Sex Disabil (2010) 28:119–128 DOI 10.1007/s11195-009-9131-2 CASE REPORT

Lost in the Shadow of the Crowd: Will I Be Healed? Choosing Treatment Targets and Approaches Lino Faccini

Published online: 23 September 2009  Springer Science+Business Media, LLC 2009

Abstract The treatment plan for a person with Intellectual Disability (ID) and Intentional Imaginary Companions, a Gender Identity and Depersonalization Disorder including a Koro-Like Symptom, Trauma/abuse, and Sex Offenses is presented. A complex set of comorbid disorders was targeted for treatment. A review of the related literature, and treatment targets are presented to address sexual knowledge deficits, the banishing of all Imaginary Companions, managing gender identity and depersonalization disorders along with trauma and abuse, and continuing with traditional Old Me New Me Sex Offender Treatment for Persons with ID. The Old Me New Me Treatment model would be the core treatment paradigm with other specialized treatments incorporated into its core treatment phases. Pictorial displays for his Old Me and New Me as well as the treatment plan would be presented to enhance his understanding of the complex and prioritized set of treatment targets and procedures. Since the number and type of comorbid disorders is significant, and prioritized targets and treatments can only be presented in this continued case study; the efficacy of this treatment package will be the focus of a subsequent study. A significant aspect of this case study is that it provides a longitudinal-developmental perspective for the comorbid disorders, and the rationale for the targets and treatment in a person with ID. Keywords

Imaginary companions
Intellectual disability
Koro
Sex offense

The case of ‘‘T’’, a person with Intentional Imaginary Companions, PTSD, Depersonalization and Gender Identity Disorders (including a Koro-like symptom), Schizoid Personality Traits and sex offenses was presented in Faccini [1, 2]. The essential clinical components of the case involve a person with Intellectual Disability (ID) experiencing early trauma, creating Intentional Imaginary Companions (IICs) to help cope but who then perceived that three of the IICs controlled his body, and were blamed for the commission of various sex offenses. The first case study presented in Faccini [1] introduced the case and its relationship to the Koro-related literature. Once it was discovered that the ‘‘baby’’ L. Faccini (&) N.Y.S. OMRDD, 888 Fountain Avenue, Brooklyn, NY 11208, USA e-mail: [email protected]

