

Psychological Assessment Cont. Speech- Rehearsed-soft, innocent, sensual. As a child described as being quite and shyThought content- Frequent depressive thoughts, obsessed with improving herself as an actor Preoccupation- With appearances Thought process/memory- Able to memorize 8 pages of a script at times, but at other times would “go blank” (possibly a result of barbiturate use) Estimated intelligence- Average or above average Insight- Acknowledges need for counseling

Psychological Assessment–Presenting Problems

● Insomnia, depression, suicidal thoughts–Family

● No relationship with immediate family. Still has relationship with ex-husband Joe DiMaggio

–Substance Use● Sleeping pills, and reports of alcohol use

–Social Support● Friends, ex-husband Joe DiMaggio, and Lee Strousberg

–Coping & Strengths● Loves to read, and write poetry● Motivated to further her career

–Lethality● Suicidal

Biopsychosocial Formulation● Genetically predisposed to mental illness ● Early Life Traumatic Experiences: Insecure attachment to her

mother and other caregivers. She was placed in foster care and orphanages because her mother could not take care of her as she was put into institutions for “psychological problems”

● Physical abuse: Marilyn stated that one of her earliest memories was her mother trying to smother her with a pillow

● Sexual Abuse: She was sexually assaulted at age 7, and raped at age 11

● Received attention for the first time when she matured into a beautiful young woman

(Monroe, 2014)

Biopsychosocial Formulation Cont.● The norms of the film industry supported sexual promiscuity. ● Her persona received the love and attention that she desired,

fueling her desire to act and be perfect. ● 20th Century Fox refused to cast her in serious roles. She was

constantly battling others for the respect that she deserved. ● Experienced significant distress due to 3 failed marriages and 2

miscarriages.● She was tricked into being committed to a psychiatric institution

by her psychiatrist.● Additionally, she was not given adequate care from health

professionals: prescribed medication, formation of dual relationships, lack of knowledge.

(Buchtal, Hobby & Garbus, 2012)

Symptoms● Fear/anxiety- caused by a desire to be loved and a sense of worthlessness ● Depression- feelings of emptiness ● Insomnia ● Excessive talking- shown by making phone call after phone call to friends● Racing thoughts- illustrated in her poetry/journal entries ● Excessive involvement in activities (dancing, singing, acting) ● Suicidal thoughts- Hospitalized at Payne Whitney and placed on suicide watch ● Impulsivity- sexual indiscretions/affairs ● Substance use- sleeping pills, and alcohol ● Extreme preoccupation with appearance● Identity disturbance- adoption of the Marilyn Monroe persona● Social and occupational impairment

Possible Diagnoses

● Borderline Personality Disorder (BPD)● Bipolar II Disorder● Substance-Related and Addictive Disorder● Post-Traumatic Stress Disorder (PTSD)

Borderline Personality Disorder (F60.3)A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by the early adulthood and present in a variety of contexts as indicated by 5 (or more) of the following: 1. A pattern of unstable and intense interpersonal relationships as

characterized by alternating between extremes of idealization and devaluation (questionable)

2. Identity disturbance: markedly and persistently unstable self-image or sense of self

3. Impulsivity in at least two areas that are potentially self-damaging (e.g. sex, substance abuse)

Borderline PD cont. 4. Recurrent suicidal behavior, gestures or threats 5. Affective instability due to a marked reactivity of mood (e.g.

intense episodic dysphoria, irritability, or anxiety) 6. Chronic feelings of emptiness 7. Inappropriate, intense anger or difficulty controlling anger8. Severe dissociative symptoms

Special characteristics: Sleep disorders

Bipolar II Disorder (F31.81)Hypomanic EpisodeA. A distinct period of abnormally and persistently elevated mood

expansive, or irritable mood and abnormally and persistent activity or energy, lasting at least 4 consecutive days

B. During the mood disturbance 3 (or more) of the following symptoms have persisted 1. more talkative than usual or pressure to keep taking 2. increased in goal-directed activity 3. excessive involvement in activities that have high potential

for painful consequences

Bipolar II Disorder Cont. Major Depressive Episode A. Five or more of the following symptoms have been present during

the same 2-week period 1. Depressed mood most of the day, nearly every day2. Insomnia or hypersomnia nearly every day 3. Feelings of worthlessness 4. Diminished ability to think or concentrate5. Recurrent thoughts of death, suicidal ideation, a suicide

attempt or a specific plan Specify: With moderate anxious distress. Current episode (depressed). Severity (Severe)

Differential Diagnosis Bipolar Disorder vs. Borderline Personality Disorder ● Bipolar: Mood Swings are entirely neurological

o Borderline: Always see an environmental trigger ● Bipolar: Depression disables them

o Borderline: Impulsive even when depressed ● Bipolar: No dichotomous thinking

o Borderline: Dichotomous thinking ● Chronic feelings of emptiness ● Inappropriate, intense anger or lack of control of anger. Frequent

displays of tempter● Transient, stress-related paranoid ideation or Severe dissociative

symptoms

Sedative-,Hypnotic-, or Anxiolytic-Related Disorder (F13.20)

A. Problematic pattern of sedative use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period

1. Sedatives are often taken in later amounts over a longer period of time than intended

2. There is a persistent desire or unsuccessful efforts to cut down or control use3. Craving, or a strong desire or urge to use the sedative 4. Recurrent sedative use resulting in failure to fulfil major role obligations 5. Tolerance, as defined by either of the following

a. A need for markedly increased amounts of the sedative to achieve affect

b. A markedly diminished effect with continued use of the same amount of the sedative

6. Withdrawal, as manifested by either of the following a. Characteristic withdrawal symptoms are present: insomnia, anxiety b. Sedative or closely related substances (such as alcohol) are taken to

relieve or avoid withdrawal symptomsSpecify: Severe (presence of 6 or more symptoms)

Post Traumatic Stress Disorder (F43.10)A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways

1. Directly experiencing the traumatic event(s)B. Presence of one or more of the following intrusion symptoms associated with

traumatic event(s), beginning after traumatic events occurred. (without further information we can not know for certain whether she experienced symptoms related criteria).

