Читать книгу Schizotypal Personality Disorder: A Case Study of the Movie Classic TAXI DRIVER - Francine R Goldberg PhD - Страница 6

The main character, Travis Bickle, is introduced as he walks into the office of a New York City taxi cab company and inquires about a job as a driver.

It is not surprising that Travis is applying for this type of job because people with STPD gravitate toward jobs that demand little interaction with others (Sperry, 2003, p. 242).

He tells the interviewer that he wants to drive a cab because he cannot sleep nights and that going to all night porno movies has not been a helpful alternative. When the interviewer asks Travis what he does now, while most people would offer a response about their employment or vocational activities, Travis follows the conversation thread he had begun and responds:

Now? Ride around nights mostly. Subways, buses. [I] figure, you know, [if] I’m gonna do that, I might as well get paid for it.

Interviewing people with STPD usually elicits surprising statements and peculiar ideas (Sperry, 2003, p. 249).

Travis is a 26 year old US Marine veteran of the Vietnam War. He seems to identify with that role as he wears a Marine jacket with a patch from his King Kong Company and displays a Vietnamese flag in his impoverished, messy apartment. Travis’ success at becoming a Marine leads to speculation that Travis was able to meet high standards. However, other than the fact that he was a Marine no real information about Travis’ military career is revealed to support such speculation.

Clinicians dealing with clients who have served in the more recent military must speculate differently as the current US Army has relaxed its standards and entry requirements for recruitment and training. Recruits now pass basic training at a time when the Army has been under terrific pressure to bring in new soldiers. In 2005 the Army raised the limit on the so-called Category 4 recruits it would allow, the designation for soldiers with the lowest scores on its aptitude test. The Army has also been handing out more waivers—including case-by-case exceptions for criminal offenses—which increased by 3 percent last year. Basic training has slipped as well. In years past, basic was geared to "wash out" those unfit for the stresses of military life. Now it has been reformulated to keep as many recruits as possible. The most recent washout numbers show a dramatic decline in standards: currently only 7.6 percent of new recruits fail to get through their first six months of service, down from 18.1 percent in May 2005, according to the latest Army figures. (Childress and Hirsh, 2006).

According to the Defense Department health officials the military is working to improve the way it implements a policy of discharging troops based on pre-existing personality disorders…Air Force Col. Joyce Adkins, director of psychological health and strategic operations, clarified that a personality disorder does not necessarily bar an individual from serving in the armed forces. "Certainly there are many people who have personality traits that we would characterize as a disorder who have stayed in the military," she said. "It's only when their personality doesn't fit well with the job that they are separated." … In most cases, no psychological evaluation can determine whether a personality disorder is apparent at the time of enlistment, as many signs of a latent disorder are undetectable. But despite difficulties in detecting pre-existing personality disorders, Adkins said, the military could improve the way it evaluates service members returning from combat who are suspected of suffering from such disorders. "We are really stepping up on specifying the clinical criteria for what that evaluation should include," she said. "We want to make sure that (misdiagnoses) do not happen, that when a person is supposed to get a thorough evaluation, they do get a thorough evaluation (American Forces Press Service, 2007).

In addition to observation, the Minnesota Multiphase Personality Inventory (MMPI-2), the Million Clinical Multiaxial Inventory (MCMI-III), and the Rorschach Psychodiagnostic Test can be useful in diagnosing STPD. On the MMPI-2 a 2-7-8 (depression-psychasthenia-schizophrenia) code is likely. Scales F (frequency) and O (social introversion) are also likely to be elevated. On the MCMI-III, elevations on S (schizotypal), 2 (avoidant), 7 (obsessive-compulsive), and 8A (passive-aggressive) can be expected. On the Rorschach, these individuals have records that are more similar to schizophrenics and borderline personality-disorded individuals than to schizoid individuals (Sperry, 2003, p. 250). The Multidimentional Personality Questionnaire (MPQ) has been found to be a powerful measure of personality that has been used in research. It is a paper-and-pencil true/false test that has used to identify personality correlates of violence and crime across cultures, countries race and gender (Nestor, 2002, p. 1977).

In contrast to the impressive record inferred by having been a Marine, Travis offered a very unimpressive response to the question about his education:

Travis: Some, Here, there, you know.

People with STPD are prone to vague descriptions. Perhaps, also related to this response is the fact that the symptoms of STPD may begin in childhood or adolescence showing as a tendency toward solitary pursuit of activities, poor peer relationships, pronounced social anxiety, and underachievement in school. Other symptoms that may be present during the developmental years are hypersensitivity to criticism or correction, unusual use of language, odd thoughts, or bizarre fantasies. Children with these tendencies appear socially out-of-step with peers and often become the object of malicious teasing by their peers, which increases the feelings of isolation and social ineptness they feel (Gilles, 2003).

Travis leads a dark, lonely and isolated life where he seems to be confined to his depressing apartment, the dreary taxi cab he drives or a shady movie house showing pornographic films.

This is consistent with the biosocial formulation reported by Sperry (2003, p. 246) which is that STPD is self-perpetuated by social isolation, overprotection and self-insulation. While social isolation has immediate benefits, in the long run they are counterproductive as they deprive these individuals of opportunities to develop social skills and they foster dependency. Furthermore, the individual’s tendency toward self-insulation further perpetuates the spiral of cognitive and social deterioration that typifies STPD.

