A Case Study of: Norma
Jeane Mortenson (Marilyn
Monroe)
Rachel Miller and Sarah Brothwell
Wednesday November 12th 2014
The Case Background
● Historic Public Figure found her story interesting after watching the
documentary Love, Marilyn, which showed the complexity of her life
through journals and poems that she had written.
● Overall, she survived an abusive, and neglectful childhood, and
developed the persona Marilyn Monroe to mask her own insecurities.
● Marilyn Monroe has captivated the hearts of Americans since her rise
to fame in the early 1950’s. Her willpower to establish herself as a
serious actress while struggling with deep internal conflict has been
astonishing and inspiring.
Assessment: Identifying Information
Age- 36
Gender- Female
Socio-cultural- White European descent, father unknown, lower middle class
Education- Dropped out of high school at age 15. Took various classes like
dramatic, dance, singing, and horseback lessons. Studied acting with Lee
Strasberg at the Actors’ Studio in New York
Employment- Model, actress, singer, movie producer
(Buchtal, Hobby & Garbus, 2012)
Assessment: Medical History
Personal Medical History
● Insomnia (took barbiturates to fall asleep)
● 2 Miscarriages
● Pre-performance anxiety that sometimes made her
physically ill
● Chronic gynecological problems, that often would be
the reason for missing work
● Good physical health, exercised regularly
(Buchtal, Hobby & Garbus, 2012)
Family Medical History
● Father unknown
● Mother (Gladys Monroe Baker) had severe
psychological issues and was institutionalized many
times. She was diagnosed with paranoid schizophrenia
● Her grandmother was also committed to a psychiatric
institute
● Uncle reportedly committed suicide
(Monroe, 2014)
Psychological Assessment
–Mental StatusAppearance- She created the Marilyn Monroe persona (i.e. the way she
walked, talked and her overall appearance) to mask her insecurities. Marilyn
was described as self-absorbed and would often spend hours perfecting her
her hair, makeup and clothing
Mood (season) -More often depressed. Significant lability in mood (from
elevated to depressed). Possibly only elevated when in persona
Affect (weather)- Positive: determined, active alert, enthusiastic, inspired,
proud, strong cheerful, happy, energetic. Negative: irritable, ashamed, sad,
timid, alone, sheepish, nervous, hostile, distressed and lonely
(Buchtal, Hobby & Garbus, 2012)
Psychological Assessment Cont.
Speech- Rehearsed-soft, innocent, sensual. As a child described as being
quite and shy
Thought content- Frequent depressive thoughts, obsessed with improving
herself as an actor
Preoccupation- With appearances
Thought process/memory- Able to memorize 8 pages of a script at times, but at
other times would “go blank” (possibly a result of barbiturate use)
Estimated intelligence- Average or above average
Insight- Acknowledges need for counseling
Psychological Assessment
–Presenting Problems
● Insomnia, depression, suicidal thoughts
–Family
● No relationship with immediate family. Still has relationship with ex-husband Joe DiMaggio
–Substance Use
● Sleeping pills, and reports of alcohol use
–Social Support
● Friends, ex-husband Joe DiMaggio, and Lee Strousberg
–Coping & Strengths
● Loves to read, and write poetry
● Motivated to further her career
–Lethality
● Suicidal
Biopsychosocial Formulation
● Genetically predisposed to mental illness
● Early Life Traumatic Experiences: Insecure attachment to her
mother and other caregivers. She was placed in foster care and
orphanages because her mother could not take care of her as she
was put into institutions for “psychological problems”
● Physical abuse: Marilyn stated that one of her earliest memories
was her mother trying to smother her with a pillow
● Sexual Abuse: She was sexually assaulted at age 7, and raped at
age 11
● Received attention for the first time when she matured into a
beautiful young woman
(Monroe, 2014)
Biopsychosocial Formulation Cont.
● The norms of the film industry supported sexual promiscuity.
● Her persona received the love and attention that she desired, fueling her
desire to act and be perfect.
● 20th Century Fox refused to cast her in serious roles. She was constantly
battling others for the respect that she deserved.
● Experienced significant distress due to 3 failed marriages and 2
miscarriages.
● She was tricked into being committed to a psychiatric institution by her
psychiatrist.
● Additionally, she was not given adequate care from health professionals:
prescribed medication, formation of dual relationships, lack of
knowledge.
