|Diagnosing Charlie Fineman
Charlie Fineman is a white male who was a dentist with three daughters and a wife, unfortunately due to the September 11, terrorist attacks in America during 2001, his daughters and wife passed away in a plane crash. Mr Fineman experienced grief after the loss of his loved ones, stopped working as a dentist and starting telling people that he has no family. He would avoid his in-laws and play music to escape from dealing with his indirect traumatic experience. Charlie experienced loss while growing up but now has outbursts of anger, flashbacks of his family memories, delusions and stays awake till peculiar hours in the morning, however he does have social support from his friend Alan who suggested he see a therapist, after seeing the therapist for a few brief sessions, Charlie attempted committing suicide. Mr Fineman’s major symptoms are his anger outbursts and complete avoidance of anything representing his traumatic experience
Viewing the text box “Diagnosing Charlie Fineman” represents the main character in the movie Reign over me played by Adam Sandler which highlights the symptoms of a mental disorder (Binder, 2007). This essay will be beneficial to student or clinical psychologists as well as other health professionals as this paper discusses the diagnosis process of mental disorders and emphasizes a thorough psychological evaluation of an individual. This essay will examine Charlie Fineman’s symptoms leading to a diagnosis of Post-Traumatic Stress Disorder (PTSD) which an individual experiences after being exposed to a traumatic event according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR). One may disagree with diagnosing Charlie Fineman with PTSD therefore a proper evaluation will be discussed throughout the paper examining Mr Fineman’s life and medical history, his symptoms that occur in DSM IV-TR of PTSD, two of his major symptoms will be explored briefly, a multiaxial evaluation will be conducted using the DSM IV-TR axis, his PTSD symptoms that occur in DSM IV-TR will be compared to the current DSM 5 and the ICD 10 as well as look at Charlie Fineman PTSD diagnosis compared with other disorders he may portray as evidence to verify the PTSD diagnosis.
- Life History and Observable Signs and Biography
According to Austin (2009) in his book Abnormal Psychology: A South African Perspective, one of the initial steps for diagnosis is to determine the background or life history of the client, therefore in order to diagnose Charlie Fineman one must look at his life history. A life history can include an individual’s upbringing or development from fertilisation to adulthood containing a series of events (Dictionary.com , 2013). Charlie’s life history includes a series of detrimental events that influence his PTSD symptoms. In Reign over me Mrs Gillian informs Alan who is; Charlie’s college roommate that Charlie’s parents passed away while he was in grade school thereafter his aunt, the person he lived with after his parents passed away, died just before he got married (Binder, 2007). Mr Fineman lives without a job but is wealthy from the money he saved. It could be possible that the initial trigger for Charlie’s symptoms came from experiencing his parent’s death and aunt passing away. Charlie perhaps may not have grieved well enough; during these events, especially since his wedding occurred soon after his aunt’s passing.
Austin (2009) goes on to say that included in the stages of diagnosis, a clinician must note the observable signs of the client which may include his appetite, tone of voice or skin colour, eye contact as well mention his feelings and experiences. For Charlie Fineman some of the observable signs are that Charlie is detached, socially withdrawn, avoids making eye contact and has a slow paced voice until he becomes angry, which leads to a rapid change in pitch and tone of the voice leading to aggression and violent behaviour. Another sign is his lack of sleep; Charlie tends to be awake watching movie marathons till 05h00 and one may see his growing appetite throughout the movie has he craves Chinese food or pizza (Binder, 2007). Some of the feelings Charlie experiences are related to loss and he may find comfort in eating regularly to fill that void of losing his family. He experiences loneliness, grief and anger which leads him to seeking help. He admits he has become insane to his in laws while he tells them that he sees his family every day in everyone else’s faces and even sees his poodle bred dog in a German shepherd. Overall from Charlie Fineman’s life history of traumatic events, observable features and his beliefs about himself one may be persuaded in believing Charlie does have PTSD.
