Case Presentation

Amy Elliot Dunne

 Background
The background and the case history are taken at the point where the
movie ends.

A pregnant woman in her 30s named Amy Elliot Dunne enters the clinic
with a chief complaint of "My marriage is not working". She complains of
her husband being uninvolved in the marriage and insists that she feels
unloved. She requests for convincing her husband to come for marriage
counseling and says that she needs his support. The woman says that she
thinks counseling is the only way to fix her husband and save the marriage.
 Identification Data
Name: Amy Elliott Dunne
Age: Not given
Sex: Female
Marital Status: Married
Occupation: Writer
Education: B.A. Psychology from Harvard
University, Major in Psychology from Yale
University
Religion: Unmentioned
Residence: North Catharage, Missouri
Language: English
Socioeconomic background: Upper class
Informant: - Herself

Referral: - Self

Chief Complaint:
● Verbatim - “My marriage is not working”
● Feeling unloved by her husband.
● Feeling that the husband is not involved in the
marriage.

Precipitating factors: Childhood, Parents, “The

Amazing Amy” book series

Mode of onset: Insidious

Duration of illness: Unidentifiable due to inadequate
information.
Course of illness: Increasing
 History of Present Illness
The client was born a single child in a higher class family to a heterosexual married couple. In her childhood she was portrayed as a high
achiever and as extraordinary by her parents through the release of a book series called “The Amazing Amy”, which also made her
popular. The client is jealous of this perfect character in the book and often views herself as “flawed” in comparison. During her high
school - about 20 years ago - the client accused a man she was in a relationship with of showing obsessive behaviour towards her after
their relationship ended. The client however kept in contact with the man through letters.
She completed her post secondary education from Harvard University pursuing a BA in Psychology.

The client then had a romantic relationship with a man, whom she accused of commiting rape on her and took legal action against him.
The client later had a 2 year long relationship and then married the person, who is her spouse now. The client confessed to ‘really like’
the man during a voluntary act of cunnilingus between them. During the marriage there are financial issues as a result of which there is
an argument between the couple, during which she states “ Why you’re daring me to be someone I do not want to be. The nagging
shrew. The controlling bitch. I am not that person. I am your wife.” Soon after, the client claims to have anticipated that “everything was
about to get worse”. The client lost her job and moved to Missouri with her husband ,without being asked, because her mother-in-law had
cancer. After moving to Missouri, the client states that she felt as if she was “something loaded by mistake” by her husband and
questioned if he was happy that she was with him. She also felt that she was “something to be jettisoned, something disposable”and
stated ”I feel like I could disappear”.
The client then felt used by her husband for sexual pleasure and said that “otherwise I didn’t exist”. The client states that she became
“from desperate to pathetic” one night when she asked her husband to stay back at home instead of going out with his friends. The same
night the client had an argument with her husband over having a baby, where she viewed the act as having an “inspiration” and “purpose”
whereas the husband viewed it as something to “save” the marriage. During an enraged fight over this, the client got pushed by her
husband and fell to the ground. She felt scared of “how much he wanted to hurt her more”.
She quoted, “ I realized I am frightened of my own husband”. The client bought a gun for herself on
Valentine’s day and said “that’s how crazy I had become. She felt that her husband wanted a divorce
and was in the marriage only due to money and the prenup. The client did not go back to her parents
because she was unsure if she believed herself. While thinking of her husband hurting her, she calls
herself “paranoid and crazy”.
The client then decided to make a plan of punishing her husband by sending him to prison by
framing him for her murder - which would actually be suicide. The client wrote 300 diary entries
about her relationship with her husband to be found by the police as a result of her planned treasure
hunt.
She manipulated and befriended a pregnant woman to convince her of her “husband’s violent
temper” She deceitfully used her husband’s credit cards and changed her life insurance. She
manipulated other people into loving her for the sake of accomplishing her plan. She manipulated
her legal medical records by stealing the pregnant woman’s urine. She then staged her crime scene
by making herself bleed and clean the blood.
On 5th of July the client faked being “missing” with the intent to commit suicide and send her “lazy,
lying, cheating, oblivious” husband to prison for her murder. She stated that “He took my pride and
my dignity and my hope and my money, took and took from me until I no longer existed. Thats’s
murder, let the crime fit the punishment”
The client said that her husband loved the “cool girl” she was pretending to be. She claims to have
known that it was what her husband wanted from her when she met him. She mentions abundant
activities that she only performed for him and admits that she “enjoyed” some of them. The client
stated, “I made him smarter sharper I inspired him to rise to my level I forged the man of my dreams”
She was revengeful about her husband's infidelity and quoted that she thought “he doesn’t get to
win” She also said “Grown ups have to pay; have to suffer consequences”
Later, she befriended a stranger and ended up secretly spitting in her drink when called a “rich bitch”
by her and saying that “she got what she deserved” to her story on the news.
The client, after being robbed by the same stranger, manipulated her way back to her ex boyfriend to
seek shelter on 13th July and planned to elope to Greece with him after anticipating to watch her
husband go to prison. However, upon seeing the news of her husband apologizing for being a bad
husband, the client changed her plan and decided to go back to him making the entire chain of
events look like abduction. She killed her ex-boyfriend and injured herself to convince people that he
persistently tortured her. The client was admitted in a hospital and interrogated by the police, and
successfully deceived them to pose as a victim of her ex-boyfriend. On 4th August, the client then
went back to her husband and said that “she fell in love with” him when she saw him on TV. On
being accused of being a murderer by him, she replied by saying, “I’m a fighter. I fought my way
back to you” and blackmailed her husband to stay with her.
The client thanked the media for forgiving her husband and supporting their marriage. After 5 weeks,
the client tried to comfort her husband by saying that she would never hurt him and said,” I need you
to do your part.” She rehearsed her answers with her husband for the media and told him that he
needs to admit having committed certain felonies to the media for her to feel “safe”. She then
blackmailed her husband to stay in the marriage by her pregnancy which was conceived out of a
sperm sample of the husband. On hearing this the husband pushed the client and in a short
argument the client said, “ The only time you liked yourself was when you were trying to be someone
this cunt [herself] might like. I’m not a quitter. I have killed for you. Who else could say that?” and
claimed that he can only be happy with her.
She now claims to feel unloved by her husband and says that he is uninvolved in the marriage.
 Concomitant Changes in Attitude: Paranoia.
Concomitant Changes in Biological needs/ functions: None

