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Black Swan Case Study

In this case study, we are looking at a young ballerina in her mid-twenties, who we

believe has Borderline Personality Disorder (BPD). We also believe that the client may suffer

from Anorexia Nervosa. In this paper, we will talk about the demographic information, the

issues she has to deal with, the diagnosis, and a treatment plan.

Demographics

Family

The client reports that she grew up in a middle class apartment in New York City,

where she lives with her mother. She did not report having any siblings, nor did she mention

her father. From observations, we could conclude that her phone is an older model, and which

indicates that she and her mother do not have a lot of income. She and her mother have a

very mixed relationship. The client states that they get along very well and her mother shows

a lot of affirmation towards her. For example, the client states that her mother would buy

cake to celebrate with her daughter when she got roles in ballet. Her mother would also

obsessively paint pictures of her daughter. On the other hand, her mother holds our client

guilty of ending her career as a ballerina after she got pregnant by a choreographer. They

both share a passion for ballet and their lives revolve around it. However, we believe that the

mother is jealous of her daughter’s career, as she is able to dance and the mother cannot. It

appears as if the client is feeling pressure and guilt from her mother. We can assume, since

her mother did not end her career the way she wanted it to end, that she wants to put pressure

on the client to make her achieveme what her mother could not. This could explain why she

is overprotective and makes sure that her daughter’s health is optimal for dancing. Since we

do not know anything about the client’s father, we can assume that he left the family either

before or shortly after the client was born. The client’s support system is very limited to her

mother, who would often call and text her and would want to know how our client did at
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rehearsals. The client’s support system would also extend to the director of her greatest

casting so far, “Black Swan”.

Interpersonal relationships

Our client reports that she does not have a supportive network of friends. She would

not go out or go to social events. Instead, our client would spend nights with her mother

polishing and fixing her ballet shoes and then go to bed early. Recently, she had become

closer to another dancer. However, she reported that there was extreme jealousy and that she

was nervous her ‘friend’ would take the role as the “Black Swan”. Our client and her so

called friend went out for drinks one night, during which she used ecstasy. Our client’s

history could be seen as a potential problem for her current disorder. She had previously been

cutting and scratching herself. She also felt pressure from her director, who she had a sexual

relationship with and who pressured her to practice the black swan. This secret, intimate

relationship secured her role, but she could not disappoint, or else the job would be passed on

to a different ballerina. We can assume that her lack of interpersonal relationships was due to

the pressure that was put on her from being a ballerina, as well as her depressed mood from

her restricted eating habits.

Presenting Problem

Hallucinations

The client presented with the primary issue of having vivid hallucinations, which

ranged from seeing herself in black clothing to seeing and feeling feathers growing out of her

skin. The visual hallucinations were also associated with an auditory hallucination consisting

of a rustling sound. Some of the client’s hallucination were highly disturbing to her, while

others were only confusing. For instance, her hallucinations ranged from experiences of her

legs breaking and reforming into those of a swan, to seeing a fellow ballerina stabbing
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herself, to simply seeing herself in dark clothing. Furthermore, the client reported that she

often harmed herself during these hallucinations by scratching herself on the shoulder.

The client’s current level of dysfunction seems to have been brought about by her

being cast as the lead in a major ballet production, Swan Lake. For instance, her

hallucinations of herself in black may have implied the seductive side of herself she had

trouble bringing out for her role. Other hallucinations involved the client growing feathers

and other swan-like body parts. The client’s other hallucinations involving violent imagery

such as tearing her skin off, seeing her fellow dancer stabbing herself, or murdering another

dancer with a shard of glass may have been a manifestation of the emotional aspects of the

black swan. The rest of the client’s hallucinations may have resulted from her own emotional

issues, such as when she thought she assaulted and murdered a fellow dancer who she had

been feeling jealous towards, but later came to realize that she had stabbed herself. In a

similar incident, the client reported that she destroyed some of her mother’s artwork after

hallucinating that it was speaking to her. Shortly afterwards the client fought with her mother,

and broke her hand by slamming it in a door.

