Moore, Mallory - MRN; AO294831 - 10/20/2005

NAME ON FILE: Mallory Moore 

DATE OF BIRTH; 10/20/2005 

CHRONOLOGICAL AGE: 20 years and..

PARENTS: Winfred Moore-Smith and Rick Moore 

DATES OF ASSESSMENT: 10/11; 10/15 

DATE OF REPORT: 10/17

IDENTIFYING DATA AND REASON FOR REFERRAL:

Mallory is a twenty-year-old Caucasian young adult who was referred to by the courts to determine cognitive and emotional status after [REDACTED]. Mallory has a history of intrusive thoughts and behavior akin to mania, including impulsive actions (purchases, speeding while driving) and at times an irritable mood. Despite referrals to other clinicians and medications, she still participates in sensation-seeking and risk-seeking behaviors. It has been further reported by her parents that she has “odd” behavior, where she will wander around the house looking at things and tugging on the doors.

​

SOURCES OF INFORMATION:

 Background information was obtained from her mother, social worker, lawyer, former psychologists, and numerous psychological, educational, and medical records. This information appears to be from reliable, competent sources and is valid. Current status of cognition and behavior has been assessed through observation during therapy sessions.

​

ASSESSMENT METHOD

The evaluation has consisted of both structured and unstructured interviews and standardized psychological tests: the MMPI, the Yale-Brown Obsessive Compulsive Scale, and mood disorder questionnaire, the Beck Anxiety Inventory, the Beck Depression Inventory, and Behavioral Observations.

​

BEHAVIORAL OBSERVATIONS 

During observation, Mallory was dressed in her prison scrubs. Her hair was messy, as though it had not been brushed, and she had several bits of prominent bruising on her face and hands. Despite this, she spoke politely and was cooperative for the duration of our conversations. She often uses metaphors to describe how she is feeling, although these metaphors seem quite “gothic.” She will describe things as being akin to death, though snakes, moths, and other similar imagery will enter as well. She likes to describe things as different rooms as well.

SESSION #1

Session Notes and Observations:

We started our first proper session after intake with Mallory delegating herself entirely to the couch. She complained about the texture of it, said that it was too scratchy and that it made her skin feel like it was prickling. She said that she liked the color of my office though. (Teal, mainly.) She has this habit of fiddling with the end of her sleeves when she's thinking; she will pick at a stray orange thread. At one point, she mentioned that she wanted water because her entire mouth tasted like sour bile, and no matter what she did, she couldn't get the taste out of her mouth.

Mallory is extremely aware of her senses and her surroundings and is seemingly hypersensitive to the changes in her environment. She also tends to be extremely honest, blunt, but not impolite. She tries her best to be really patient, but she's always tapping her toe (musicians? They tap the toe instead of the heel?)

I decided to let her explore the room, and she stared at the bookshelf for a very long while. She kept swallowing randomly. Mallory would leave the bookshelf, and then walk away, and then come back to the bookshelf. I would ask her what was wrong. She shook her head in a way that reminded me of a disappointed parent.

"What if I did something else bad and I just don't remember it?" Was something she asked me today. I asked for elaboration again, but she just shook her head, went back to fiddling with the stray thread at the end of her jumpsuit.

I decided not to prompt her to talk about [REDACTED] this session. It didn't really seem conducive to treatment, in my opinion, when she was already showing signs of anxious behavior. That isn't really fair to her at all.

Session #2

Mallory started the session by taking a breath, stammering and speaking in short bursts, like she was about to have a panic attack, and she grabbed a book off of my shelf and threw it across the room. It hit the wall with a very firm bang, and then hit the ground, the sound of the paper opening and hitting the hardwood. It almost reminded me of a stock sound. It startled me, and I don't jump easily. 

I asked Mallory why she did that, and why she felt it necessary to do that.

She said that she didn't know, but she knew that she had to do it, because if she didn't do it, I would get hurt. She had no desire to hurt me like she did [REDACTED].

When in a state of confusion, she speaks in a very roundabout way. "I would love to do X, but I can't because of Y, I need to do Z, but I can always do A if that's easier for you." The words sometimes come out all garbled. 

"I would love to go home, but I can't because the book is evil, so I needed to throw it, but I need to drink water too." She says that she was getting that feeling of bile burning in her throat again. I gave her some water, but she wouldn't take it unless I put it halfway through the room and let her grab it from there. I let her do it, and tried to press to see why she had these compulsions.

"Do you think I'm crazy, Doctor?"The question was very sudden, and another thing I wanted to take note of observing.

I asked her if she felt like she was crazy. She told me yes. Said that she had to be some flavor of crazy.