- Medical History
Austin (2009) confers that a clinician needs to examine the client’s medical history in order to gain greater insight into a possible diagnosis however in Reign over me; there is no mention of Charlie Fineman’s medical history as a child. As an adult however, the movie does portray Charlie’s medical encounters (Binder, 2007). In one of the scenes in Reign over me, a medical encounter was prompted as Charlie pointed a gun at a driver who almost knocked him. This occurred to attract the attention of the policemen which may have shot Charlie if he did not put his gun down. Charlie hoped the policeman would shoot at him fulfilling his suicidal thoughts thereafter the state declared, Charlie go for a three day psychological evaluation as he was a danger to himself and the city.
The psychiatric ward’s findings at a court hearing were Charlie had PTSD with delusional tendencies related to incapability of functioning. One may agree with this finding because Charlie Fineman does display most of the symptoms of PTSD. The judge at this hearing asked Charlie’s in laws to make a decision about admitting Charlie to a psychiatric hospital for a year or for him to live without hospitalisation and heal on his own and they decided on the later as it was most appropriate for Charlie. From the movie, Charlie did not seem to have any other medical condition that may be related to his mental illness and no evidence shows he had a family history of mental illness. Overall from the one piece of medical history gathered, the hospital diagnosed Charlie with having PTSD. This once again proves that Charlie does display symptoms of PTSD.
- Symptoms displayed that give a PTSD diagnosis from the DSM IV-TR Criteria
Austin (2009) believes in order to make a diagnosis one must describe the problem in terms of symptoms displayed. Nolen-Hoeksema (2011) confers and suggests that a diagnosis is a label clinicians attach to a set of symptoms that occur together. To diagnose a client, one must look at the Diagnostic and Statistical Manual of Mental Disorders (DSM) which has existed for more than 50 years to ensure reliability. For the purposes of this section, the DSM IV-TR will be used as the main criteria to diagnose Charlie Fineman.
Some of the symptoms Charlie displays can be determined from the DSM IV-TR for PTSD (see Appendix 1), in Criterion A the person must have been exposed to a traumatic event; Charlie Fineman witnessed actual death of others (A1) which are his loved ones and experiences intense helplessness(A2) (Wastell, 2004). Charlie’s helplessness is portrayed when he plays violent video games, these games may give him a sense of power because he can control which video game character he wants to kill. In these video games he has the power of controlling life and death whereas in reality he does not have this power (Binder, 2007).
In Criterion B which are intrusive symptoms of PTSD, Charlie Fineman acts or feels as if the traumatic event were recurring (B3) we see this throughout the movie as he has dissociative flashbacks of his wife and children, which occurred just before his suicide attempt indicating this brought back intense feelings of the traumatic event (Herman, 1992). This occurred three times before his suicide attempt, initially speaking about the traumatic event with Alan brought back these feelings of the trauma, hearing talk about the terrorist attacks on the television or radio also brought back these feelings and lastly he had the dissociative flashbacks of his family leading to such extreme emotions that he attempted to end his life (Binder, 2007). Mr Fineman has intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (B4). This occurs when Charlie sees the pictures of his family or when people mention their names; Charlie becomes distracted or uncomfortable in these scenes because he is distressed. Charlie has physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (B5). This is seen when Charlie starts shaking his head trying not to listen to anything involving his family, he blocks his ears or screams excessively.
In Criterion C which according to Herman (1992) are the avoidance symptoms of PTSD. Charlie Fineman makes efforts to avoid thoughts, feelings, or conversations associated with the trauma (C1) as he avoids having conversations about his family, he tends to avoid answering questions about them, changes the subject or pretends that they do not exist (Binder, 2007). He makes efforts to avoid activities, places, or people that arouse recollections of the trauma (C2) this is evident when Charlie avoids speaking to his in laws in the beginning of the movie. Charlie Fineman has a markedly diminished interest or participation in significant activities (C4) we see this because he gave up his job as a dentist which was a daily significant activity and he has feelings of detachment or estrangement from others (C5) whereby he detaches himself from his in laws and friends. Charlie also has sense of a foreshortened future (C7) has he avoids questions about coming back to being a dentist or having a girlfriend.
