I grew up in Duxbury, which is why I keep coming back to this case. Everyone is talking about diagnoses. The diagnoses came from a specific book with specific rules, so I sat down with my copy and worked the case the way I would work a differential in clinic.
Buy the book. Hold it in your hands. Look at how many people were involved in writing it. It is hard not to be impressed by it.
The DSM-5-TR opens with a legal disclaimer. It sits at the front of the book, before any diagnosis, and almost nobody covering this trial has read it.
A diagnosis does not demonstrate that an individual was unable to control his or her behavior at a particular time.
How the manual says to use it.
The criteria are guidelines informed by clinical judgment, not to be used in cookbook fashion.
Developed for clinical, educational, and research settings. A trained person decides and the book supports the decision, which is why this trial is a battle of experts.
Brief psychotic disorder. The best fit for the reported presentation.
Duration is at least one day but less than one month.
A command hallucination at the time of the crime satisfies the symptom criterion. The defense claim is eighteen minutes, which sits inside the window.
Every criteria set ends with a differential, and the differential is what routes you. This one routes to malingering.
Malingering. (aka Faking)
Strongly suspect malingering when the individual self-refers while criminal charges are pending.
That is the first of four indicators, and it applies to every defendant in every insanity case by definition. The manual is telling clinicians that in this setting, the consideration is mandatory. Both sides’ experts have to walk through it.
The section also says to strongly consider Antisocial Personality Disorder.
Antisocial personality disorder. No pattern in her history, her employment, or anything public.
Antisocial and narcissistic presentations share a tendency to be glib, exploitative, and lacking empathy.
That cross reference took me to the next stop.
Narcissistic personality disorder.
They insist on having only the top person or the best institutions.
Insisting on facing the Highway 3 commute north to Boston to continue working at Mass General. Does not want to go back to work. Does not need the job because the husband makes enough money. You putting this together?
Perfectionistic standards, especially for appearance and performance, with critical concern about not measuring up.
Measuring up to Duxbury. Measuring up to the perfect mom. Measuring up to Facebook.
Interpersonal relations are typically impaired by self-preoccupation, entitlement, and disregard for the sensibilities of others.
Competent and high functioning with professional and social success is possible. Self-control, stoicism, and interpersonal distancing can sustain a career and a marriage.
That is the part people get wrong about this diagnosis. It does not look like a mess from the outside. It can look like a labor and delivery nurse at Mass General living in Duxbury with three kids.
Only when traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute the disorder.
Plenty of high achievers have these traits and do not have the disorder. What makes it a diagnosis is inflexibility and what it costs.
Inflexible. Running a race on the same day she gave birth. Needing to keep her job even though she doesn’t need to and has three kids.
Obsessive compulsive personality disorder. The last stop, because the narcissistic differential points there. It has to be taken seriously here, because she wrote a lot of notes.
Preoccupation with details, rules, lists, order, organization, or schedules.
She wrote lots of notes, right? That is the criterion that makes you stop and check.
Perfectionism that interferes with task completion because strict standards are not met.
Excessively devoted to work to the exclusion of leisure activities and friendships.
I am not sure about that one.
Overconscientious and inflexible about matters of morality, ethics, or values, not accounted for by culture or religion.
Rigidity and stubbornness.
And the manual says you do not have to pick.
If an individual meets criteria for one or more personality disorders in addition to OCPD, all can be diagnosed.
So the question is not which one it is. The question is where the perfectionism is pointed and what happens when it fails.
OCPD perfectionism is immersed in order and rigidity. Narcissistic perfectionism is about appearance and performance.
Narcissistic individuals believe they have achieved perfection. OCPD individuals are usually self-critical.
OCPD turns it inward and blames itself. The narcissistic presentation does not, and it has the professional capability and the interpersonal distance to hold it together while it comes apart underneath.
Narcissistic and antisocial presentations lack generosity but indulge themselves. OCPD is miserly toward self and others alike.
No matter what happens, one thing is clear: a star is born
The system cannot fix everyone and we do not live in a perfect world. The way we maintain civility and prevent bad things from happening is by individually sharpening our adult minds and removing emotion.
That’s the challenge, because the media is fueled by it.
Jonathan Murphy, PMHNP-BC. For educational purposes. Not medical or legal advice, and not a clinical opinion regarding any individual.