123

120

Sex Disabil (2010) 28:119–128

(IIC) had returned, a more comprehensive assessment indicated that 10 imaginary friends were present, three of who were directly involved in the commission of sex offenses. Also present were issues related to gender, sexual, and a depersonalization disorder (including the koro symptom) resulting in a complex arrangement of comorbid disorders. The male in this continued case study will continue to be referred to as ‘‘T’’ to maintain his confidentiality; also identifying background information has been altered, except for that information that is clinically relevant but non-identifying. During the initial course of therapy, additional diagnostic questions were identified and ‘‘T’’ interviewed again. When asked about the relative time periods for the occurrence of different symptoms, he reported that at six-and-a-half years of age he started to believe that he was half female and half male; at 8 years of age, he perceived himself as having a penis and at other times as having a vagina (his ‘‘pee pee’’ would change into a vagina), and also at this time, he started to form his imaginary companions (i.e., Baby, Evil 1 and 2). In addition, also around this time he reported that he remembered starting to have erections. Subsequently, at the age of 16, he stated that the baby IIC would change/shrink his penis (koro symptom) and change him into a baby. The baby IIC would also tell him to play with his ‘‘pee pee’’, takes his clothes off, and that it would ‘‘go into his pee pee and make it hard, and when I come back to myself-confused’’. It was hypothesized that ‘‘T’’ may have misidentified sexual arousal as the ‘‘baby being in his penis’’. However, in response to questioning regarding this issue he clearly indicated that his ‘‘pee pee’’ getting hard when the baby is in it was not like ‘‘being horny and jerking off’’. In addition, his early socialization experiences were also explored. ‘‘T’’ stated that when he was a child and as a teen, that he didn’t have any friends, and as an adult that he only interacted with other adults as part of an organization that he was a member. He stated ‘‘didn’t want any, nope, tell you what to do, get you in trouble, confusing to talk to people, scared to tell people …they think that I am crazy and take me to the hospital’’. He agreed that the creation of the IICs was in response to being alone much of the time. During this follow up interview, ‘‘T’’ was also asked if he experienced any other traumas or abuse (other than the birth event of the twins). He perceived that his mother and sisters were demanding/controlling and frequently bossed him around. He also reported that when he was little and playing house, in particular the baby that needed to be changed, that his sisters and later a babysitter ‘‘played with his pee pee’’ (he described it more as being embarrassed than sexual abuse). Although he denied ever touching/exploring his sisters’ genitals because ‘‘I would get in trouble’’, he immediately added that ‘‘I did it later on’’ (relating to the children that he touched). This possible exploratory touching is consistent with another of his accounts that he touched children on the genitals exploring what genitals the children possessed. The examiner also recognized the probable reality that this may have been another cognitive distortion minimizing what occurred, similar to the denial that he abducted the baby (it was the baby that was in control of him at the time). Also, when a toddler, he perceived that he was frequently ‘‘left out’’ in that his mother would continually ask him to wait (e.g., to be changed, to eat) when the twin sisters needed her. Basically, he described being neglected via his statement ‘‘sometimes she would forget about me not coming to care for me’’. In regards to his father, he reported that his father was somewhat unavailable (due to being tired from work and wanting to relax); his father being relatively unavailable, and his predominately female household and playmates in the neighborhood, contributed to his female identification exemplified by the statement that ‘‘my body wants to be a boy but sometimes I want to be a girl on the inside’’. Also, he reported that his father would sometimes threaten and actually ‘‘walk out’’ on his family, whereupon ‘‘T’’ was scared that he wouldn’t return. These experiences would fall under the perception of emotional abuse

123

Sex Disabil (2010) 28:119–128

121

that has been identified as a precipitating factor for a Depersonalization Disorder (DD) [3], as well as for his schizoid traits. Lastly, when asked if he missed having real friends, he responded that he ‘‘wished’’ that he could become ‘‘make believe like them’’ (his imaginary friends) but then added that he ‘‘sometimes wished he had a real friend who would ‘not tell you what to do’’. During the process of ruling out medical disorders, the examiner discovered that ‘‘T’’ had a history of an anal fissure that was repaired by surgery, internal hemorrhoids, and a benign prostatic hypertrophy. Possibly due to the anal fissure being perceived as a vagina, ‘‘T’s’’ reported that his ‘‘butt hole’’ was really a vagina that bleed (he agreed that hemorrhoids also played a role), as was the fold where his inner thigh met his genitals (which could have bleed when he wore very tight underwear and then really pulled up his pants high), as well as his penis being able to ‘‘bleed very tiny bits of red liquid’’/blood (prostatic hypertrophy usually involves a microscopic amount of blood in his urine). These experiences may have reinforced the perception that he had a penis and vagina; these conditions seemed to contribute, but not totally account for his genital confusion. Even when corrective information (and drawings), about these conditions were presented and discussed, his level of correctly identifying a vagina from a penis in regards to himself remained unaffected. The examiner believed that ‘‘T’’ may have used this medical information, or misunderstood it, as evidence reinforcing his gender/depersonalization related beliefs, increased his self-focus and idiosyncratic interpretations involving going crazy or loss of control that contributed to reinforcing his DD. Since the case of ‘‘T’’ is complex in regards to the comorbidity of disorders and clinical conditions (i.e., Koro-like symptom, IICs), the literature was examined regarding effective interventions dealing with the IICs, depersonalization, gender identity issues, Koro, trauma and sex offending. A brief but pertinent literature review for most of these disorders is presented. In regard to understanding and eliminating his IICs, Ralph Allison M.D., [4] states that IICs are created via one’s ‘‘emotional imagination’’. Basically, ‘‘it has no structure of its own, as they are made up of emotional energy’’. ‘‘Since he created it, he is always stronger than it. It only has power that he has given to it… (he) created it therefore (he has) the power to get rid of it…by an act of will’’. Essentially, when the disadvantage of having the IIC outweighs the advantages (i.e., such as when being hospitalized in a forensic hospital for an offense ‘‘committed’’ by the IIC) the person must make a firm decision to get rid of it, and then can do so on their own. For other individuals, Dr. Allison has used the ‘‘bottle routine’’. In this technique, Dr. Allison describes ‘‘with the patient in a light trance, I put an empty jar between both (her) hands. I ask her to move all of the energy from her feet, legs, trunk and head into her shoulders and then out her arms, into the bottle. When she has expelled all of her energy into the bottle, the bottle would feel too hot to hold, and she would throw it on the floor. Once the energy is expelled from the patient’s mind, a ‘vacuum’ exists within the patient. That vacuum must be filled with positive energy or the (old) energy will come in from somewhere else.’’ This conception of the structure and function of the IICs is pertinent to the case of ‘‘T’ in that he naturally understood that he created the IICs and that he could get rid of them (i.e., he ‘‘divorced’’ the ‘‘teenager with glasses’’, and that he has banished the baby and other IICs 10 times in the past). However, in the case of ‘‘T’’, the first three IICs, namely the baby, Evil 1 and 2, were created closer to the time of the trauma and the beginning of his sexual impulses, and are those that have been most resistant to being permanently banished without the therapist’s help. Consistent with Dr. Allison’s views, Humberto Nagera, MD [5] regards the creation of the IICs as a ‘‘developmental buffer that mitigates for the child’s primitive ego what at

