43 Cyclothymic Disorder
Name: Dolores Price
Source: She’s Come Undone, (book by Wally Lamb, 1992)
Background Information
The book follows Dolores through childhood, adolescence, and young adulthood. Dolores Price begins as a young girl growing up in New England. After her father leaves her and her mother, they move in with her uptight grandmother. Her mother experiences a nervous breakdown and is sent off to a mental hospital. Dolores claims it’s her “nerves.” Her grandmother represses everything and has difficulty speaking of her mother’s mental issues. At the age of 13, Dolores is raped by her grandmother’s upstairs tenant. Following the rape, Dolores’ mother constantly gives her food. Throughout adolescence, Dolores continually gains weight until she weighs 257 pounds at age 18. She attempts to go to college, but ends up leaving and goes to Cape Cod to attempt suicide. After a failed attempt at drowning, she ends up in a private mental institution where she undergoes immense amounts of psychoanalytic therapy. Once released, she goes to Maine and gets a job as a grocery clerk. Now, as an adult, she marries an abusive and manipulative man. She does nothing to anger him until her grandmother’s death. Because of his aversion to children, she has an abortion for him. Throughout her entire life, Dolores has issues with relationships. She had one close friend in childhood but never made many more in adolescence. Due to her weight and the rape, she kept to herself in high school. In college, she works tirelessly to please her roommate and the other girls she is around. She does the same with her husband, Dante. Her main goal is to please others around her to achieve approval. She is short and rebellious with her mother and her grandmother. She experiments with marijuana a few times but never uses any drug heavily. She drinks occasionally, but again never heavily. She has no real goals. She strives to be loved but gives up on it easily when it fails her. She strives to gain power over others at times but also gives up on that. Towards the end of the story, she simply wants a child, after obsessing over her abortion. It is incredibly hard for her to handle sexual relationships after the rape and only enjoys it sometimes with Dante. She cannot handle rejection or abandonment. The only coping skill she really has is eating, and it causes her just as much pain as the issue she aims to avoid.
Description of the Problem
Dolores’ weight gain stemmed from her traumatic rape. This unnecessary weight causes her to feel extraordinarily inferior to others around her. She goes through periods of depression, believing she has harmed everyone around her. She then goes through periods of what she describes as “power.” She spews vicious sarcasm at those around her and is, at times, cruel. After a lesbian encounter in college, she kills the woman’s goldfish to prove she has control. She enjoys leaving her therapist upon her release from therapy. She waves the fact that a psychic has given her more help in front of his face in order to anger him. In Maine, she feels accomplished often. During these times, her job performance improves, her sexual life increases, and she cleans and cooks every day for her husband. Her depression and “power” continue after therapy. If Dante is unhappy, Dolores is unhappy. She feels useless, especially when she angers him. After her grandmother’s death, Dolores leaves Dante and again becomes depressed. She says she wishes she could hold on to the power and go back in time to fix what she did to others. Dolores describes her life in sections. Her parents’ divorce is one section, the rape is another section, her adolescence is one section, her college life is a section, her therapy is a section, and her adult life is a section. Throughout each section, she develops an obsession with whales. She describes a parallel between herself and whales. She craves their power and feels their hopelessness when they wash up on the beach.
Diagnosis
The diagnosis that seems most appropriate for Dolores Price is Cyclothymic Disorder (301.13).
Diagnostic criteria:
A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note; in children and adolescents, the duration must be at least 1 year.
Dolores’ times of “power” contain within them hypomanic symptoms such as excessive involvement in pleasurable, yet possibly dangerous, activities. This is manifested through her increased sex drive and sexual activity with Dante the first night they met, her increased interest in sex throughout certain times in her life, and her lesbian experience with her dorm’s maid. She has elevated mood and feels control over others around her. She is grandiose and believes that she will succeed in imagining her life with Dante, who is clearly abusive and unfaithful. She also exhibits grandiosity in her correspondence with her college roommate prior to moving in. She makes up stories and a completely different life in order to create a good image. She becomes highly distracted during her stay in the halfway house with an etch-a-sketch. She spends hours recreating artistic masterpieces on multiple etch-a-sketches and tunes out the rest of the world. Dolores also exhibits depressive symptoms at many times. She exhibits weight gain, not only in adolescence but later in her adult life after she moves back into her old house. She tries once to cut herself but is taken aback by the blood. She expresses feelings of inferiority and worthlessness and tries to stifle them with food. In her marriage, she is depressed when Dante is not happy. This drives her to an abortion. Even during the course of her heavy psychoanalytic therapy, she swings between depression and power. At times, she hates her therapist and wishes she could leave. At other times, she idolizes him and imagines sexual activity with him.
B. During the above 2 year period (1 year in children and adolescents), the person has not been without the symptoms in Criteria A for more than 2 months at a time
There is never a time in Dolores’ life where she does not experience any of these symptoms. Even after therapy she still experiences hypomania and depression.
C. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.
Although at one point Dolores contemplates committing suicide, she does so because she wants to feel united with the dying whales at Cape Cod. She does not sincerely want to die, she just wants to feel one in the same with something else. Her plan is disorganized and incomplete. She also never reaches full mania.
D. The symptoms in Criteria A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Dolores exhibits no psychotic symptoms. She possesses no firmly held delusions.
E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug abuse, a medication) or a general medical conditioned (e.g. hyperthyroidism).
Her weight gain stems from her own belief in herself, not a medical condition. While she experiments with alcohol and marijuana, she has no history of substance abuse or dependence.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Dolores fails at almost all of her relationships. She has no friends in high school and her only friend in college was the dorm’s maid. Her marriage is unsuccessful and she fails to relate to grandmother her whole life. She does not care about school so she fails in high school and drops out in college. She only manages to succeed at a job when she is in control, or in power. After she moves back to Easterly, her jobs are menial and she only works when she is experiencing hypomania.
Accuracy of Portrayal
Dolores is not a likable character by any means. She is unsympathetic, hard to relate to, and it is almost impossible to feel bad for her. She manages to ruin her relationships all on her own and she takes tragedy to an extreme. The book demonstrates the difficulty that may be faced by others who have relationships with cyclothymic individuals. It also demonstrates the impacts a mood disorder can have on every aspect of one’s life. It is accurate in its depiction of the feelings that accompany cyclothymia, describing hypomania as “power” and depression as “oppressive.” Dolores’ mother may also have bipolar disorder, reflecting the possibility that bipolar disorder may be more common in first degree relatives. There are some inaccuracies, though. The therapy that Dolores undergoes is inaccurate. Her therapy is very psychoanalytic in nature, focusing on her mentally unstable mother and sex. Her therapist even goes as far as to pretend to be her mother. Her treatment is also only slightly effective and she still experiences cycles as she gets older. The book does not do much to describe any sort of mental disorder. Instead, it paints a picture of a woman who has lived a miserable life, caused mainly by her own hands.
Treatment
The first treatment that should be implemented for Dolores is a lifestyle change. Her extremely sedentary lifestyle would benefit from exercise and diet, which could help stabilize mood. This would have to be highly regulated in order for her to follow it and actually make the changes. Following the implementation of exercise, cognitive therapy should be used. Cognitive behavioral therapy, interpersonal therapy, or group therapy could be utilized. Due to Dolores’ inability to relate well with others, cognitive behavioral therapy should be used. If therapy is ineffective, medication could be used, but only as a last result due to the health problems Dolores already has due to her weight.