The Man Who Could Fit on the Head of a Pin

Clinical Psychiatry News - Volume 36, Issue 1, Page 21 (January 2008)

Some years ago, an internist referred a man to me whose presenting problems included feeling like he was shrinking four or five times a day. This happened at work and in many social situations, especially when he was under stress.

The patient, who was 44 years old, was very successful in business and financially comfortable—with a large appetite for clothes and meals in expensive restaurants.

For almost 20 years, he had been experiencing episodes of seeing himself shrink. He described the feeling as “shrinking to the size of the head of a pin.”

As the years went by, these episodes became more frequent and of longer duration. He had sought psychotherapy on numerous occasions and had been put on antipsychotic medications for “delusions.” One psychiatrist labeled the patient schizophrenic.

A second psychiatrist saw the patient as depressed and viewed his lavish spending patterns as an effort to overcome sadness and despair. The patient had admitted that at times he did feel depressed but saw those feelings as secondary to concerns about his business and fear of economic decline. Exploring this and taking antidepressants were not helpful. The internist who had made referrals to both previous psychiatrists now called me to see what help I could offer—knowing that I focused on short-term, goal-oriented psychotherapy.

On my first visit with this patient, he described the experience of talking about himself as “OK” and made it clear that he did not want to take medications because they made him feel sick. After an hour and half, I began to formulate a diagnosis of a depersonalization disorder with derealization features. In this case, micropsia (seeing altered sizes and shapes, especially himself) was the central set of disabling symptoms that dominated the clinical picture. Anxiety, depression, a sense of confusion, and even the appearance of a thought disorder can complicate the clinical picture and make the diagnosis more difficult.

DSM-IV dissociative disorders are divided essentially into four categories: fugue, dissociative identity disorders (formerly called multiple personality disorder), amnestic dissociation, and depersonalization disorder—as in the “shrinking man.” Defining these dissociative disorders is complicated, in that there is controversy about what they represent.

For example, in dissociative identity disorder (DID), interpretations differ as to what is happening. Some believe DID is more of an extreme type of suggestibility in a certain type of personality configuration rather than a disorder.

I do like the multiple personality label for this disorder, whether extreme suggestibility is at work or not, in that when we see the disorder it does present with multiple personalities.

According to Dr. Nader Galal, a psychiatrist in New York City who studies and treats multiple personality disorders, the disorder and treatment are so complicated and the variations so great that they almost defy a good label. Dr. Galal thinks the multiple personality label fits better. “It's what is happening,” he said when I asked him about it.

When treating these patients, I like to move quickly through the three stages of treatment that I believe work best. That way, the patient understands that the aim is to move away from the multiple personalities and toward stability, resolution, and most importantly, integration.

When my patient with the dissociation disorder combined with depersonalization and derealization symptoms returned for a second visit, he and I talked about establishing a basis in learning for this “crazy thing,” as he called it. I kept trying to keep my learning, philosophizing, and action (LPA) technique as operative as possible to provide a solid learning and therapeutic matrix in which to understand and cognitively reprocess his problem.

As we reviewed some of his experiences over the previous decade, it appeared that his business had gone well, as had life in general. His social life was focused. The patient preferred being single, with close friends and a few relatives, over a family commitment. In essence, nothing about his life jumped off the page for him or me that could be used to develop into an example or set of examples to build on as I sought to understand the ensuing disorder.

As we went further back into what he remembered about his past, it appeared that anxiety was a major part of his childhood, as both his mother and aunt had called him nervous. Since he had grown up in a war zone, he understood that it was natural to have lasting anxieties and to be nervous.

The patient remembered clearly as a child hearing bombs dropping in his town night after night. His ability to flash back to those bomb blasts from so long ago made me wonder whether the patient would be a good subject for hypnosis to possibly enhance his memory.

Over the course of my career, I've been very comfortable using hypnosis. I've given many lectures and taught numerous educational programs on the use of medical hypnosis. In a few instances with certain highly hypnotizable subjects, I have worked with age regression. Because of those experiences, I certainly know how to differentiate between those who can truly age regress and the simulators who are seen most often. This man, however, did not appear to have many characteristics of those highly suggestible/hypnotizable people.

Nevertheless, I did measure his hypnotizability, and, as I suspected, he was in the midrange and was not a candidate for age regression. As I measured his abilities, I made him aware of every step I was taking and why I was doing it. He was clearly interested and said that he wanted to go “back in time.” I assured him that although he might be relaxed in the hypnotic experience, he would not be age regressed or go “back in time.” However, during our work together, when he asked me, “Could I possibly remember something,” I answered, “Yes, you could.”

So began our journey into this patient's memory, using a simple eye roll and a deep breathing technique. I asked questions about his life, decade by decade, but nothing remarkable came to light.

On the second visit using this hypnotic model, an amazing thing happened: The patient clearly came to grips with his fears during the wartime bombings in his town. He revealed that, all those years ago, he had wished that he “would disappear” and not “be around” as the bomb blasts continued. The patient was very pleased about this revelation during his hypnotic recall.

I was not as pleased. The memory had the potential to be a good source of the origins of primary symptoms of derealization and depersonalization, I explained, but it needed to be validated by outside confirmation. I asked if there was anyone who could help confirm this memory. No one came to mind because no one knew about his problems—except his past psychiatrists and now me. He had been too embarrassed to ever mention those memories to anyone else.

The point I made was that, in order for me to go forward, I needed some confirmation or corroboration of the memory as a method of validation. This is something I did routinely for anyone using hypnosis to enhance recall.

The patient did have an aunt who had lived with him at the time of the bombings and was the only person who might be of help. After discussing this with me, he realized that he needed to ask her about his behaviors and thoughts while growing up. She confirmed the memory that all he wanted to do during the bombings and afterward was to disappear.

With that confirmation, I was able to move quickly into the learning phase of my LPA technique. In a half-dozen visits, we were able to cognitively challenge this learned processing of his very real fear of injury or death as a child. The symptoms of dissociation and derealization left him slowly, but they did leave.

I don't think any specific formula for treating these dissociative disorders exists since what's happening is very unclear and the DSM is less than adequate in its nomenclature. When neurochemistry, physiology, and imagery are elucidated (and this will happen), we'll move away from a pseudoscientific vocabulary and understand more clearly what we're treating. Until then, let's keep it simple.

Looking back at this patient, I could easily have added or slipped into a posttraumatic stress disorder diagnosis and moved differently. The results might have been the same. Regardless, these disorders need to be treated on an individual basis by clinicians who have an open mind and a broad base of treatment strategies.

Let me know what you think about this very complicated set of disorders and the approaches you have taken.

PII: S0270-6644(08)70019-5

doi:10.1016/S0270-6644(08)70019-5