Johanna R. Buchignani
This article presents a clinical case analysis of a young, female sex worker, Amanda, who voluntarily sought services from a social services and advocacy agency that is devoted specifically to those involved in and affected by the sex industry. Although she reports previously being diagnosed with bipolar disorder, Amanda has presented with symptoms, such as affective instability, self-hatred, emptiness, feelings of persecution, splitting, self-harm behaviors, volatile personal relationships, and a lack of overarching sense of self, that warrant the need to rule in or rule out the diagnosis of borderline personality disorder. As a sex worker who reports feeling trapped, dehumanized, and brutalized by her work, Amanda is also deeply impacted by structural life pressures. This clinical case analysis includes a description of Amanda¡¯s presenting problems and functioning, a diagnostic assessment and formulation (including pertinent family data and patterns of interaction as well as a profile on her ego functioning), and an analysis of a differential diagnosis between bipolar disorder and borderline personality disorder.
Client Description and Functioning
Amanda is a 29-year-old, Caucasian, single, heterosexually identified woman who lives by herself on the Upper East Side in New York City. Since the spring of 2012, Amanda has utilized therapy services at a social services and legal advocacy organization that is devoted specifically to those involved in and affected by the sex industry. Amanda and I began working together at this agency in the fall of 2012. Amanda sought out services because of her unhappiness with her work, her relationships, and herself. Amanda reported that she was seeing escort clients out of her home and having conflict with several of them as well as with her neighbors. Amanda was experiencing severe depression as evidenced by feelings of hopelessness, suicidal ideation, and cutting behaviors, and reported that all of her friends and family had dropped her. She also exhibited significant self-esteem issues regarding her appearance, intelligence, and abilities. Amanda initially worked with another clinician and then ceased contact with the agency for approximately six months. Since many of the agency¡¯s clients go in and out of therapy, it is agency policy to maintain regular follow-up. I reached out to Amanda upon beginning my internship and Amanda became my client.
Amanda is an educated, young woman with an upper-middle class upbringing. She left her parents¡¯ home at the age of 17 and attended college, but reports doing poorly academically, not graduating, and not being able to maintain a job after dropping out of college. For the past ten years, she has supported herself through sex work. Amanda believes that sex work is the only work that she is able to do and that she also fails in this field because of her appearance. Amanda reports that she has no history of serious romantic involvements or meaningful friendships, and that she does not want or need to develop relationships in either domain. Amanda presents as highly emotional and reactive, and tends towards quick irritation, anger, confrontation, and deep sorrow. In our sessions together, she alternates between utilizing an unflinching, aggressive gaze accompanied by direct questioning, and checking out from our interactions during which she makes no eye contact and busies herself with her phone, make-up, and other distractions. While Amanda is often keeping herself ¡°together¡± externally, she is suffering a great deal internally as is revealed by her behaviors and interpersonal relationships. Amanda is often able to accomplish her daily life tasks and meet her basic needs, but she also reports living a life that makes her want to die.
Due to Amanda¡¯s worries about harassment from unsatisfied clients and fear of being turned in to the legal authorities by her neighbors, Amanda and I initially focused on identifying harm-reduction modifications to her work in order to reduce her stress. As such, Amanda has begun working for a variety of massage agencies, so that her clients do not have access to her private contact information and her apartment no longer feels like a ¡°prison¡± as she used to refer to it (personal communication, September 13, 2012).