In Criterion D which Herman (1992) states are the hyperarousal symptoms of PTSD, Charlie Fineman has difficulty falling or staying asleep (D1), has irritability or outbursts of anger(D2) and hypervigilance (D4) which is the increased awareness of threats and the environment which is similar to paranoia. This we see frequently in the movie has Charlie questions Alan claiming someone sent him to speak to himself.
In Criterion E, the duration of the disturbance occurs for more than one month. In Criterion F, Charlie’s disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. This is evident as Charlie is socially withdraw, lives in isolation and resigned from his job as a dentist proving his occupational impairment from the distress of losing his loved ones. The duration of Charlie Fineman’s symptoms is chronic as it occurred for more than three months. This is evident in that his land lady says he has been this way for months, the lawyer says he has been this way for years therefore according to the DSM IV-TR Charlie Fineman has PSTD without delayed onset.
- Avoidance and Hyperarousal (outbursts of anger) in Charlie Fineman
Avoidance symptoms as stated occur in Criterion C1 and C2 of the DSM IV-TR for PTSD which Charlie displays frequently (see Appendix 1). These avoidance symptoms according to Herman (1992) are a form of constriction which is a numbing response to the exposure of trauma. She believes this is a state of freezing as the body’s self defence system shuts down, detachment and disconnection occurs during this period. These symptoms usually occur in war veterans due to the trauma they experience while others may enter a hypnotic or passive state. We see this throughout Reign over Me as Charlie avoids his in laws which are people that remind him of the trauma leading to distress and anxiety (Eagle & Kaminer, 2010). He avoids looking at the pictures of his family in the court room to prevent re-experiencing the trauma; he closes his eyes, disconnects and detaches himself from the situation. His avoidance symptoms are exceedingly observable throughout the movie verifying he has PTSD.
Hyperarousal (outbursts of anger)
Hyperarousal symptoms which have been stated previously occur in the DSM IV-TR although one particular symptom such as irritability and outbursts of anger are clearly portrayed, in Charlie Fineman throughout the movie evidenced in four or five different scenes. Herman (1992) speaks about hyperarousal has the persistent expectation of danger and chronic arousal of the Automatic Nervous System while Eagle and Kaminer (2010) agree that outbursts of anger or irritability occurs from minor frustrations or perceived hostility from others. This is evident in Charlie has he has outbursts of anger from perceived hostility as he believes Alan was sent from other people that are out to get him. This causes Charlie extreme stress leading to his violent behaviour which Eagle and Kaminer (2010) note as meeting the criteria for PTSD.
- Evaluation of diagnosis along the multiaxial system
The DSM IV-TR uses a 5 level diagnostic system to classify illnesses or disorders when considered together, these 5 levels give the clinician a complete diagnosis which evaluates a person’s behaviour (Nolen-Hoeksema, 2011; Sheryl, 2009). This is useful for effective treatment planning (Sheryl, 2009). Axis I includes all clinical disorders which one may categorize Charlie as having PTSD. Axis II includes all personality disorders or mental retardation whereby one may categorize Charlie with Borderline Personality Disorder. Axis III includes any general medical condition which Charlie does not display. Axis IV includes all psychosocial and environmental problems which will be discussed later as Charlie has social support from Alan, has social issues with interpersonal relationships and he may have legal problems has his lawyer claims he takes care of him (Binder, 2007). Axis V includes the global assessment of functioning and Charlie’s performance as usual daily activities seems to change frequently being antisocial lacking of occupational functioning, academic and interpersonal functioning.