SESSION #3

NOTES AND OBSERVATIONS:

Mallory curled up on the floor today. She said that she really wanted to hurt me today and that she wanted me to hide the power cords from her. These thoughts have been bringing her a great deal of personal distress.

She curled up on the ground and was letting out these deep, heaving breaths. Whenever I came close, she would start screaming at me to go away. When I tried to touch her, she hit me and backed away into the corner. We attempted to go through some breathing exercises. She reported many somatic symptoms, including a tight chest, a stabbing pain near her heart, and I observed tears.

She kept repeating that she didn't want to hurt me, that she didn't want to hurt anyone at all. Once she had calmed down a substantial amount, she told me that she was scared that she was going to be forgiven.

She kept nervously tucking her hair behind her ear. It's starting to look wet; it's so greasy, and borderline matted like a waxy rat's nest. I asked her what she meant by being scared of being forgiven.

She doesn't believe that she deserves to get better. Every single time that she resists an impulse, it's like she is slowly getting better. And if she gets better, that means that the family of [REDACTED] is going to maybe forgive her. And she hurt him. Getting better and being able to cope properly with her problems. And being able to cope properly means that her life will be able to continue in the way that [REDACTED] has not.

"You keep telling me that I'm going to get better, but how is that a good thing?" She then also added that she doesn't see much of a future for herself. Her commentary was slightly sardonic; she compared her thought process to a job interview. "Where do you see yourself in five years?" She asked me, her voice having a mocking tilt to it. "I see myself still in prison." She is very aware of the fact that she is competent and extremely aware of her impulses. She knows that she cannot get off not guilty by reason of insanity, and knows that she will not get the mental health treatment that she needs-- but doesn't want-- because they're just going to put her into a prison for [REDACTED EVENT].

So she stubbornly digs her heels in, and while she's desperate for the treatment like a man in the desert coming across the mirage oasis, she doesn't want the treatment because it will mean that she might, just maybe, be given some level of forgiveness. And she doesn't want to be forgiven.

She wants to control her behavior, but if controlling her behavior means that she gets another chance, then she doesn't really want it. 

I find myself extremely proud that she was able to leave the office without hurting myself or anyone else. She did not act on her impulses today, and she was able to take deep, calming breaths. She even asked if she could give me a hug on the way out. 

SESSION #4

NOTES AND OBSERVATION

Mallory picked up a book and threw it across the room at the start of the session. It landed with the loudest thump.

"I didn't want to," Mallory told me.

She says that she doesn't mean to think like “this”. She says that she feels like some creature in a cage, throwing herself against the bars because she can see the prey (me) but simply can't get to it. She says that she has to stop herself. Mallory noted that she often thinks about the spiraling consequences, too. "If I jump off this roof," she said, "my family would be sad, the victim's family would be angry or relieved. The world would keep going on and on without me." She then described in great detail every single person, down to her college professors and her former teachers, that might be affected by her death.

She frequently refers to [REDACTED] as "the" victim rather than "my" victim, or simply as his name. There is a degree of separation there, but unlike other patients who may try and push responsibility and say it is something out of their control, she regards everything she does and everything around her as being her fault. If she doesn't do X, then she would be solely responsible for preventing the harm and ensuring that everyone is safe and happy. She takes full responsibility for her actions and realizes that what she did was wrong, but there is still a degree of separation between her and her relationship with [REDACTED].

The conversation about her and [REDACTED] has seemed to trigger some anxiety-based symptoms, because she did end up having a panic attack.

She was heaving deep sobs, clawing at the floor and reaching for me like she was scratching at the door of heaven. She kept clawing at her throat, begging and pleading for me to please do something, to please fix her. A note has been made in her file of extreme emotional distress when mentioning [REDACTED]. She was crying and screaming, and she seemed to retreat away from me as though she had been burned, but wanted to curl up in my lap like she was a baby looking for her mother. She eventually ended up lying on the floor, and I lay on the floor with her, helping her through some breathing exercises until she was ready to get back up. The rest of the session was spent on the floor.

She said that I looked rather silly, with my heels and my pencil skirt, lying on the floor. She noticed how it smelled.

A lot of the discussion today was "what if I did this." She talked about how she wondered what would happen if she grabbed my pencil, how much pressure it would take to stab it into my neck. 

Patient is seeming to show symptoms of Obsessive Compulsive Disorder and potentially a mood spectrum disorder. However, the available observations do not establish a history of a manic episode, and Bipolar I Disorder remains a differential consideration rather than a confirmed diagnosis.

She says that she's extremely grateful that I'm not scared of her. 