The client reported that she had been experiencing these symptoms for several weeks

prior to seeking out therapy, and that she also had a history of self-harm. Given that the

client’s self-harm in her recent recurrence of symptoms were almost exclusively associated

with her dissociations, it is possible that she also suffered from hallucinations in her previous

episodes, although the client did not explicitly state this. The client also did not report the

frequency or duration of her symptoms in the past, or that she had sought out any treatment in

the past. However, the client’s mother was aware of her symptoms and attempted to control

them with some success by sheltering her daughter and controlling her life. Given the client’s

passion for ballet, pressure from her mother and her director, as well as competition from her

peers, she experienced enormous stress during her practice and rehearsal for the production.
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This stress seems to have triggered a recurrence of her previous symptoms, except now to a

greater degree

Interpersonal issues

Beyond her self-harming and hallucinatory symptoms, the client also reported having

interpersonal issues between her mother and coworkers. The client’s interactions with others

were characterized by shifts in her attitude and level of assertiveness. For instance, the client

would often let her mother coddle and control her, and would act sweetly and even meekly

towards her. This was true particularly when the client’s mother would become angry, such

as when the client refused cake that her mother had bought for her. The client quickly ate

some of the cake to appease her mother. This was the client’s typical behavior towards her

mother, but at times she reported becoming angry and bitter towards her mother. Some

instances of this behavior included when the client discussed ballet with her mother,

questioning her mother’s own past career, and when the client destroyed her mother’s

paintings, broke her hand when her mother attempted to help her, and then told her mother

that she would be moving out.

The client reported similar shifts in behavior towards her fellow dancers. Prior to

being casted, and before her symptoms began recurring, the client reported being very

passive and meek around her coworkers. Later, she started acting more dominantly,

particularly towards her understudy, who she felt jealous towards. At one point the client

stated that she began acting paranoid towards her understudy, who she felt was out to get her.

Despite her jealousy and at times outright aggression towards this coworker, however, the

client reported going out to a bar with her. During this outing the client knowingly consumed

ecstasy and alcohol, engaged in sexual intercourse with several men she was unfamiliar with,

and, apparently, hallucinated having sexual intercourse with her co-worker as well. It was just

before this period that the client also began to change her clothing style; previously she had
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worn light colored, modest clothing, but the client reported that she started wearing more

risque and darker clothing. This change may again be the result of her casting as the black

swan and the influence it had on her.

The client reported that she felt a constant drive for perfection, and though she did not

explicitly state this, seemed to have had feelings of emptiness as she focused her entire life

around becoming a better ballerina. In order to obtain this goal, the client also restricted her

eating; she would often only eat part of a grapefruit for breakfast and was not observed eating

anything else on a regular basis despite her intensive exercise. She would also purge by

vomiting on occasion, though she reported that sometimes she could not vomit because she

had nothing in her stomach to purge.

Diagnosis

The client appears to meet the criteria for BPD, as she had unstable interpersonal

relationships as shown by her interactions with her peers, mother, and director, and unstable

sense of self as shown by her changing clothing and variety of interaction styles around

others. Furthermore, she showed other symptoms such as her impulsivity in activities such as

sexual intercourse and substance use, which could potentially pose a risk for substance abuse,

frequent and recurring self mutilation, and affective instability in such cases when she would

hallucinate and become very distressed but later act relaxed. Finally, the client also showed

chronic feelings of emptiness and had several stress related incidences of dissociation in the

form of her frequent but brief hallucinations, as well as her paranoid behavior towards her

fellow dancer.