Amanda has identified many other problems that she experiences as devastating over the course of our work together. However, her latent content, rather than her manifest content, has most meaningfully informed my assessment of the source of her difficulties. According to Amanda, her main problems are that she is ugly and that she does not have enough money. She also believes that no one can have access to a wealthy lifestyle unless they are attractive. Amanda appears less concerned with her basic survival and more concerned with having enough money to live a wealthy lifestyle, retire from sex work, and not have to depend on anyone else financially. Amanda reports that she thinks she needs at least $500,000 to $1,000,000 in yearly income, with dividends from investments, in order to avoid ¡°being poor,¡± which she believes to be a fate worse than death. Amanda has had extensive plastic surgery, but still hates the appearance of her face and wants to have more work done. Sometimes Amanda reports thinking that getting more plastic surgery done would make her attractive enough to make more money, yet at other times she thinks that she needs to find a high paying career, and still at other times she thinks that she needs to find a rich man (which brings her back to her concerns about her appearance.) Amanda also vacillates between being acutely distressed that she has no romantic partner or friends, and being adamant that she hates everyone and wants to be alone. Sometimes Amanda makes practical plans to save money, but just as often she declares that unless I can provide her with money or a new face, I cannot help her. Occasionally, she states that suicide is her only option. Amanda reports that she was diagnosed with bipolar disorder in the past, but avoids discussing the timing, whereabouts, or circumstances in which her diagnosis took place. She reports that she has not received mental health services prior to coming to this agency, where we provide therapy but not psychiatric treatment or medication. In my assessment, the source of Amanda¡¯s distress is not her lack of money or appearance, but rather deep and pervasive personality problems that obstruct her intrapsychic and interpersonal functioning.
Theorists on the etiology of Borderline Personality Disorder (BPD) argue for the importance of assessing for early losses and separations, and a family history of verbal, sexual, or physical abuse (Austrian, 2005). At this agency, however, we approach our client assessments with a consciously non-invasive approach, which includes not inquiring directly about the clients¡¯ relationships and family histories. Since more often than not, our clients are survivors of sex trafficking, assault (sexual and otherwise), incarceration, police harassment and brutality, and other forms of trauma (such as traumas that occur on a daily basis in sex work), it is this agency¡¯s philosophy and policy that we respect our clients¡¯ autonomy, privacy, safety, and boundaries by taking a non-intrusive approach. As such, the clients determine how, what, and when they share about personal and family information. The limitation of this approach is that we do not always receive all of the information that would be helpful in terms of formulating a thorough assessment and a treatment plan.
In our work together, Amanda has shared very little about her family history or relationships with others¡ªessentially dismissing them altogether. When Amanda does reveal thoughts about her family, friends, or partners, these thoughts center around the following two themes: ¡°They don¡¯t care about me¡± and ¡°I don¡¯t care about them¡± (personal communication, November 13, 2012). When revealing these thoughts, her emotional expressions oscillate between deep hurt and anger, but are often masked under a defensive stance of not expressing any emotion whatsoever. While these beliefs are partially rooted in Amanda¡¯s mental health issues, they are also co-constructed by Amanda¡¯s environment. The majority of the clients at this agency are sex workers who have experienced family rejection and lack of family involvement. Though Amanda has reported very little about her social environment and family history, I think this silence is further evidence that Amanda has experienced a paucity of stability, love, and external support.
While her silence is somewhat informative, I also have a significant gap in data in that I have no collateral information regarding Amanda¡¯s childhood events, family relationships, and major life events. Clients who have BPD often give self-reports that are somewhat distorted by their present moods and circumstances. Thus, when possible, it is helpful to gather information from collateral contacts (Austrian, 2005). Unfortunately, given that Amanda is a sex worker with BPD who feels rejected by her family and is unable to maintain close adult relationships, there is no one for me to consult with about Amanda¡¯s history except Amanda herself.
Amanda presents with major internal conflict, disturbed intrapsychic structure, and primitive defenses. According to both object relations theory and self psychology theory, adult ego functioning is largely dependent upon one¡¯s experiences in early childhood. Object relations formulations privilege the importance of interpersonal relationships in development: One¡¯s relationships with caretakers and with the self influence one¡¯s emotional states and behaviors (Goldstein, 2001). According to object relations theory, the primary parent¡¯s failure to provide a sufficient holding environment produces a deficit that leaves children and adults with the painful symptoms that I observe in Amanda, the symptoms of a person with BPD. One of these symptoms, the need-fear dilemma, has led Amanda to develop a defensive pattern in her interpersonal relationships that prevents her from experiencing others as soothing and from developing a coherent sense of self (Goldstein, 2001).
