Treatment Tuesday - Acute Stress Disorder

This week's assessment comes from Sierra. She's writing a psychological thriller short story in the present day about Adriane,* a woman who stabs her husband with a kitchen knife after 6 years of being emotionally abused and constantly compared and found lacking to her husband's first wife. She was steady and reliable, smart and successful prior to this. She is seeing Dr. Black* who is consulting for the defense and conducting their sessions in prison. Adriane still doesn't remember what happened.

Sierra wants to know: Would it be normal for Adriane to remember as she goes through the process of therapy, and if so, what kind of reaction would an inherently good person have after finding out that they did something terrible to someone they loved? What kind of process does someone go through when they make a "mistake" with such horrible consequences?
This sounds like a fascinating plot, Sierra. You are right in assuming that Adriane dissociated to some degree while killing her husband if she does not remember it. We just have to figure out what diagnosis best fits the circumstances.

When a person dissociates, they separate their thoughts, emotions, or experiences from one another. 
This can be on purpose or involuntary. Adriane's was likely involuntary. The presence of amnesia is indicative of many different disorders, such as Dissociative Amnesia or Acute Stress Disorder, the two I want to look at more closely.

With Dissociative Amnesia, the person usually can't recall important personal information, and the information is too extensive to be explained by ordinary forgetfulness. This can happen once or several times. If the amnesia occurs during the course of another disorder, though, that disorder takes precedence. This leads me to Acute Stress Disorder after ruling out the below.

Since you had no indication that Adriane was two or more personalities, she doesn't fit Dissociative identity Disorder. Since you indicated no traveling away from her home or work or assuming a partial or complete different personality, she doesn't fit Dissociative Fugue. There is some indication that she could suffer from Posttraumatic Stress Disorder, but in your sketch, you didn't include any of the traditional symptoms like flashbacks or dreams or avoidance of things that remind her of the trauma.
 
So we are left with the likelihood that Adriane has Acute Stress Disorder. Adriane experienced an event in which she caused the death of her husband, which is definitely traumatic. Shen then would have to exhibit 3 of the 5 characteristics, one of which is the amnesia:

(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness
(2) a reduction in awareness of his or her surroundings (e.g., "being in a daze")
(3) derealization (i.e., feeling a loss of reality or sense of unreality)
(4) depersonalization (i.e., feeling like she's not alive, floating above her body, not a person)
(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma) 

The last three traits are essentially all aspects of dissociation...a separation from her own body and mind.  Even though she doesn't remember the event at present, she could still experience recurring images or dreams associated with what happened, even if they don't make sense. You'd also want to give her some hyperarousal symptoms, such as inability/difficulty sleeping or concentrating, constantly trying to detect threats to herself (hypervigilance), or exaggerated startle response.

The only thing to consider with this diagnosis is that the symptoms last for a minimum of 2 days and no longer than 4 weeks. If this fits your thrilled time line, then great. If it doesn't, then you can consider a lasting diagnosis of PTSD, more than likely.

Yes, she could eventually remember. But she could also have blocked this memory from resurfacing. Some of my colleagues adhere to hypnosis for this type of memory recovery, but I've never done anything with hypnosis because you have to be trained in the process.

Sierra also wants to know: How would a therapist conduct this sort of thing? What constitutes mental competence to stand trial? How would the therapist go about discussing this with her?

I Googled what constitutes mental competence to stand trial (since I'm not lawyer), and it was pretty much what I thought: the person has to have the capacity to assist their lawyer to defend them and to understand the nature of the proceedings in which they are involved.

You're Dr. Black is going to have a clinical interview with Adriane in which he will assess her with psychological tests or personality tests, like the MMPI-2. He'll take a social and psychiatric history and may use a state competency exam, depending on which state you're in (I found out Georgia has one). Most importantly, Dr. Black will perform a Mental Status Exam and assess current level of functioning of Adriane.


So what's in a Mental Status Exam? I could go into a detailed approach, but why reinvent the wheel? I found a great website with a full explanation of each are of an MSE, so here it it. Essentially, Dr. Black will just ask pertinent questions to cover each of the areas, probably done in a very getting-to-know-you kind of way as part of building rapport with Adriane. However, this would be done at the beginning of the process. You mentioned "sessions" with Dr. Black while Adriane is in prison, which makes me think ongoing counseling. I'm not sure about the legal ins and outs of this type of set-up, and you also want to think about your time line of the diagnosis.

So as it stands, mental competency for Adriane to stand trial would be the results of the following equation:

Functional Assessment

Defendant's Current Mental Status

Specific Demands of Case

I've enjoyed this little foray into legal proceedings and learned quite a bit myself, so thanks for that, Sierra. Hope this helps....thanks for writing in!

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