Because of these symptoms, the client meets the criteria for BPD according to the

DSM-V (American Psychiatric Association, 2013). The prognosis for BPD is somewhat

optimistic. Over time, this disorder seems to fade, with many studies showing that people

with BPD go into remissions of 8 years. Some studies have even shown that after several
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decades, many people diagnosed with BPD no longer meet the criteria for BPD. This

prognosis is even more optimistic if treatment is given in the early stages of the disorder

(Biskin, 2015). The client may also meet the criteria for a secondary diagnosis of Anorexia

Nervosa due to her restrictive eating, distress about gaining weight as shown by her initial

refusal to eat even a small amount of cake, and because of her vigorous exercise, which was

in excess of the required practice for the production. However, a more complete investigation

would have to be undertaken to confirm this diagnosis.

Treatment

Dialectical Behavioral Therapy

The approach we believe would be most suitable for the client would be Dialectical

Behavioral Therapy (DBT), a form of Cognitive Behavioral Therapy, in order to control her

emotional distress, as well as stress tolerance. The main goal of this approach would be that

the client could independently form new relationships. After the therapy, the client should be

able to walk into a place where people typically socialize and interact with them. We hope we

will be able to reach that goal by offering the client therapy over the phone, so that she could

call her therapist whenever she feels the need to. We see her mother as a potential barrier, as

she claims ownership of her daughter. Nevertheless, by being able to reach out to someone

who our client is able to talk to, her mother will not end up totally preventing her daughter

from socializing. We expect our client to be more likely to be able to form relationships after

at least six months. In order to proceed with this type of therapy and reach this goal, one must

first enhance the client’s capabilities with DBT skills training. This requires our client to

tolerate her pain and distress, for example, when she is under pressure to successfully play a

role. One way one could treat her distress is by exercise. Although she is already very active

with doing ballet, one could suggest that she do yoga. In yoga, she would still be very active

and working on strength as well as flexibility, but also meditate and relax. In this step, the
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client also needs to learn how to properly engage herself in interpersonal relationship. This is

especially important in her relationship with her mother. We might see a barrier here as the

client would be very likely to continue her usual behavior and not change the way she

interacts at home. Our client, who has not really experienced friendship, would also need to

learn how to make friends and know the importance of giving and sharing. She would also

have to learn how to regulate emotions, especially controlling her anger when her “darker

side” is present. Finally, our client needs to learn about mindfulness and know that she lives

in the present.

The second step in DBT is to enhance our client’s motivation. It is important that our

client not only learns the skills previously mentioned, but also is able to use them in her

everyday life. A potential barrier could be that our client is very driven by ballet and would

not want to sacrifice her career by sharing her motivation with a different aspect of her life.

The client will have to be able to form relationships, control emotions, show mindfulness and

tolerate pain. Third, coaching will be provided for every situation. This means that if the

client is in a moment of distress and needs immediate help, telephone-therapy is supplied.

Our client may fall back into calling her mother when she is stressed or needs someone to

talk, but since our client is not experiencing the most loving relationship with her mother, she

will be assured that she has a support group at any time that will help her. The next step is to

provide an environment in which the client is challenged to use her newly learned skills more

regularly. For example, the client could be sent to more ballet castings, to see how she will

react in stressful situations. Her mother can be engaged too, in order to test their relationship.

One might set up meeting in bars, where the client is forced to be social. With the learned

skills, the client should be expected to socialize and maybe form relationships.

The final step in DBT is the support of the therapist and other individuals that were

engaged in the treatment of the client. This required group sessions and leadership training.
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This is important for both the therapist and the client, in order to keep the therapist motivated

and engaged in the patient’s recovery. Especially when the case of BPD is so severe as for

our client, it can prevent the therapist and the other individuals from developing extreme

stress or burnout.

Medication

In addition to DBT, there are several types of medication which could benefit the

client and increase the efficacy of treatments. These medications include antipsychotics, for

the purpose of controlling the client’s hallucinations as well as her affective instabilities. In

particular, we would recommend Olanzapine. If this medication proves ineffective, then

mood stabilizers could also be used. The primary goal in prescribing antipsychotics would be

to reduce the client’s hallucinations. Since the client’s hallucinations happen regularly, it

would be a simple matter to track the effectiveness of the medication by having her count the

amount of hallucinations she had per week. Antipsychotics have proven helpful to other

clients with BPD, and so it is reasonable to expect that they would help this client as well.