Amanda often comes to the therapeutic situation in the thick of crisis and tends not to discuss her childhood or family relationships, but her internal working model is revealed through her presenting problems and her interactions with me in therapy. As Goldstein (2001) asserts, an important indicator in assessment is whether a client tends to see themselves and others as integrated and stable or in a uni-dimensional or contradictory manner. Signs of the latter, which indicate the use of the primitive ego defense, ¡°splitting,¡± include black and white thinking about the self, others, and life events (Goldstein, 2001; Austrian, 2005). Amanda is fixated on the thought that she is ¡°ugly and stupid¡± and the thought that others are stupid, cruel, and out to steal from her or treat her badly (personal communication, October 11, 2012). She reports the belief that ugly people, including herself, should not be allowed to reproduce and should not even be alive. Amanda¡¯s black and white thinking includes the following: either one is born pretty and has a good life, or one is born ugly and is doomed for a life of pain, isolation, abuse, and poverty. Amanda appears infuriated that her sister had a child, and says that her sister is ugly and created an ugly child, whose life is already ruined and doomed for failure. Amanda has sympathized with the Sandy Hook shooter and imagines why he might have wanted ¡°to take out a bunch of bully kids¡± (personal communication, December 17, 2013). Amanda imagines that the Sandy Hook shooter was bullied as a child just like she was bullied as a child. Amanda reports believing that the children who died were probably ugly and would have had sad, worthless lives, and so it is better that they are no longer suffering. Amanda also says that she wishes she had been one of the children who were killed.
In addition to Amanda¡¯s uni-dimensional view of herself as ugly, stupid, and incapable, her behavior with me in sessions exhibits the dramatic reversals that occur when individuals with BPD are using the splitting defense: During one session, Amanda spoke respectfully to me about her concerns and contracted with me around a plan of action. The following week, she cried throughout our session, told me that she sees no hope, yelled at me, and threatened to leave and terminate therapy. Depending on the week or the moment, Amanda views me as either ¡°all good¡± or ¡°all bad.¡± Whenever I think that we have made some progress and Amanda¡¯s behavior is stabilizing, the switch flips and she declares that I am stupid, unhelpful, and a waste of her time. As Silk (2005) contends, it is not unusual for clients with BPD to become negative, defensive, and critical of the therapeutic work shortly after some progress has been made in session. Individuals who have experienced trauma, and particularly individuals with BPD, often expect cruelty and rejection from those who are in a caretaking position and sometimes from the world in general (Silk, 2005). Even with little concrete knowledge about Amanda¡¯s childhood history and history of abuse, trauma, or neglect, Amanda¡¯s behavior in sessions has led me to conclude that she has been ¡°primed for rejection¡± through her early attachments (Silk, 2005, p. 97). Amanda feels ambivalent and frightened when we create a more intimate therapeutic attachment because she does not expect that others will truly have her best interests at heart. It is unsurprising that she rejects our work and flees when our relationship becomes too close during treatment.
Amanda¡¯s affect states and relational patterns often overwhelm her and the people with whom she interacts. She alternates between playing the role of the victim and the role of the attacker. At times, it is as if she is all defense mechanisms and no self. Building on the work of Mahler (1971), and Masterson and Rinsley (1975), Kernberg¡¯s (1992) conflict model of BPD explains Amanda¡¯s aggression as deriving from her frustration over her developmental failures in separation and individuation (as cited in Austrian, 2005). Without concretely knowing any specifics about her early environment, I surmise that it did not meet Amanda¡¯s basic needs. I hypothesize that Amanda had caregivers who invoked the need-fear dilemma in her and did not give her the supportive space necessary to develop a sense of self and a sense of autonomy (Austrian, 2005). These conflicts resulted in Amanda¡¯s fixation at an early stage of development, her poorly organized sense of self, and her reliance on primitive defenses. As is true for many individuals who are struggling with BPD, Amanda has difficulty managing her arousal levels and affect states, moves quickly from disappointment and sadness to irritability and rage, and anger is her most common affect state (Austrian, 2005; Lester, 2004). This is evidenced by numerous instances, such as Amanda¡¯s wish for ¡°a gun to get rid of all of the awful people¡± around her or her smile of satisfaction when she told me about some small vengeful acts that she had committed towards people who had hurt her (personal communication, January 21, 2013). Amanda also appears to take pleasure in her attempts to make me uncomfortable via her cold, unflinching stare and her frequent expression of her desire to hurt others as she has been hurt. She often states that ¡°Only ugly people have to work hard and are not married¡± and insinuates that she thinks I am one of these ugly people by fixing her gaze on me, vocally emphasizing the word ¡°ugly,¡± and cocking her head as if to assess whether she has impacted me with her statement (personal communication, November 8, 2013). These defenses also obstruct Amanda¡¯s ability to engage in reality testing: As mentioned previously, Amanda imagines that acquiring attractiveness and wealth would solve all of her problems. Amanda does not accurately witness the world around her and this prevents her from experiencing that others who are not attractive or wealthy are able to live happy, productive lives.