Symptoms
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Fear/anxiety- caused by a desire to be loved and a sense of worthlessness
Depression- feelings of emptiness
Insomnia
Excessive talking- shown by making phone call after phone call to friends
Racing thoughts- illustrated in her poetry/journal entries
Excessive involvement in activities (dancing, singing, acting)
Suicidal thoughts- Hospitalized at Payne Whitney and placed on suicide watch
Impulsivity- sexual indiscretions/affairs
Substance use- sleeping pills, and alcohol
Extreme preoccupation with appearance
Identity disturbance- adoption of the Marilyn Monroe persona
Social and occupational impairment
Possible Diagnoses
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Borderline Personality Disorder (BPD)
Bipolar II Disorder
Substance-Related and Addictive Disorder
Post-Traumatic Stress Disorder (PTSD)
Borderline Personality Disorder (F60.3)
A pervasive pattern of instability of interpersonal relationships, self-image,
and affects, and marked impulsivity, beginning by the early adulthood and
present in a variety of contexts as indicated by 5 (or more) of the following:
1. A pattern of unstable and intense interpersonal relationships as
characterized by alternating between extremes of idealization and
devaluation (questionable)
2. Identity disturbance: markedly and persistently unstable self-image or
sense of self
3. Impulsivity in at least two areas that are potentially self-damaging (e.g.
sex, substance abuse)
Borderline PD cont.
4. Recurrent suicidal behavior, gestures or threats
5. Affective instability due to a marked reactivity of mood (e.g. intense
episodic dysphoria, irritability, or anxiety)
6. Chronic feelings of emptiness
7. Inappropriate, intense anger or difficulty controlling anger
8. Severe dissociative symptoms
Special characteristics: Sleep disorders
Bipolar II Disorder (F31.81)
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated mood
expansive, or irritable mood and abnormally and persistent activity or
energy, lasting at least 4 consecutive days
B. During the mood disturbance 3 (or more) of the following symptoms have
persisted
1. more talkative than usual or pressure to keep taking
2. increased in goal-directed activity
3. excessive involvement in activities that have high potential for
painful consequences
Bipolar II Disorder Cont.
Major Depressive Episode
A. Five or more of the following symptoms have been present during the
same 2-week period
1. Depressed mood most of the day, nearly every day
2. Insomnia or hypersomnia nearly every day
3. Feelings of worthlessness
4. Diminished ability to think or concentrate
5. Recurrent thoughts of death, suicidal ideation, a suicide attempt or
a specific plan
Specify: With moderate anxious distress. Current episode (depressed).
Severity (Severe)
Differential Diagnosis
Bipolar Disorder vs. Borderline Personality Disorder
● Bipolar: Mood Swings are entirely neurological
o Borderline: Always see an environmental trigger
● Bipolar: Depression disables them
o Borderline: Impulsive even when depressed
● Bipolar: No dichotomous thinking
o Borderline: Dichotomous thinking
● Chronic feelings of emptiness
● Inappropriate, intense anger or lack of control of anger. Frequent
displays of tempter
● Transient, stress-related paranoid ideation or Severe dissociative
symptoms
Sedative-,Hypnotic-, or Anxiolytic-Related Disorder
(F13.20)
A. Problematic pattern of sedative use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12 month period
1. Sedatives are often taken in later amounts over a longer period of time than intended
2. There is a persistent desire or unsuccessful efforts to cut down or control use
3. Craving, or a strong desire or urge to use the sedative
4. Recurrent sedative use resulting in failure to fulfil major role obligations
5. Tolerance, as defined by either of the following
a. A need for markedly increased amounts of the sedative to achieve affect
b. A markedly diminished effect with continued use of the same amount of the
sedative
6. Withdrawal, as manifested by either of the following
a. Characteristic withdrawal symptoms are present: insomnia, anxiety
b. Sedative or closely related substances (such as alcohol) are taken to relieve
or avoid withdrawal symptoms
Specify: Severe (presence of 6 or more symptoms)
Post Traumatic Stress Disorder (F43.10)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways
1. Directly experiencing the traumatic event(s)
B. Presence of one or more of the following intrusion symptoms associated with traumatic
event(s), beginning after traumatic events occurred. (without further information we can not
know for certain whether she experienced symptoms related criteria).
C. Persistent avoidance of stimuli associated with traumatic events (again more information is
needed).
D. Negative alterations in cognitions and mood associated with the traumatic event, as
evidenced by two (or more) of the following symptoms
1.
2.
Feelings of detachment or estrangement from others.
Persistent negative emotional state
E. Marked alterations in arousal and reactivity as evidenced by 2 (or more)
1. Irritable behavior and angry outbursts
2. Reckless or self-destructive behavior
3. Sleep disturbances
Specify with: Mixed anxiety and depressed mood. Mixed disturbance of emotions and conduct.
Final Diagnosis:
Final diagnosis if we had to take our best guess:
● Borderline Personality Disorder
● Sedative-, hypnotic- or anxiolytic-related
disorder (severe)
● With PTSD-traits
Evidence Based Intervention
What treatment/intervention might be hypothesized to be
effective with this person?