C. Persistent avoidance of stimuli associated with traumatic events (again more information is needed).

D. Negative alterations in cognitions and mood associated with the traumatic event, as evidenced by two (or more) of the following symptoms

1. Feelings of detachment or estrangement from others. 2. Persistent negative emotional state

E. Marked alterations in arousal and reactivity as evidenced by 2 (or more) 1. Irritable behavior and angry outbursts2. Reckless or self-destructive behavior 3. Sleep disturbances

Specify with: Mixed anxiety and depressed mood. Mixed disturbance of emotions and conduct.

Final Diagnosis:

Final diagnosis if we had to take our best guess: ● Borderline Personality Disorder ● Sedative-, hypnotic- or anxiolytic-related

disorder (severe)● With PTSD-traits

Evidence Based InterventionWhat treatment/intervention might be hypothesized to be effective with this person?● Inpatient, dual diagnosis treatment for BPD and

addiction ● Individual psychotherapy● Classes and counseling session on relapse prevention ● Peer run support groups ● Psychiatric medication- selective serotonin reuptake

inhibitor (SSRI) (dual diagnosis .org)

Dimeff and Linehand (2008).

Evidence Based Intervention Therapeutic Approach: Dialectical Behavior Therapy (DBT)● DBT is a well established treatment for individuals with multiple and severe

psychological disorders. Dialectic means the synthesis of two opposites (e.g change and acceptance).

● DBT classifies behavioral targets hierarchically. In MM’s case to decrease behaviors that are life threatening (e.g. suicide) and then substance abuse-specific behaviors.

● The treatment includes five essential functions o Improving patients motivation to change o Enhancing patient capabilities o Generalizing new behaviors o Structuring new environmento Enhancing therapist capabilities and motivation

What is the evidence for the recommended plan?

Research on DBT

● DBT has been shown to be effective for treating individuals with borderline personality disorders (Koerner & Linehan, 2000).

● Research has also demonstrated that DBT can be effective when treating individuals with co-occurring borderline personality disorder and substance abuse ( Dimeff & Linehan, 2008).

● Meta analysis conducted to examine the use of DBT to treat borderline personality disorder found a moderate global effect size and a moderate effect size for suicidal and self-injurious behaviors (Kliem, Kröger, & Kosfelder,

2010).

Treatment Considerations ● What moderators or mediators might be relevant in this case? Marilyn

Monroe’s determination to be an actress may limit her ability to structure a new environment for herself. It seems to me that her vocational choice may be detrimental to her progress in treatment.

● What practical considerations might limit the feasibility of using the intervention in this case? Marilyn may be hesitant to enter into inpatient treatment, due to her traumatic past experience of being hospitalized. Motivation and insight into the need for therapy is often a challenge for this population. Her high status may enable her to leave treatment early.

Treatment Considerations Cont. ● How might you plan for possible complications? I would try to send her to a

clinic that felt more “home” like. When Marilyn was hospitalized, she complained about her room feeling like a prison cell. In terms of helping her trust trust new counselors, education on the characteristics and symptoms of BPD would go a long way. This way she will know what to expect from her counselors, as well as from her overall experience in treatment.

● How will you evaluate the intervention in this case?● Self report measures- Pre and Post-treatment Personality Assessment

Inventory-Borderline Features Scale (Kathryn Gardner & Pamela Qualter 2009).

● Pre and Post-treatment FFM Borderline Index (Maddux & Winstead 2012)

● Clinician reports and progress notes

Prognosis● Prognosis/expectations regarding outcome? There is considerable

variability in the developmental course of BPD. The most common involves serious affective and impulse dysregulation in early adulthood, which is when risk of suicide is the greatest.

● Although these clients may struggle with intense emotions and interpersonal instability throughout their lifetime, they often show improvements within the first year of therapy. After 10 years of therapy roughly 50% of individuals will no longer meet the diagnostic criteria for BPD (American Psychiatric Association, 2013)

ReferenceAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Buchtal, F, S., Hobby, A., Garbus, L. (2012), Love, Marilyn. US: Diamond Girl ProductionsDimeff LA, Linehan MM (2008). Dialectical behavior therapy for substance abusers. Addict Sci Clin Pract.2008;4:39–47.

Kathryn Gardner, Pamela Qualter. (2009). Reliability and validity of three screening measures of borderline personality disorder in a

nonclinical population, Personality and Individual Differences, Volume 46, Issues 5–6, April 2009, Pages 636-641, ISSN

0191-8869, http://dx.doi.org/10.1016/j.Koerner, K., & Linehan, M. M. (2000). Research on dialectical behavior therapy for patients with

borderline personality disorder. Psychiatric Clinics Of North America, 23(1), 151-167. doi:10.1016/S0193-953X(05)70149-0

ReferencesKliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using

mixed-effects modeling. Journal Of Consulting And Clinical Psychology, 78(6), 936-951. doi:10.1037/a0021015

Maddux, J, E., & Winstead, B. A. (2012). Psychopathology: Foundations for a contemporary understanding (3rd ed.) Mahwah, NJ.

Lawrence ErlbaumMarilyn Monroe. (2014). The Biography.com website. Retrieved 03:01, Oct 28, 2014, from http://www.biography.com/people/marilyn-monroe-9412123. Website: http://www.dualdiagnosis.org/borderline-personality-disorder-and-addiction/