Amanda seems to have very little observing ego: she lacks the capacity to mediate between her emotions and her behavior, and struggles to mediate between herself and others. Amanda¡¯s fragile sense of self reveals a poorly integrated intrapsychic structure that is predicated on her belief that the world sees her as ugly. She cannot identify her strengths, passions, and connections to the world around her. She declares that ugliness is constantly reflected back at her by others, as exemplified by her confronting me and attempting to force me to confess that I believe she is ugly. One stigma that many clinicians hold regarding clients with BPD is that these clients might merely be saying that they think they are worthless in order to gain attention and sympathy (Lester, 2004). However, regardless of whether Amanda is unconsciously being manipulative in order to gain attention or is authentically expressing her views about herself, Amanda is most certainly in great pain.
Differential Diagnostic Assessment
In line with this agency¡¯s philosophy that direct inquiry often feels too invasive to individuals who have been involved in the sex industry, agency policy is to form a differential diagnostic assessment via the information gleaned from unstructured self-reports from clients. We do not ask for collateral information or submit clients to intensive diagnostic intakes. While a formal diagnosis is not required for insurance purposes at this agency, one¡¯s therapeutic approach must be informed by a diagnostic understanding of the client. Ideally a clinician and a client will have a shared understanding of the presenting problems and diagnosis, but this is often challenging with clients who present with personality disorders. Amanda¡¯s view of the origin of her problems was so different from my understanding and assessment that jointly coming to a diagnosis was not possible and, therefore, would likely have created a rupture that might have led to premature termination. Clients with BPD often struggle with a lack of self-awareness that further muddies an already complex diagnostic process (Austrian, 2005).
In reaching my diagnostic assessment, I do not discount that Amanda is experiencing life stressors that exacerbate her mental health issues. Amanda¡¯s role as a sex worker causes many severe stressors, including frequent physical and emotional intrusion and violation. She reports experiencing regular harassment by clients, co-workers, and managers, as well as several incidents of client-perpetrated stalking and violence. Amanda reports that on a number of occasions she has agreed to sexual transactions and then been refused payment by clients who told her that she was too ugly to be worth their money. Having initially been drawn to this profession due to desperation and a need for self-validation, Amanda has become trapped by her belief that she is not competent enough to make a living doing anything else. While she appears to be financially stable, she fears that she is on the verge of being destitute. Without a college degree and other work experience, I think that it is understandable that Amanda fears that she might become impoverished and that she would not be able to find other work. Thus, Amanda¡¯s life stressors and mental health issues result in her feeling wed to sex work in a hopeless, helpless way. Sex work engenders trauma, isolation, and loss of boundaries in Amanda¡¯s life that most certainly exacerbate her mental health issues. However, Amanda¡¯s symptoms are so intense, pervasive, and long-term, and affect her functioning to such a degree that I conclude that her distress is primarily due to a personality disorder and not merely an environmentally caused phenomenon. According to Amanda¡¯s narrative, her suffering existed long before her experiences as a sex worker or her fear of poverty.