● Inpatient, dual diagnosis treatment for BPD and
addiction
● Individual psychotherapy
● Classes and counseling session on relapse prevention
● Peer run support groups
● Psychiatric medication- selective serotonin reuptake
inhibitor (SSRI)
(dual diagnosis .org)
Evidence Based Intervention
Therapeutic Approach: Dialectical Behavior Therapy (DBT)
● DBT is a well established treatment for individuals with multiple and severe
psychological disorders. Dialectic means the synthesis of two opposites
(e.g change and acceptance).
● DBT classifies behavioral targets hierarchically. In MM’s case to decrease
behaviors that are life threatening (e.g. suicide) and then substance abusespecific behaviors.
● The treatment includes five essential functions
o Improving patients motivation to change
o Enhancing patient capabilities
o Generalizing new behaviors
o Structuring new environment
o Enhancing therapist capabilities and motivation
Research on DBT
● DBT has been shown to be effective for treating individuals with borderline
personality disorders (Koerner & Linehan, 2000).
● Research has also demonstrated that DBT can be effective when treating
individuals with co-occurring borderline personality disorder and substance
abuse ( Dimeff & Linehan, 2008).
● Meta analysis conducted to examine the use of DBT to treat borderline
personality disorder found a moderate global effect size and a moderate
effect size for suicidal and self-injurious behaviors (Kliem, Kröger, & Kosfelder,
2010).
Treatment Considerations
● What moderators or mediators might be relevant in this case? Marilyn
Monroe’s determination to be an actress may limit her ability to structure a
new environment for herself. It seems to me that her vocational choice
may be detrimental to her progress in treatment.
● What practical considerations might limit the feasibility of using the
intervention in this case? Marilyn may be hesitant to enter into inpatient
treatment, due to her traumatic past experience of being hospitalized.
Motivation and insight into the need for therapy is often a challenge for this
population. Her high status may enable her to leave treatment early.
Treatment Considerations Cont.
● How might you plan for possible complications? I would try to send her to a
clinic that felt more “home” like. When Marilyn was hospitalized, she
complained about her room feeling like a prison cell. In terms of helping
her trust trust new counselors, education on the characteristics and
symptoms of BPD would go a long way. This way she will know what to
expect from her counselors, as well as from her overall experience in
treatment.
● How will you evaluate the intervention in this case?
● Self report measures- Pre and Post-treatment Personality Assessment
Inventory-Borderline Features Scale (Kathryn Gardner & Pamela Qualter 2009).
● Pre and Post-treatment FFM Borderline Index (Maddux & Winstead 2012)
● Clinician reports and progress notes
Prognosis
● Prognosis/expectations regarding outcome? There is considerable
variability in the developmental course of BPD. The most common involves
serious affective and impulse dysregulation in early adulthood, which is
when risk of suicide is the greatest.
● Although these clients may struggle with intense emotions and
interpersonal instability throughout their lifetime, they often show
improvements within the first year of therapy. After 10 years of therapy
roughly 50% of individuals will no longer meet the diagnostic criteria for
BPD (American Psychiatric Association, 2013)
Reference
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Buchtal, F, S., Hobby, A., Garbus, L. (2012), Love, Marilyn. US: Diamond Girl Productions
Dimeff LA, Linehan MM (2008). Dialectical behavior therapy for substance abusers. Addict Sci Clin
Pract.2008;4:39–47.
Kathryn Gardner, Pamela Qualter. (2009). Reliability and validity of three screening measures of borderline
personality disorder in a
nonclinical population, Personality and Individual Differences, Volume 46, Issues 5–6, April 2009, Pages
636-641, ISSN
0191-8869, http://dx.doi.org/10.1016/j.
Koerner, K., & Linehan, M. M. (2000). Research on dialectical behavior therapy for patients with borderline
personality disorder.
Psychiatric Clinics Of North America, 23(1), 151-167. doi:10.1016/S0193-953X(05)70149-0
References
Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A
meta-analysis using
mixed-effects modeling. Journal Of Consulting And Clinical Psychology, 78(6), 936-951.
doi:10.1037/a0021015
Maddux, J, E., & Winstead, B. A. (2012). Psychopathology: Foundations for a contemporary understanding
(3rd ed.) Mahwah, NJ.
Lawrence Erlbaum
Marilyn Monroe. (2014). The Biography.com website. Retrieved 03:01, Oct 28, 2014, from
http://www.biography.com/people/marilyn-monroe-9412123.
Website: http://www.dualdiagnosis.org/borderline-personality-disorder-and-addiction/