123

122

Sex Disabil (2010) 28:119–128

times is an impossible situation that he cannot manage…it is a vehicle for the discharge of impulses no longer acceptable that justify deviant behavior and help maintain self-esteem.’’ He states that the creation of the IIC is in response to feelings of rejection, neglect and loneliness and can ‘‘disappear when the person finds real companions.’’ This conceptualization of how imaginary companions are given up by their creator is similar to one of many reasons that was identified by Majorie Taylor [6] namely, the child making real friends, or due to a loss of interest in the imaginary companion, the creation of a new one, due to parental disapproval or when adults take control of the imaginary companion. In regards to the case of ‘‘T’’, he experienced significant difficulties in making friends due to deficient social skills, and a tendency to withdraw into fantasy consistent with schizoid personality traits. The conceptualization of Drs. Nagera and Taylor may apply to children’s IICs and less complicated adult cases where the formation of ‘‘real companions’’ is easier or possibly facilitated via social skills training but where the deviant behavior hasn’t risen to the level of significant social-sexual problems. However, in essence, Drs. Allison and Nagera agree that the creation of IICs can be for the purpose of embodying and justifying deviant or antisocial behavior. This basic conceptualization is pertinent to the case of ‘‘T’’. To further understand the issue of uncontrollability of the IICs, the work of Dr. Barbara Sanders [7] from the University of Connecticut is relevant. Dr. Sanders evaluated the differences in IICs between abused and non-abused children. She found that, for abused children, the IICs ‘‘engaged in actions that run counter to the child’s wishes or for which the child is amnesic or the vividness and intensity of the fantasy experience could be at the root of this perceived uncontrollability of the ICs actions’’. Also, consistent with this finding are those of Markman [8], that ‘‘children with dissociative problems were confused about whether the imaginary friend is real or imaginary, believe that the imaginary friend can take over the body, feel the need to protect the privacy of the IC identity and often report conflicts between the IC that leave the child confused about how to behave.’’ In essence, Drs. Sanders and Markman believe that there is a connection between early abuse, possible dissociation and the different facets regarding the IICs. All of these identified conditions are relevant in the case of ‘‘T’’. In summary, the conditions of early trauma, depersonalization, the vividness or uncontrollability of the IICs and deviant behavior/ impulses that are justified should be included as treatment targets. In reviewing the literature on the treatment of DD, no one recognized treatment approach has been widely accepted by practitioners. In regards to the course of the disorder, it can remit on its own or it can persist and cause marked difficulties and distress. Usually, a DD can begin in adolescence or even early adulthood, unlike in the case of ‘‘T’’ where it began around the age of 8 years. Research has identified emotional abuse as an important predictor of the disorder [3], with the more immediate antecedents of severe stress, depression, panic, high grade marijuana and hallucinogen ingestion being present. In regard to treatment, Psychoanalytic thought as espoused by Oberndorf [9] identified one core component of the depersonalization as the ‘‘erotization of thought and especially upon the wish to adopt the way of thought of the opposite sex’’…group psychoanalytic therapy was effective in removing all depersonalization symptoms in a case study. Other interventions that have been or are being investigated include using transcranial magnets ‘‘to apply a magnetic field to the brain for a short period of time’’ by Antonio Mantovani, MD of NYS’ Psychiatric Institute; ‘‘the use of 3-D glasses to successfully induce depersonalization… and coping strategies that resulted in rapid habilitation within session [10], and intensive trauma therapy to deal with the core issue of trauma of which depersonalization can be a symptom (as applied by Intensive Trauma Therapy offered by West Virginia Associates). In addition, ‘‘medications that have been helpful to patients with DD include