According to my assessment, Amanda was misdiagnosed with bipolar disorder. Amanda presents with many symptoms that are similar to the criteria that could indicate a diagnosis of bipolar disorder: affective instability, depression, suicidal ideation, low self-image, and co-morbidity with substance abuse, disordered sleeping, and disordered eating. However, Amanda also presents with chronic, persistent symptoms endemic to a BPD diagnosis: rage, homicidal ideation, black and white thinking, lack of self-awareness or personal responsibility, feelings of alienation, persecution, and emptiness, self-harm behaviors, and extreme and long-term conflict in and avoidance of interpersonal relationships. Although several of these symptoms may exist intermittently in people with bipolar disorder, the range, the nature, and the pervasiveness of these symptoms, as well as my firsthand knowledge of Amanda¡¯s primary defenses (splitting, impulsivity, and active passivity) and lack of an observing ego brings me to a primary diagnosis of Axis II, cluster B, BPD (American Psychiatric Association, 1994).
Formulating a diagnosis of BPD is challenging in its own right: it may be the least comprehended and most controversial of all mental health disorders. Theorists speculate (Austrian, 2005; Lester, 2004) and one study (Ruggero, Zimmerman, Chelminski, & Young, 2010) found that bipolar disorder might be over-diagnosed in part due to confusion regarding symptom overlap between the two disorders. When inexperienced clinicians attempt to differentiate between BPD and bipolar disorder or other personality disorders, they are often so confounded regarding symptom overlap that they merely use whichever label they are most familiar with (Austrian, 2005). In addition, comorbidity (with substance abuse, mood disorders, anxiety disorders, and somatization) with BPD is so common that clinicians might easily misdiagnose or incompletely diagnose clients who have BPD (Austrian, 2005).
As in the case of Amanda, clients with BPD are most often misdiagnosed with bipolar disorder because the symptomologies of the two disorders are so similar. Misdiagnosis, however, has serious implications for clinical treatment (Ruggero et al., 2010). Some psychiatrists argue that we ought to re-conceptualize BPD as a type of bipolar disorder and recommend mood stabilizers for treatment, but this appears to be an ineffective course of treatment for clients with BPD (Hatchett, 2010; Paris, Gunderson, & Weinberg, 2007). That said, BPD is frequently co-morbid with other disorders that do respond well to psychiatric medication (Paris et al., 2007; Zimmerman & Mattia, 1999). There is little evidence, however, that BPD and bipolar disorder belong on the same spectrum because of crucial differences in phenomenology and response to psychiatric medication (Hatchett, 2010; Lester, 2004; Paris et al., 2007; Ruggero et al., 2010). It is also likely that some clinicians favor bipolar disorder as a diagnosis over BPD and use it more often because they wish to protect clients from the stigma surrounding the BPD label. Other clinicians might be concerned by BPD¡¯s unresponsiveness to medication and might be more likely to use a bipolar disorder diagnosis due to their desire to prescribe mood stabilizers and antipsychotics, which are sometimes viewed as fix-it medications for mood disorders. Furthermore, the treatment of personality disorders is less likely to be covered by insurance providers than the treatment of mood disorders (Hatchett, 2010).
In order to address this trend in misdiagnosis, Lester (2004), a prominent clinician and educator on the etiology, epidemiology, and treatment of personality disorders, has established a criteria apparatus for differentiating between bipolar disorder and BPD diagnoses. Diagnosis of BPD must be more finely tuned than merely checking off impulsivity and emotional lability as symptoms. When applying Lester¡¯s assessment test to Amanda¡¯s symptomology, history of conflicted and ruptured intimate and family relations, and patterns of behavior in therapy, Amanda meets the criteria of BPD for every item. For instance, when challenged or confronted, Amanda uses splitting, while a person with bipolar disorder would deny her mood state. Amanda¡¯s affects are intense and evocative of empathy, while a person with bipolar disorder has depressive affects that are often flat and lacking in depth. Whereas a person with bipolar disorder has mood shifts that are not greatly dependent on external factors, Amanda¡¯s mood shifts are environmentally triggered. Everything, to a person with BPD, feels as if it has happened to them personally (Lester, 2004).