Given the slow acting effects of antipsychotics, the client should expect to see improvements

in no more than two months. Reducing or eliminating the client’s hallucinations would be

helpful in several ways. First, the client reported that her hallucinations were often

frightening and occasionally painful. By reducing her distress about her hallucinations, the

client would be better able to focus on her treatment in other areas such as interpersonal

skills.

Furthermore, the client often harmed herself during her hallucinations, so much so

that they may put her at risk for suicide, as when she stabbed herself. It is possible that if her

hallucinations are eliminated, her self harming behaviors would be as well. By reducing her

affective instabilities, it is also possible that Olanzapine would help further the client’s efforts

in her interpersonal skills. If antipsychotics prove ineffective, then mood stabilizers could
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also be used. Topiramate in particular could be helpful. Although this type of medication

would not directly treat the client’s hallucinations, they could be helpful in reducing her

affective instability and in improving her interpersonal skills. Furthermore, since the client’s

hallucinations seem to be stress related, reducing her affective instability and increasing her

interpersonal capabilities could help to reduce her stress and thereby reduce the intensity of

her hallucinations. If the client does not comply with her medications, perhaps due to side

effects, then the client’s mother could be called to assist with ensuring her compliance.

Considering the client’s mother’s tendency to be controlling of her child, she would likely be

very helpful in this aspect.

Maudsley and Interpersonal Therapy

If the Dialectical Behavioral Treatment for her BPD would prove itself to be

successful, we would start treating the clients eating disorder, which we believe to be

Anorexia Nervosa. There is a chance that the antipsychotics we would give her cause her to

gain weight and get healthier. However, there is no guarantee for that. She might get more

worried about continuing doing ballet if she gains extra weight.

In order to treat her Anorexia Nervosa, we would suggest Psychotherapy, especially

family based (Maudsley) and interpersonal therapy. Maudsley therapy consists of three stages

(Le Grange). The first one is to restore the weight of the patient, which means the client has

to first of all understand that she is severely underweight. Our client and her mother need to

be educated about the dangers of anorexia so that they can change their eating patterns. Since

both of them had been very actively engaged with ballet, they are probably very focused on

being a certain size, which is not healthy. Both of them need to understand that anorexia is

severe malnutrition, which can lead to infertility, hypothermia, organ failure and even death.

It is also very important that our client knows that they are not to blame for their eating

disorder, and her mother must understand that she is the problem.
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For the second phase, the client’s mother will be challenged to encourage her

daughter to eat healthy and the right amounts. This could be tricky, as the client will most

likely be moody due to the weight gain. Since the client might fall back to unhealthy

behaviors, the client’s mother is strongly encouraged to sit down with her daughter and have

meals together. If possible, the client should also go out for dinner with her newly formed

relationships. This may help to stabilize her mood and she would be very likely to actually

eat. Finally, when the patient is restored to a somewhat healthy weight, she needs to form a

unique identity. Her life had evolved around ballet and being skinny, however, and she needs

to understand that being skinny is not everything. Personal autonomy has to be established,

and boundaries to her mother’s control need to be set. We would encourage our client to find

different hobbies with friends, and focus on things other than ballet.

Conclusion

Overall, the main goal for our client is to bring her back to reality by treating her

hallucinations and form new, secure relationships. We hope to accomplish this by applying

DBT and antipsychotics. If this is possible and proves itself to be successful, we will start

tackling our client’s eating disorder.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Biskin, R. S. (2015). The Lifetime Course of Borderline Personality Disorder. Canadian

Journal of Psychiatry. Revue Canadienne de Psychiatrie, 60(7), 303–308.

Le Grange, D. (n.d.). Maudsley Parents. Retrieved November 26, 2017, from

http://www.maudsleyparents.org/whatismaudsley.html