123

Sex Disabil (2010) 28:119–128

123

the benzodiazepine tranquilizers such as lorazepain (Ativan), clorazepate (Tranxene), and alprazolam (Xanax), and the tricyclic antidepressants, such as amitriptyline (Elavil), doxepin (Sinequan), and desipramine (Norpramin) [11], and a ‘‘combination of lamotrigene and an SSRI have shown promise’’ [12]. A model of Depersonalization Disorder (DD) that has some initial clinical research validating effectiveness is the cognitive treatment model. ‘‘The cognitive model of DD proposes that the catastrophic misinterpretation of the transient symptoms of DD as indicative of madness, loss of control, becoming invisible and/or a harmful disease is likely to lead to exacerbate and perpetuate the symptoms of DD. Moreover, cognitive models of anxiety disorders suggest that the person is also likely to develop a range of behaviors and cognitive biases that form a maintenance cycle to further perpetuate the symptoms’’ [13]. The recommended treatment package of the cognitive treatment approach involves the use of psychoeducation and normalizing the symptoms, diary keeping to monitor for antecedents, decreasing avoidance behaviors and self-focused attention, challenging catastrophic assumptions, and relapse prevention. To date, 21 patients were treated in individual therapy with the cognitive approach and evidenced significant improvements in depression, anxiety, dissociation/depersonalization and improvements in general functioning; subsequent research was recommended since this trial only involved 21 single case studies that were analyzed as a group without a control group or more rigorous methodology. The literature on DD identifies certain conditions that are pertinent in this case. First, ‘‘T’’ did relate that he had experienced emotional abuse (neglect/abandonment, possible demanding parents and sisters, possible embarrassment when others played with his penis) and current antecedents of severe stress and depression. Also, gender confusion, where he perceives himself as half female, and engages in many female-oriented activities is consistent with Obeindorf’s view of him adopting female ways. In summary, these three conditions, namely emotional abuse, antecedents of stress and depression, and gender difficulties are relevant as symptoms to be monitored and treatment targets. In regards to the treatment of the Koro-like symptom, eastern and western approaches have been used. For instance, Franzini and Grossberg [14] reported that eastern folk remedies have included immediate fellatio being applied to the sufferer’s penis, pouring cold water over the heads of sufferers, increasing one’s consumption of ‘‘yang foods’’ (e.g., lean meats, lime juice, ginseng root), and a physician prescribing calcium glucorate to produce bodily sensations of warmth. Western remedies have regarded the koro syndrome as a form of an anxiety disorder. As a result, tranquilizers and psychotherapy have been prescribed. In addition, SSRI medications and even Haldol have been prescribed to manage the koro symptom. Since the Koro-like symptom, in this case, was directly related to the presence of the baby IIC, Evil 1 and 2, it is expected that banishing all of the IICs would also eliminate the koro-like symptom; any residue from this procedure would then be addressed with the cognitive treatment approach. In addition, the underlying gender identity issues would be dealt with in the Old Me New Me treatment approach. As reported in Faccini [1], ‘‘T’’ was already engaged in Jim Haaven’s Old Me New Me Model of ID Sex Offender Treatment. The initial refocusing on strengthening his New Me identity of being an assertive leader helped him cope with the Koro symptom (by paying less attention to how in control the baby was via the coercive mechanism of koro), and focused for ‘‘T’’ how he could feel and act more in control by acting more in line with his New Me Identity. This intervention, along with ‘‘T’’ practicing relaxation exercises, was temporarily effective. Since, ‘‘T’’ was already involved in Old Me New Me ID Sex Offender Treatment, and that this was somewhat effective with his complex problems, the Old Me New Me (OMNM) Treatment Approach was adopted as the core approach. The