Lester (2004) argues that a person with BPD lacks an overarching ego, a sense of ¡°I¡± that connects the events of her life together. Without an observing ego to claim some ownership over her feelings, behaviors, and the resulting consequences, it is almost as if a person with BPD is an object that is batting about in the wind with no sense of control. A person with BPD often struggles to accurately see causality and consequences. Even acts that a person commits herself are often experienced as if they just happened to the person at the will of someone else or the universe. A person with BPD often finds it challenging to trace her memory and history because there are no connections that have been created and there is no integrated self that has existed in each moment and traveled between each moment. Amanda recently revealed that she has no memories of her youth except for ¡°flashes¡± of moments and that her recent history is also disappearing into ¡°flashes¡± (personal communication, December 17, 2012). Amanda says she can ¡°make a story¡± that makes sense to other people, but that she does not actually remember her life events as a continuous journey (personal communication, December 17, 2012). When Amanda recounts these flashes, she experiences these memories as if they were events that happened to someone else. Amanda struggles to stitch her life together in a way that is understandable and meaningful to her. Amanda¡¯s resulting confusion is accompanied by fear and pain.
I began my social work education with a holistic and environmental understanding of peoples¡¯ mental health struggles. Admittedly, I also held some antipathy towards the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) regarding the way in which it imposes uniformity on uniqueness and pathologizes mental and emotional discord. I preferred to focus my analysis of individuals on structural factors of oppression that not only cause pathology but also perpetuate oppression via the act of pathologizing. However, my process of working with Amanda has caused me to take increased stock in and gratitude for my developing knowledge about the etiology, epidemiology, diagnosis, and treatment of the chronic, pervasive mental health disturbances, such as BPD, that plague some of my clients. Through the application of Lester¡¯s (2004) differential diagnostic assessment to the latent and manifest content of my work with Amanda, I have concluded that Amanda¡¯s clinical diagnosis is BPD. This diagnosis informs my continued assessment of Amanda and helps me to modify her treatment plan and my therapeutic approach in an effective manner. Continued devotion to a deep, detailed, and evolving knowledge about mental health struggles, such as BPD, will assist me in my quest to meet the developmental and emotional needs of the people with whom I work and to help them begin to meet their own needs.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Washington, DC: Author.
Austrian, S. G. (2005). Mental Disorders, Medications, and Clinical Social Work. New York, NY: Columbia University Press.
Goldstein, E. G. (2001). Object Relations Theory and Self Psychology in Social Work Practice. New York, NY: The Free Press.
Hatchett, G. T. (2010). Differential diagnosis of borderline personality disorder from bipolar disorder. Journal of Mental Health Counseling, 32(3), 189-205.
Lester, G. (2004). Borderline Personality Disorder: Treatment and Management That Works. Brentwood, TN: Cross Country Press.
Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48, 145-154.
Ruggero, C. J., Zimmerman, M., Chelminski, I., & Young, D. (2010). Borderline personality disorder and the misdiagnosis of bipolar disorder. Journal of Psychiatric Research, 44(6), 405-408.
Silk, K. R. (2005). Object relations and the nature of therapeutic interventions. Journal of Psychotherapy Integration, 15(1): 94-100.
Zimmerman, M. & Mattia, J. I. (1999). Axis I Diagnostic comorbidity and borderline personality disorder. Comprehensive Psychiatry, 40(4), 245-242.
About the Author
Johanna R. Buchignani is graduating in 2013 with an MSW from the Silberman School of Social Work at Hunter College in Clinical Practice with Individuals and Families. She is currently a clinical social work intern working with individuals involved in the sex industry. Johanna holds a MA in Human Sexuality Studies from San Francisco State University and a BA in Sociology from Vassar College. She has worked in therapeutic counseling, advocacy, education, and community organizing around issues pertaining to gender, sexuality, trauma, and mental health issues. Johanna is a professional filmmaker who wrote, directed, edited, and produced several documentary films focused on these issues. She is proud to have helped in the founding of a clinical institute in Los Angeles, California that is devoted to the necessary integration of mental and sexual wellness in diverse populations of individuals and couples. She can be reached at firstname.lastname@example.org.