Past Psychiatric and Medical History:

Medical - hospitalisation due to self induced injuries.

Family History:

Family tree:

The client’s parents were recently in debt and borrowed almost one million dollars from her trust fund. The client
was the breadwinner of the family for some time when her husband lost his job. The family was concerned about
the client when they were looking for her, however they had partially ulterior motives.
Personal and Social History:
Perinatal History: None given

Childhood history:
The client was raised by her mother and father. A book series that depicted a high achieving and fictionalised identity of the
client named “Amazing Amy” was launched and glorified by the media when she was 10 years old. One of the books showed
that the character gets into college because of playing volleyball, whereas the truth was that the client was eliminated from
the game in the first year of high school. Such identical instances took place time and again in her childhood. Her mother’s
personality traits and self centeredness could be suggestive of maternal deprivation.

Educational History:
The client completed her education from Harvard University by pursuing a Bachelor of Arts in Psychology. She also completed
her major in Psychology from Yale University.

Play history: None given

Puberty: None given

Menstrual and Obstetric History:

The client recently inseminated herself with her husband’s sperm sample and got pregnant.
Occupation:
The client used to work as a writer and designed quizzes for magazines. She lost her job due to recession.

Sexual and Marital history:

Sexual History:
The client was sexually active before the marriage. She alleged (and took legal action against) one of her
partners in the past for committing ‘first degree felony rape on her. The client shows sexual fantasies of
submission and being punished and has had intercourse in public places.
Marital History:
She was in a relationship with her spouse for 2 years before marriage. The marriage took place out of
choice and was not arranged by her parents. A prenup was signed before the marriage. Later in the
marriage, the client felt used by her spouse for having sexual intercourse. The client and her spouse went
through financial issues and disagreements, which the client felt were triggering.
The client also came to the knowledge of her spouse being romantically involved with another person during
their marriage. The client was physically pushed by her husband once during the course of her marriage.
Subsequently, she felt unsafe in her marriage and often worried about being attacked. The client’s spouse
wanted a divorce but did not express it to her due to being financially dependent on her. Currently,
according to the client, the husband is only part of the marriage due to their baby.
Premorbid Personality:
Adequate details are not present to decipher the premorbid personality as it is not distinguished by
the client or her family or friends,

Alcohol and Substance Abuse History:

The client consumes alcohol occasionally.There is no history of drug use.
 Mental Status Examination
1. General Appearance and Behaviour -
a. Appearance -
i. Level of grooming - Normal
ii. Level of cleanliness - Adequate
iii. Level of Consciousness - Alert
b. Cooperativeness - More than so
c. Eye to Eye Contact - Maintained
d. Rapport - Spontaneous
e. Psychomotor activity - Normal
f. Other movements - Adequate

2. Speech -

a. Relevance - Relevant
b. Coherence - Fully coherent
c. Volume - Normal
d. Tone - Monotonous
e. Reaction Time - Normal
3. Mood

a. Subjective - I feel damaged

b. Objective - Neutral
c. Range - Normal
d. Reactivity - Normal
e. Congruence - Congruence
f. Appropriate/Inappropriate - Appropriate
4. Thought