123

124

Sex Disabil (2010) 28:119–128

additional problems of early trauma, depersonalization-Koro, IICs, and gender difficulties were treated with some deviation from the Old Me New Me Model based on expert opinion or research literature suggesting that a particular intervention was effective. The Old Me New Me Model of ID Sex Offender Treatment has been used since 1990 in treating persons with ID who have committed sex offenses. According to the developer of this approach, Jim Haaven [15], the Old Me New Me model presents a theory of positive psychology in that the offender identifies present characteristics and behaviors (Old Me) associated with the offending lifestyle and then develops new characteristics and behaviors (New Me) of the non-offending life that the person wants to lead. The New Me is the endorsement of positive approach goals to live one’s life in healthy, fulfilling ways without sexual offending behavior. This model highlights humanistic values in addition to addressing dynamic risk factors for offending. The problem that many practitioners make in applying the model is that they understand the relationship between the Old Me and New Me to be unidirectional. Some believe that once the Old Me then the New Me are identified then skills can be developed and the treatment is near complete. Nothing can be further from the actuality of applying the model to treatment. The Old Me New Me Model of treatment is a comprehensive model in that it addresses identity change, self-management, enhancing motivation, skill development and lifestyle enhancements. At the core of the treatment is the identification of the Old and New Me’s identities, thoughts, feelings, behaviors, and situations. The utility of using the Old Me identity is that it allows enough of a personal distance from the past lifestyle and offenses that disclosures and acceptance of responsibility, and heightened levels of motivation are facilitated. The New Me, or success-oriented identity, is especially meaningful to the ID population since many have had to live with the stigma of their developmental disability, and have even had this disability come to define their identity; the New Me identity, goals and Good Life provides powerful motivation to progress through treatment. However, the relationship between a person’s Old and New Me is dynamic and always present. The two ‘‘identities’’ are always battling for control, namely the Old Me is probably stronger and smarter when therapy is initiated. One goal of therapy is for the New Me (the person who is now in treatment), to ‘‘hang in’’ (persist in coping) to become stronger and learn the tricks of the Old Me (e.g., cognitive distortions, problems of immediate gratification) so that the person can further approach who they want to become (i.e., the success-oriented New Me identity), and approach their ‘‘good life’’. Rather than a unidirectional relationship, the relationship that exists between the Old Me and New Me is transactional and dynamic. The treatment model has four different phases, namely ‘‘Getting Ready, Learning the New Me, Making the New Me Smarter and Stronger and New Me Every Day’’ (Haaven [16]). The first phase of ‘‘Getting Ready’’ involves such tasks as developing a support plan, learning how to be a good group member and getting to know the other group members, telling one’s autobiography in group, and getting to learn about feelings and treatment concepts and terms. The second phase in treatment, ‘‘Learning the New Me’’, involves teaching and engaging each group member in meaningful and empowering personal projects to identify the Old and then New Me’s identities, thoughts, behaviors, and situations. Other tasks during this second stage include developing a simple timeline discussing Good and Bad experiences during the person’s life, who was in control during these times (i.e., Old Me or New Me), the disclosure of their Old Me’s past sexual offending and its consequences, and the losses involved. Subsequently, a relationship development plan, goals and characteristics of their New Me and Good Life, and different coping skills are worked on. The third phase in therapy involves ‘‘Making the New Me Smarter and Stronger’’ such as seeking help skills, problem solving and emotional control. One

