Tuesday, March 14, 2006

Diagnosis of Inferior Social Proclivity Disorder in Young Adult Patients: A Case Study

Rodgers N. Hart, F. Sinatra, and E. Fitzgerald, Lorenz Institute for the Advancement of Clinical Psychology

Note: This paper has also been accepted for publication in the Annals of reformat_songs.


Inferior social proclivity disorder, or “trampiness”, is commonly mistaken for adjustment disorder not otherwise specified.1 However, this condition is surprisingly common in early post-adolescent patients, especially females.2 We examine the diagnosis and treatment of one patient, who we shall refer to as Lady. Lady, when she began treatment, was a 24-year-old who referred herself to our private practice. She had become increasingly concerned over her difficulty in forming social relationships at her place of employment, a finishing school.

Initial Work

We spent several sessions simply becoming familiar with the patient3 and allowing the therapeutic relationship to coalesce, and listening to the cognitive-behavioral paradigms4 which the patient used to self-describe the internalities5 of her situation. Lady seemed to view herself through a neo-behavioralist6 lens, and attempted to leverage this paradigm to assert control over her situation. She would often attempt to defer meals until excessively late hours, although these control attempts were never successfully realized due to her inability to stave off her hunger. Peculiarly, she was unusually consistent in her failures; she routinely ate dinner at exactly 7:55 in the evening. This led us to suspect a possible anorexia nervosa (restricting type) in conjunction with obsessive-compulsive personality disorder.7 Her consistent timeliness at cultural events — she was a regular patron of the theatre — reinforced this notion.8 However, our experiences with disorders of these spectra suggested that it would be premature to form anything more than a tentative diagnosis at this point.9 Using a hybrid talk therapy approach,10 we probed further.

Contraindications for Obsessive-Compulsive Personality Disorder

Further work with Lady led to the discovery that she exhibited several behaviors which contraindicated OCPD. First and foremost amongst these was a strong revulsion to gambling and excessive personal grooming.11 Two contexts in which her coworkers often socialized were informal gambling nights with members of the local political establishment and outings to nightclubs with rigorous formal dress codes. Lady claimed that she felt excluded from these events due to her aversion to these activities. In addition to serving as social bonding rituals, her coworkers used these occasions to undertake the exchange of critical back-channel social collateral, or “gossip”.12

Contraindications for Anorexia Nervosa

We also found evidence that she did not have anorexia nervosa, or any other eating disorder. Eating disorders are typically characterized by a need by the patient for control over his or her environment, actualized by control over the frequency and manner of dietary events.13 It is expected, in cases of these disorders, to find, upon a closer examination, a pattern of control mechanisms. However, Lady did not seem to have any extra-dietary retentiveness behaviors. She was almost alarmingly nonchalant about upcoming major life events and her financial situation. She hoped to leave California (her state of residence) at some point, stating a preference for a warmer, more arid climate, but neither had nor desired strategies for attaining this goal. On a smaller scale, she would often arrive for appointments with her hair in a state of disarray, claiming (when prompted) that it had been disturbed by the wind on the drive over, but making no attempt to correct it.

Diagnosis of Inferior Social Proclivity Disorder

We concluded that Lady was probably not suffering from OCPD or anorexia nervosa. We considered a diagnosis of general social anxiety disorder, but she genuinely did seem to desire to connect with her coworkers, and she was quite active in other social circles. Then, in one session, Lady revealed a key piece of information. She said that her avoidance of the contexts in which her coworkers preferred to socialize was probably a good thing, because her financial situation did not permit her to engage in the expense of attending such nights on the town. She felt that her non-luxury automobile and other secondary socioeconomic characteristics placed her in a position of inferiority, and that she would be taken advantage of by the sophisticated and (in her view) unsavory characters who would often accompany her coworkers on these social outings. She wished to pursue a deeper connection with her coworkers, but she characterized their other associates as “sharpies” and “frauds.”

We then asked how her coworkers could maintain such extravagant lifestyles while she, in a similar job at the same place of employment, could not. Her response to this was the final piece of the puzzle. This reinforces the critical importance of a close reading of responses to even innocuous questions in talk therapy.14 She said that she had been offered many increases in salary, but had repeatedly turned them down because she “didn’t want the hassle.” This was a clear-cut case of ISPD. The patient was intentionally holding herself to an “inferior” social position, had difficulty functioning because of it, and did not perceive of her assumed position as problematic.15

Motivating Factor Analysis

At this point we had diagnosed Lady, but this only really told us the “how” of her “trampiness”. Although it is often difficult or impossible to do so successfully,16 we elected to explore the motivating factors behind her disorder (the “why” of her “trampiness.”) Such analysis often reveals additional disorders, or at least provides information which may prove invaluable in treatment. This analysis is still ongoing, and we do not have any results yet.

Treatment Plan

Treatment of Lady is currently ongoing. We are continuing talk therapy, both for its own merits, and as a component of the aforementioned motivating factor analysis. We are also attempting to use a combination of cognitive behavioral therapy and desensitization to address some of her avoidance issues.17 We have had some preliminary success in exposing her to fast food sprayed with a solution which will cause it to induce greater than normal levels of nausea when consumed, and we have instructed her to bring gradually larger amounts of cash with her on her visits to our office. We hope to discuss the efficacy of these techniques in a future publication.

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