Form
a. Derailment - No
b. Substitution - No
c. Omission - No
d. Fusion - No
e. Drivelling - No
Stream
a. Flight of ideas - No
b. Circumstantialities - No
c. Perseveration - No
d. Thought block - No
Possession
a. Obsession and Compulsion - No
b. Thought Insertion - No
c. Thought Withdrawal - No
d. Thought Broadcast- No
Contents
Delusions - Grandiosity

5. Perception

Hallucination - No
Illusion - No
6. Cognitive Functions

Orientation - Intact
Attention and Concentration - Intact
Memory - Intact
Intelligence - Intact
Judgement - Intact

7. Insight
Grade 1
 Diagnostic Formulation

The client is in her 30s and is currently pregnant. She has had feelings of jealousy
and being “flawed” since her childhood due to a comparison with a fictionalised
character of herself from the book series launched by her parents named “The
Amazing Amy”. The client has had a history of unstable relationships in which she
has accused her partners for obsessing over her after breaking up and first degree
felony rape. The client had a fear of being and harmed in her marriage as a result of
being intensely pushed once by her husband. She felt “paranoid” and “crazy” while
thinking of her husband harming her. She anticipated abandonment in her marriage
and felt “used, disposable, and something loaded by mistake.”
Due to marital and relationship problems, the client planned to punish her husband
by framing him for murder by committing suicide. She blamed her husband for
taking away her pride, dignity and money and wanted to punish him for the ‘crime’.
She later manipulated her ex-boyfriend to seek support and intended on
running away to Greece with him. However, after watching her husband
apologise on News, the client murdered her ex-boyfriend, framing it as
self-defense, to go back to her husband. She claimed that she is a “fighter” to
fight her way back to him. She blackmailed her husband to stay in the marriage
till an extent where she impregnated herself with his sperm sample and
convinced him to stay for the baby. She said that in order to feel “safe”, she
needed her husband to own up for certain felonies that she committed. She
also rehearsed with her husband and portrayed an image of a loving husband
and good marriage to the media. The client has constantly felt the need for her
husband to be involved in the marriage.
Difference between ASPD and BPD
What is the diagnosis:
Borderline Personality Disorder
F60.3

Symptoms:
Liability to become involved in intense and unstable relationships, often
leading to emotional crisis
Marked tendency to engage in quarrelsome behavior and to have
conflicts with others
Excessive efforts to avoid abandonment
Recurrent acts of self-harm
Feelings of emptiness
 Case Formulation
Biological Social Psychological

Predisposing/Precipi Parents The Amazing Amy

tating Childhood Jealousy
Idealisation

Perpetuating Relationship Issues Fear of

Behaviour of the Abandonment
husband Fear of being hurt
Facing Adultery Felon’s Claw

Protective
 Mode of Treatment
● The most effective mode of treatment for Boderline Personality Disorder is DBT - Dialectical
Behavior Therapy. It is also the only empirically supported treatment for BPD.

● It focuses on skills of mindfulness, living in the present, regulating emotions, tolerating distress
and effectively managing relationships with others.

● Structure of DBT -

The structure of DBT is based on 4 components, which are:

1. Skills Training Group

2. Individual Psychotherapy
3. Telephone Consultation
4. Therapist Consultation Team
 Skills Training Group
This is a weekly group, run like a class, focusing on these 4 skills -

1. Core Mindfulness - This includes teaching patients observation,

participating in the moment, having a non judgemental mindset and
focusing on one thing at a time. It is meant to tackle impulsivity and
emotion-driven behaviours as well as the tendency of patients to devalue
and idealize themselves.
2. Interpersonal Effectiveness - This focuses on practising social skills such
as maintaining self-respect and saying ‘no’ when required.
3. Emotion Regulation - Strategies for enhancing control over personal
emotions.
4. Distress Tolerance - This teaches patients to accept pain and distress
non-judgementally, without trying to change it.
 Individual Psychotherapy
This involves one on one interaction with the therapist to deal with problem
solving behaviours and engaging in active coping.

Telephone Consultation
This allows the patient to contact the therapist for in moment guidance in
everyday life.

Therapist Consultation Team

This is a weekly meeting of individual and group therapists who are
working with the patients to maintain motivation and commitment.
 Other forms of treatment may include:
● Medication such as mood stabilizing drugs in this case.
● Hospitalization
● Other forms of therapy such as:

1. Schema focused therapy - for identifying needs and promoting positive life patterns.
Techniques used in this therapy are data collection, schema flashbacks, guided
imagery, schema dialogues and role play.
2. Mentalization based therapy - this helps identify thoughts and feelings at a given
time and creating an alternate perspective on the situation. Techniques used are
demonstrating empathy, exploration, clarification and challenge, establishing an
affect focus, mentalizing the relationship.
3. Systems training for emotional predictability and problem solving - this includes
involving family members and caregivers into therapy. Techniques used are
psychoeducation, destigmatization of the illness, educating friends or family
members, managing emotion and behaviour management skills.
Thank you