123

Sex Disabil (2010) 28:119–128

125

particular New Me coping skill is identified, practiced and strengthened on a daily basis. Other essential tasks, during this phase, involve identifying ‘barriers’’ to one’s New Life, learning thoughts, behaviors and situations that could lead one to reoffend, and how to cope with them (i.e., avoidance strategies, cognitive and arousal control). The last phase of therapy, New Me Every Day, involves maintaining a realistic idea of one’s risk level for relapse and reoffending, and to maintain relationships, openness, hanging in behaviors, seeking help when necessary and working on short and long term goals. Prior to implementing the specialized treatment components, Bernstein and Gaw [17], urge that ‘‘underlying organic diseases such as genitourinary disorder or an organic brain disorder must be ruled out when a patient has the chief complaint of genital retraction’’. In terms of diagnostic differentials or rule outs regarding the DD, epilepsy, headaches and migraines need to be investigated. Taking into account the Old Me New Me Treatment guidelines as the foundation of his treatment and then addressing his individual problems, his treatment was revised to include the following: 1. Provide psychoeducational training in basic anatomy terms and concepts both to increase his sexual knowledge and to start addressing healthy sexual behaviors; this would be addressed during a sexual awareness class that he attends as part of his regular program while in secure care. 2. ‘‘T’’ would be engaged in identifying and labeling his Old and New Me Identities. He would be encouraged to identify his Old Me as feeling, thinking and acting like a combined baby/female/male with imaginary companions, three of which control his body and behavior. His New Me Identity could involve identifying himself as a Good Man (Knight) without any imaginary companions. It is believed that his gender identity problems could be addressed by identifying his New Me as a male, identifying with females as part of his Old Me, and then structuring his time with pleasurable, masterful and masculine-oriented activities; this structured schedule would also address his moderate level of depression which includes symptoms of confusion and difficulty making decisions. This approach of identifying with the masculine and discouraging identification with the opposite sex was found to be effective by Bradley and Zucker [18]. This approach was considered to be easily integrated into his Old Me New Me treatment and probably more beneficial than a trial of lithium carbonate, as was used by Larden and Rasmussen [19] for an autistic girl with Gender Identity Disorder. In addition, associated thoughts, behaviors, symptoms and situations would be identified for both the Old and New Me Identities. ‘‘T’’ will be engaged in learning about his Old and New Me Identities by creating drawings, collages, and discussions with his therapist. 3. To more fully understand the relationship between ‘‘T’’, his IICs and the illusions of autonomic functioning and of being controlled, the metaphor of a ventriloquist and his puppet would be presented. A metaphor of a ventriloquist and his puppet would be made between the relationship between ‘‘T’’ and his baby ICC and Evil 1 and 2 to highlight that ‘‘T’’ is in total control, and that he created IICs by using his creative ‘‘make believe’’ energy. Basically, the metaphor involves the use of a ventriloquist as a person in control and that he makes the puppet talk and act by using his own energy to make believe. Also, it would be a mistake to identify that the puppet is separate from the ventriloquist and that the puppet even controls the ventriloquist, despite that this sometimes appears to be so in the act. These concepts would be presented to ‘‘T’’ via a puppet demonstration to try and restructure his beliefs in autonomic functioning and being controlled by what he created. Subsequently, a benefit-risk analysis would have