- PTSD diagnosis evaluated across DSM IV-TR, ICD 10 and DSM 5
In DSM 5, Charlie would still have PTSD because he was indirectly being exposed to the trauma in Criterion A2 (See Appendix 2). Criterion B symptoms remain the same as DSM IV-TR only traumatic nightmares do not seem to be portrayed in Charlie Fineman. In Criterion C he displays symptoms of C1 and C2 which are the most extreme avoidance symptoms Charlie displays (DSM-5 Criteria for PTSD, 2013). In Criterion D, negative alterations in cognitions and mood is the change from DSM IV-TR however Charlie displays symptoms in D4, D5, and D6 which are similar to DSM IV-TR. In Criterion E, alterations in arousal and reactivity made a significant change from DSM IV-TR which includes self-destructive or reckless behavior (E2) that helps one understand Charlie Fineman’s suicidal attempt. Charlie displays E1, E2 E3, and E6 of the criteria while his duration of symptoms are more than one month, with functional impairment socially and occupationally with disturbance not due to medication. In Classification of Mental and Behavioural Disorders (ICD 10), Charlie displays almost all the symptoms of the criteria which are A, B, C, D2 (a) (b) (d) and E that is similar to DSM IV-TR (see Appendix 3) (Wastell, 2004). This further proves that Charlie Fineman has PTSD as he meets Criteria for the current DSM 5 and ICD 10.
- Bio psychosocial framework that influence diagnosis
Charlie Fineman’s biological factors cannot be determined due to insufficient knowledge gained from Reign over me (Nolen-Hoeksema, 2011). His sociocultural factors include family instability having been raised by his aunt and his family being absent for most of his life plus living wealthily in an urban setting contributing easily to his isolation. Living in isolation, he does not interact with many people and when he does he tends to say inappropriate things to people regularly, without a value system of acknowledging right from wrong. His psychological factors influence his diagnosis as parental roles were absent contributes negatively to his development and interpersonal relationships with family, friends and the community. He suffers great loss resulting in anxiety, depression, shame and guilt after having anger outbursts at his wife. He may not have a sense of control in response to danger, as he portrays anger outbursts and violent behaviour while his level of emotional development seems weak as his emotions fluctuate frequently, leading to oscillations between intrusion and constriction symptoms which Herman (1992) categorizes has symptoms of PTSD.
- Differentiating between other disorders and PTSD
From all the information, Charlie Fineman does have PTSD; however this can be confused with Borderline Personality Disorder (BPM) or Major Depression (MD). It is not BPM because it tends to Charlie Fineman has avoidance symptoms, which are not mentioned in the Borderline Personality Disorder Criteria in DSM IV-TR. Borderline patients seem to have a dependence on people being around them, while in PTSD patients they choose to avoid people that represent thoughts around the traumatic event (Nolen-Hoeksema, 2011). A similar quality of Charlie’s does exist in Borderline patients as they experience outbursts and suicidal thoughts which could lead to one diagnosing Charlie Fineman with Borderline Personality Disorder. Charlie Fineman could also be diagnosed with Major Depression has many of the characters in the movie believe he is a “sea of sadness” or lost in his own “Charlie world”. According to the DSM IV-TR for Major Depression, Charlie could be classified as having Major Depression because he meets the criteria for this disorder. However there is no mention of his intrusive and constriction symptoms therefore the diagnosis fails to mention the reason for his other symptoms, as a result one must consider PTSD has it explains most of his symptoms proving that Charlie has PTSD according to the DSM IV-TR Criteria.
Overall, as stated from the life and medical history, his symptoms being compared to the DSM IV-TR, DSM 5 and ICD-10, the multiaxial system evaluation of his symptoms, the biopsychosocial factors and his PTSD symptoms being differentiated with other disorders proves that Charlie Fineman has PTSD according to DSM IV-TR. The diagnosis process is thorough and can be complex but one must keep an open mind to diagnosis and the factors that contribute to it. As Winston Churchill once said, “never run away from anything. Never!” we can learn from Charlie Fineman that one cannot run away from past traumas, one must examine themselves and heal in their own way (Winston, 2013).
APPENDIX 1: DSM IV TR CRITERIA
DSM IV-TR PTSD Criteria
Diagnostic criteria for 309.81 Post-traumatic Stress Disorder
- The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour.