Travis fills his body with junk food, drugs and alcohol, the latter two which he carries with him when he is out of his apartment. He lacks the interpersonal skills to make acceptable conversation as exemplified in the work environment with the boss and in the social environment of the movie house where he tries to make social conversation with the woman working at the snack counter. In both examples he forces the other person to threaten him in some way in order to get him to stop.

This exemplifies the initial results from the Collaborative Longitudinal Personality Disorders Study, one of the first studies to document and quantify the extent of functional impairment in patients with an Axis II disorder in contrast to patients having an impairing Axis I disorder. Patients with STPD were found to have significantly more impairment at work, in social relations, and in leisure activities than patients with Axis I obsessive-compulsive or major depressive disorder…These results not only underscore the misconceptions that clinicians have been known to have of the extent of psychiatric morbidity attendant to Axis II disorders but also suggest the importance of utilizing integrative treatment interventions that emphasize psychosocial rehabilitation to mitigate the pernicious effects of personality disorders on functioning (Sperry, 2003, pp. 18-19).

Another important note here is that the comment that agitated the boss, the comment about Travis’ conscience being clear, was a tangential digression, another symptom to which people with STPD are prone (Gilles, 2003).

Travis’ only uneventful verbal communication occurs in his living environment where he is alone and writes in his diary.

When Travis is asked if the taxi driver job would be “moonlighting” for him, Travis does not know what the term “moonlighting” means.

This may be due to verbal episodic memory deficits, a well-established feature of the schizophrenia spectrum that has been found in individuals with STPD. In an NIMH Grant supported study comparing individuals with STPD to individuals with other personality disorders and a group of healthy volunteers those with STPD learned verbal and visual-spatial information at a reduced rate and recalled fewer words and objects after a long delay (McClure, et. al., 2006). Another explanation may be that people with STPD may have speech patterns that appear strange in their structure and phrasing…and some may verbalize their responses by being overly concrete. Thus, Travis may use such a term to mean “lighting the moon” (Gilles, 2003).

Travis, however, does get the job. One may speculate that it was not because of his interview behavior but, rather, because the interviewer appears to feel some camaraderie with a fellow marine and because Travis is willing to do what the interviewer needs, i.e., someone who is willing to drive on Jewish holidays and to drive nights and work uptown, South Bronx and Harlem.

Travis sees the world as dirty and “venal”:

Thank God for the rain, which has washed away the garbage and the trash off the sidewalks…All the animals come out at night. Whores, skunk-pussies, buggers, queens, fairies, dopers, junkies. Sick, venal. Someday a real rain’ll come and wash all this scum off the streets…

The DSM-IV-TR criterion A(4) for STPD, which is placed on Axis II (see next paragraph), asserts that metaphorical speech is often found in people with STPD. Other speech patterns that may emerge include overelaborate, circumstantial, stereotyped, and as mentioned earlier, vague (APA, 2000, p. 701; Sperry, 2003, p. 244).

The DSM-IV-TR (APA, 2000, pp.27-35) provides the following multi-axial system for categorizing mental disorders which guides clinical practice, research and education:

Axis I

Clinical Disorders

Other Conditions That May Be a Focus of Clinical Attention

Axis II

Personality Disorders

Mental Retardation

Axis III

General Medical Conditions

Axis IV

Psychosocial and Environmental Problems

Axis V

Global Assessment of Functioning (GAF)

Axis I disorders include, but are not limited to, Schizophrenia and Other Psychotic Disorders, Mood Disorder, Anxiety Disorders and Substance-Related Disorders.

Axis II disorders include Mental Retardation and Personality Disorders which are grouped into three clusters, i.e., Cluster A (odd and eccentric) Paranoid, Schizoid, Schizotypal, Cluster B (dramatic, emotional or erratic) Antisocial, Borderline, Histrionic, Narcissistic, and Cluster C (anxious and fearful) Avoidant, Dependent, and Obsessive-Compulsive.

Axis III is for reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder.

Axis IV includes problems with one’s primary support group, social environment, educational, occupation, housing, economic issues, access to health care services, interaction with the legal system/crime, and other psychosocial and environmental problems such as exposure to disasters and difficulty with caregivers and social agencies.

Axis V is a rating determined by the GAF Scale that considers psychological, social, and occupational functioning and symptom severity on a hypothetical continuum of mental health-illness from 0 (inadequate information), 1(persistent danger of severely hurting self or others) through 100 (superior functioning in a wide range of activities, life’s problem’s never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.)

There appears to be a “disconnect” between Travis’ inferred message of his morality by the way he sees the world and his own immoral behavior of drug use, probably speed, which keeps him from sleeping and, thus, sends him to pornographic movie houses at various hours during the day and night.

Travis’ only way of connecting with the world is when he drives people around in the taxi cab and when he sits in the pornographic movie house and watches the films.

After he begins working as a taxi cab driver he says:

All my life needed was a sense of some place to go. I don’t believe that one should devote his life to morbid self-attention. I believe that someone should become a person like other people.

Travis wants to connect with others, as exemplified by his two failed conversations discussed earlier and by the following metaphorical journal entry about Betsy that ends the scene:

I first saw her at Palantine campaign headquarters at 63^rd and Broadway. She was wearing a white dress. She appeared like an angel out of this filthy mass. She is alone. They cannot touch her.

People with STPD are more comfortable turning inward, away from others, than learning to have meaningful interpersonal relationships. This preferred isolation contributes to distorted perceptions about how interpersonal relationships are supposed to happen (Gilles, 2010).