123

126

Sex Disabil (2010) 28:119–128

to be completed where ‘‘T’’ would have to be able to identify and acknowledge that the risks and disadvantages of having all ICCs outweighs the benefits. Then ‘‘T’’ would have to shed himself of the ‘‘energy that makes it (IICs) operate’’ [4] with their associated control/coercive methods i.e., depersonalization and koro. In line with his New Me Identity, he would have to acknowledge that he created his IICs, that he is stronger than they are, and that he can exert an ‘‘act of will’’ or choose to undergo the ‘‘Bottle Routine’’ to get rid of them, and an appropriate ‘‘energy’’ (possibly associated with being a Good man) could replace them. His creative imagination would then be redirected to some other appropriate adult-oriented expression (e.g., helping adults move/set up areas, adult craft projects) since a part of his New Me would have to be completely without the IICs. 4. ‘‘T’s’’ depersonalization symptoms would be targeted for intervention first by banishing the IICs that contributed to his depersonalization symptoms via the bottle routine. Any residual symptoms would be addressed via the cognitive treatment approach and via trauma therapy. This approach would involve utilizing such interventions as psychoeducation and normalizing, decreasing avoidance and selffocused attention, challenging catastrophic assumptions, and relapse prevention. 5. Subsequently, ‘‘T’’ would then begin to learn how the Old Me affected the New Me in the past. This task would involve ‘‘T’’ devising a timeline, with his therapist, and identifying major events in his life, placing them in a Good or Bad category along the timeline that progresses along by age. Next, ‘‘T’’ will identify who was in control, the Old Me or New Me, for each of the events, and the losses that have gone into the development of the Old Me, and as the result of it. In this way, ‘‘T’’ will identify his trauma and emotional abuse, his creation of the IICs, their control, the existence of his sexually deviant impulses, his gender and sexual difficulties, and the commission of his sexual offenses along a time line and evaluate how they have affected his life. This task involves the identification of events and stressors that are tied to the development of the Old Me’s Identity, its thoughts, actions etc. as a means of him understanding his life story; this will be followed by trauma therapy (since the trauma, emotional abuse and losses have already been identified via the timeline and assessment interviews). 6. Subsequently, cognitive restructuring can begin with ‘‘T’’ taking direct responsibility for having and managing his deviant arousal. Behavioral and cognitive coping strategies can then be reviewed with him and reinforced. Since his individual issues have been addressed, his group sex offender treatment can now progress according to the Old Me New Me Model (OMNM) starting again with developing a relationship plan and culminating with the tasks in New Me Every Day. As needed, the Cognitive Therapy of his schizoid traits would be integrated into this treatment model. Due to the number and complexity of the clinical problems that ‘‘T’’ presents, a problem list, the problem’s priority and the corresponding intervention can be found in Table 1. The possible conditions that required review were examined and ruled out before these treatment targets were addressed. Since there is a significant number of problems and treatments involved, a pictorial display, via Mayer–Johnson Boardmaker pictures, would be developed. Both the problem area and most of the treatments would be arranged for each of the six areas in the order that the problem would be addressed. This pictorial display would be helpful in both describing the problem and treatment involved and to help focus ‘‘T’’ on that area that was being addressed.

123

Sex Disabil (2010) 28:119–128

127

Table 1 A table of prioritized problems and corresponding interventions for ‘‘T’’ 1. Deficits in understanding basic anatomy 1. Sexual awareness classes Training in understanding basic anatomy 2. Mental confusion, thoughts that he is going crazy; moderate depression

2. Ongoing engagement in Old Me New Me Treatment This therapy model serves as the core treatment approach The purpose of this phase is to give ‘‘T’’ some initial relief that his disorders have a name, some basic understanding of what is happening, that he is not crazy, that others have similar experiences and that a realistic treatment plan can be developed. His Old Me of being a Baby/Man/Female with IICs and New Me of a Good MAN are identified; a structured schedule of pleasurable, masterful, masculine activities would increase his identification with being masculine and decrease his moderate depression. This stage initially empowers him with understanding and a new identity, and increases his control/self-efficacy for the subsequent phases of the therapy

3. IICs

3. Ventriloquist metaphor, identifying the advantages and disadvantages of having all IICs, followed by the bottle routine to banish all of the IICs, and not talk to them anymore The purpose of this phase is to provide ‘‘T’’ with a sense of safety and control over his own body. The completion of this phase is a prerequisite for the trauma work

4. Depersonalization-Koro

4. Bottle routine ? cognitive treatment of DD The purpose of this phase is to decrease or manage all depersonalization symptoms to further enhance his sense of safety and control