- The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In young children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in young children, trauma-specific re-enactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
- Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling detachment or estrangement from others
(6) restricted range of affect (e.g. unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or normal life span)
- Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(5) exaggerated startle response
- Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
- The disturbance causes clinically significant distress or improvement in social, occupational, or other areas of functioning.
- Acute: if duration of symptoms is less than 3 months;
- Chronic: if duration of symptoms is 3 months or more.
- With delayed onset: if onset of symptoms is at least 6 months after the stressor.
APPENDIX 2: DSM 5 CRITERIA
DSM 5-PTSD CRITERIA
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required)
- Direct exposure.
- Witnessing, in person.
- Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
- Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (1 required)
- Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
- Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
- Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
- Intense or prolonged distress after exposure to traumatic reminders.
- Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)
- Trauma-related thoughts or feelings.
- Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)
- Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
- Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous.”).
- Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
- Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
- Markedly diminished interest in (pre-traumatic) significant activities.
- Feeling alienated from others (e.g., detachment or estrangement).
- Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)
- Irritable or aggressive behavior.
- Self-destructive or reckless behavior.
- Exaggerated startle response.
- Problems in concentration.
- Sleep disturbance.
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D and E) for more than one month.
Criterion G: functional significance
Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
Specify if: With dissociative symptoms.
In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
- Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
- Derealization: experience of unreality, distance, or distortion (e.g., “things are not real”).
Specify if: With delayed expression.
Full diagnosis is not met until at least 6 months after the trauma(s), although onset of symptoms may occur immediately.
APPENDIX 3 THE ICD-10 CLASSIFICATION OF MENTAL AND BEHAVIOURAL DISORDERS
F43.1 Post-traumatic Stress Disorder
- The patient must have been exposed to a stressful event or situation (either short- or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.
- There must be persistent remembering or ‘reliving’ of the stressor or intrusive ‘flashbacks’, vivid memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor.
- The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure to the stressor.
- Either of the following must be present:
(1) inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor;
(2) persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor, shown by any two of the following:
(a) difficulty in falling or staying asleep;
(b) irritability or outbursts of anger;
(c) difficulty in concentrating;
(e) exaggerated startle response.
- Criteria B, C and D must all be met within 6 months of the stressful event or of the end of a period of stress. (For some purposes, onset delayed more than 6 months may be included, but this should be clearly specified.)
Dictionary.com . (2013). Retrieved August 23, 2013, from Dictionary.com : http://dictionary.reference.com/browse/Life%20history
DSM-5 Criteria for PTSD. (2013, June 10). Retrieved from National Centre for PTSD: http://www.ptsd.va.gov/professional/pages/dsm5_criteria_ptsd.asp
Austin, T. B. (2009). Psychological Assessment and psychodiagnostics. In T. B. Austin, Abnormal psychology: a South African perspective (pp. 46-50). Cape Town: Oxford University Press Southern Africa.
Binder, M. (Director). (2007). Reign Over Me [Motion Picture].
Eagle, G., & Kaminer, D. (2010). Posttraumatic Stress Disorder and other Trauma Syndromes. In G. Eagle, & D. Kaminer, Traumatic Stress in South Africa (pp. 28-34). Johannesburg: Wits University Press.
Herman, J. (1992). Terror. In J. Herman, Trauma and Recovery (pp. 33-50). London: Pandora.
Nolen-Hoeksema, S. (2011). Assessing and Diagnosing Abnormality. In S. Nolen-Hoeksema, Abnormal psychology (pp. 68-82). New York: McGraw-Hill.
Sheryl, A. (2009, June 29). Multiaxial Diagnostic System of the DSM-IV-TR. Retrieved from About.com: http://panicdisorder.about.com/od/diagnosis/a/DSMAxis.htm
Wastell, C. (2004). Appendix. In C. Wastell, Understanding trauma and emotion (pp. 165-168). Australia: Allen & Unwin.
Winston, C. (2013, August 24). Brainy Quote. Retrieved from Brainy Quote: http://www.brainyquote.com/quotes/quotes/w/winstonchu140930.html
© 2016 Christina Tess Reddy