SESSION #5

NOTES AND OBSERVATIONS

She got a new scratch on her face. It was deep, but not deep enough for stitches. It was angry and inflamed on the sides. I asked her who did it, and she refused to tell me because she didn't want to get anyone in trouble. She described being in prison as being a pit of vipers, and she's so scared that she's going to be bitten. She is meek and small, and she worries that the others are going to try and consume her because of it. Her hands were awfully shaky today; I asked her if she was cold, and she couldn't respond. She said that she needed to check the room again, so she wandered around and let me bring her water. She looked at me dead in the eyes and swore that she would try her best not to hurt me. I said that I was glad for it.

I suspect that Mallory may have OCD. One of the primary treatments is exposure and response prevention. I want to identify her obsessions and their corresponding compulsions, then determine whether ERP would be appropriate for her. If her symptoms are consistent with OCD, treatment may help her manage them and make life in prison easier.

I wanted to tell Mal that the blood work and tests came back today. I want it on record for anyone studying these notes that the first thing we did was try to determine any biological reasoning for her behavior. We tested for heavy metals and toxins, very specifically, and the results were very clearly negative. I was going to show her, but before I could, she was studying the extension cord under my desk extremely intently. She asked me if she was a bad person again today.

I offered her another glass of water (and this time she took it without demanding that I put it in the middle of he room.) She took it, and I watched as she swished her mouth with it, trying to get whatever taste had lingered out of her mouth. In another self-soothing behavior, she traced her fingers along the condensation that had ended up on the table, in stable, slow rings. I asked her what it was like for her growing up, and she said that she found it really difficult because she got bullied a lot.

I asked her what for, and she shrugged and continued drawing in the condensation. I watched her very distinctly draw horns on something.

I pointed out that I was trying to help her, that I didn't want to demonize her or villainize her, especially in front of the court. That her diagnosis was not going to make her a bad person.

She told me, "My actions are what make me a bad person. My actions and my words."

She described to me in detail one of her frequent intrusive thoughts: how she often thinks about taking a sharp object and wonders what would happen if she stabbed the person, and how much pressure it would take. Normally, to stop the behavior, he says that she makes her parents lock all the knives away and uses a spoon to butter her toast. But she told me that those thoughts were what was making her a terrible person, not any potential diagnosis.

"You cannot even justify your claims to me because of [REDACTED]. I've acted on those thoughts against my better judgment, and that makes me a terrible person."

I decided against telling her that the thought process was unreliable, and that it wasn't fair to herself to try and paint herself with such a picture. I attempted to do some restructuring instead, where we talked about our views of ourselves and how we might be able to change those views with positive thinking.

I think the thought process really fell on deaf ears. It is hard to think positively considering the circumstances; it's something we could have worked on.

SESSION #1

NOTES AND OBSERVATIONS

I have taken over the diagnosis due to my counterpart's untimely manslaughter by Miss Moore. The aforementioned counterpart failed in treatment on several levels; too much empathy leads to a loss of objectivity and inhibits clinical examination. Her interpretations of observations sometimes exceed the preexisting evidence. I believe that the behavior exhibited by the previous professional had the risk of leading to coddling behavior. Treatment is not what we were hired to do. And, while unprofessional of me, the treatment she was attempting to use on Miss Moore didn’t even work anyway. The purpose of the therapy sessions was not treatment; rather, it was for clinical assessment to be used in courts for the use of expert testimony because of [REDACTED]. A slew of questions are needed to be answered, including:

Is Mallory competent to participate in legal proceedings?

Was she legally insane at the time of the offense?

Does she currently present a risk of harm?

What psychiatric conditions, if any, best explain her symptoms?

The session started with Miss Moore refusing to come close to me, and that's fine, because I did not want to come close to her, either. She barely talked to me at all. The session was spent mostly in silence. She may have been pretty once, but there was this awful gash on her face.

She asked me if the previous professional was ok. I told her no. Miss Moore showed a great deal of distress at the news and started wailing.

Clearly shows significant guilt and distress towards her actions. She seems extremely aware of her actions as well.

Miss Moore exhibits significant obsessive-compulsive symptoms, anxiety, impulsivity, and emotional dysregulation. She demonstrates awareness of her actions and their consequences, alongside considerable guilt and difficulty regulating harmful impulses. Further assessment, which my counterpart did not do, is required to distinguish obsessive-compulsive disorder from mood-spectrum and trauma-related conditions.

​

DIAGNOSIS NOTES

Obsessive-Compulsive Disorder (provisional)

Anxiety symptoms, unspecified

Bipolar I Disorder (rule out)

Assess violence risk.

Further evaluation is required to determine the relationship between psychiatric symptoms and behavioral control.