5. Trauma

5. Developing OMNM timeline and trauma work Once the good/bad events timeline for events in his life is developed then trauma work in individual therapy can start

6. Sex offenses

6. OMNM sex offender treatment Continues with the OMNM treatment task of developing a relationship plan and continues until the last phase of New Me Every Day. The cognitive therapy of schizoid personality traits can be incorporated into OMNM treatment

In summary, the purpose of this phase of the case study was to present a realistic treatment plan to deal with all of his comorbid disorders. A pertinent but brief literature review and how it applied to the case was presented. A complex treatment approach would be simplified for him via the use of pictures depicting the problem area and the treatment that would be used. The benefit of this continued case study is that it highlights a developmental and longitudinal perspective for how the different disorders have progressed over time. Also, it illustrates that disorders in a person with ID can resemble the same disorder in a non-ID population, and utilize many of the same basic treatments with some modification. References 1. Faccini, L.: The incredible case of the shrinking penis: a koro-like syndrome in a person with intellectual disability. Sex. Disabil. 27(3), 173–178 (2009) 2. Faccini, L., Tucker, J. (2009) The return of Koro and the companions in a person with ID: follow up assessment and dynamics. Sex. Disabil. 27(4) (in press)

123

128

Sex Disabil (2010) 28:119–128

3. Simeon, D., Guralnik, O., Schmeidler, J., et al.: The role of childhood interpersonal trauma in depersonalization disorder. Am. J. Psychiatry 158, 1027–1033 (2001) 4. Allison, R.B.: Personal Communication. [email protected]. (2009) 5. Nagera, H.: The imaginary companion: its significance for ego development and conflict solution. Psychoanal. Study Child 24, 165–169 (1969) 6. Taylor, M.: Imaginary companions and the children who create them. Oxford University Press, New York (1999) 7. Barbara Sanders cited in Taylor, M.: Imaginary Companions and the Children Who Create Them. Oxford University Press, New York (1999) 8. Markman, K.D., Klein, W., Suhr, J.A.: Handbook of Imagination and Mental Stimulation. Psychological Press: Taylor and Francis Group (2008) 9. Oberndorf cited in Schilder, P.: The treatment of depersonalization. Bull. NY Acad. Med. 258–266 (1939) 10. McKay, D., Moretz, M.W.: Interoceptive cue exposure for depersonalization: a case series. Cogn. Behav. Pract. 15(4), 435–439 (2008) 11. Frey, R. Depersonalization disorder. Encyclopedia of Mental Disorders at www.minddisorders.com 12. Medford, N., Sierra, M., Baker, D., David, A.S.: Understanding and treating depersonalization disorder. Adv. Psychiatr. Treat. 11, 92–100 (2005) 13. Hunter, E.C.M., Phillips, M.L., Chalder, J., Sierra, M., David, A.S.: Depersonalization disorder: a cognitive-behavioural conceptualization. Behav. Res. Ther. 41, 1451–1467 (2003) 14. Frazini, L., Grossberg, J.: Eccentric and bizarre behaviors. John Wiley and Sons, New York (1995) 15. Haaven, J.: The evolution of the Old Me/New Me Model. In: Blasingame, G.D. (ed.) Practical strategies for persons with intellectual disabilities: working with forensic clients with severe and sexual behavioral problems. Safer Society Press, Brandon, VT (2006) 16. Haaven, J.: Personal Communication. [email protected]. (2006) 17. Bernstein, R.L., Gaw, A.C.: Koro: proposed classification for DSM IV. Am. J. Psychiatry 147, 1670– 1674 (1990) 18. Bradley, S.J., Zucker, K.J.: Gender identity disorder: a review of the past 10 years. J. Am. Acad. Child Adolsc. Psychiatry 36(7), 872–880 (1997) 19. Landen, M., Rasmussen, P.: Gender identity disorder in a girl with autism-a case report. Eur. Child Adolesc. Psychiatry 6(3), 170–173 (1997)

123