Patient: Emily
Characteristics: Female (Transgender, MTF), brown eyes, medium brown/tan coat, dark brown mane, thirteen years old, small for her age in terms of both height and weight. Parents are Willy Whisps and Cloud Mender.
Report: Began visiting with Emily several days ago when Bright Side, from the Ministry of Foals and Families' Ponyville office, brought her to my attention. She’s a generally positive and upbeat filly, going on mare, who in general seems excited and upbeat about life in general, even in spite of difficult circumstances. However, she can have moments where her mood quickly turns dour and downcast, most commonly resulting from discussion of uncomfortable topics for her. When she’s excited, she usually displays a more childlike demeanor, and has displayed this occasionally when difficult topics have come up. She has a tendency to think out difficult questions, and has obfuscated to avoid answering at times, although she generally shows a dislike for being dishonest. She cares greatly about her perception, and has occasionally tried to downplay her maturity.
She describes having dysphagia and acid reflux, as well as asthma, and has previously been diagnosed with autism and ADHD, both of which she’s taken medication for. Those medications have included dexmethylphenidate, risperidone, and mirtazapine. She’s also taken medications for acid reflux. She has started magical gender therapy for transitioning around one year ago.
She describes her parents as being ‘okay’, although some of the things she described them doing to her could be seen as potentially abusive tactics, such as pouring water on her head to wake her up and sending her to live with friends when she misbehaves. In my estimation, it’s negligent, misguided parenting and not malicious. In addition, Cloud Mender has stated she’s been diagnosed with bi-polar, although she’s currently in both therapy and psychiatry for it.
She describes having sensory issues, and shows it, too, namely to sensations of touch. Things like certain types of fabric or her coat keep her stimulated when she touches them, but describes things like napkins and drying towels giving her sensory issues. She definitely has a few subconscious stimming mechanisms, and shows repetitive traits, like singing songs with repetitive lyrics, as described by Bright Side.
She’s had moments where she engages in self deprecating behavior, calling herself things like an ‘idiot’ when her mood is deflated, although this behavior is countered by the opposite when her mood is inflated, where she asserts how good she thinks she is. She’s previously described herself as ‘ugly, terrible, and annoying’, but stated that she wasn’t anymore, potentially due to a host of reasons. This doesn’t seem to be a symptom of any mental illness, however, she does show dissociative behaviors in simple day-to-day interactions. She seems genuinely unaware of when it’s happening, or even that it does happen, but it can be seen with careful observation. She shows a mixture of distress and annoyance when talking about these things, although over the several days of speaking to her, she’s shown more acceptance of this.
She’s shown a genuine lack of knowledge about personal details, such as her age, and seems surprised when things in her life turn out to be how she remembers them. She seems to believe it’s unexpected that things for her seem so normal, and occasionally shows anxiousness about this. She’s also described how she didn’t believe she was a pony, but that she was happy she actually was, although shows frustration and confusion when the things she says about her life as a ‘human’ previously turn out to be the same since she ‘became a pony’.
She describes previous sexual abuse she’s faced, at the hooves of a stallion named ‘Nice Lad’, who was her caretaker before he passed away. She describes being fondled and molested by him, and being coerced into playing sexual games with him up until he passed away, when she was around ten years old. The way she describes it, this abuse that took place was both patterned and long term, and she seemed to suggest that she didn’t understand it was abuse at the time, although she was anxious and uncomfortable at the time. She seems to acknowledge that it was now, although it’s uncertain if she grasps the gravity of what she faced. She showed dissociative symptoms both while and after discussing the abuse. The abuse would have taken place before she started magical gender therapy if the timeline she gave lines up.
She seems to roughly describe this abuse in a story she wrote called “Mind Over Matter” through the eyes of a colt in roughly the same circumstances. The story presents the idea of a foal becoming a pony after formerly being an alien and being helped through trauma with therapy. She follows the claim she asserts in the story, and it seems to be a story of herself inserted into the situation following previous abuse. Some of the details of the real world shown within, however, are incorrect.
Diagnosis: Along with previous diagnoses of autism and ADHD, Emily fits the criteria for Dissociative Identity Disorder. Specifically, there’s observed disruption of identity characterized by at least two personality states, recurrent gaps in the recall of everyday events, and the symptoms appear to be clinically significant and are not attributable to religious practices, substance use, or other medical conditions. However, in this diagnosis, it’s important to rule out other mental health conditions, although it doesn’t seem likely that other conditions fit.
Differential diagnoses would be, in order of likelihood, C-PTSD, Depersonalization/Derealization disorder, Partial DID, OSDD 1a, and Borderline Personality Disorder, based on testing and observed symptoms. Based on self reporting, it would be Partial DID, Borderline Personality Disorder, DPDR, C-PTSD, then OSDD 1a. She’s been previously ruled out for bi-polar type 1. Dissociative amnesia rules out OSDD 1b. Youngness of age and the presence of childhood sexual assault rules out schizophrenia. Clearness of thought and ordered, organized thinking likely rules out cluster A personality disorders. Malingering and factitious disorder seems unlikely.
While I have confidence in this diagnosis, later mental health treatment may show one of the differential diagnoses fits better. Close examination and a cautious approach should be taken with Emily, and an understanding that comorbidities might come up should be had, as well as an understanding of the differential diagnoses.
Treatment: Continued use of dexmethylphenidate for ADHD should be given. Risperidone likely isn’t needed, although it might be considered as Emily self reports flashes of intense anger and impulsive behavior. This should be considered very carefully before prescribing as her parents report not seeing these things in her. A medication like clonidine would be best for trouble with sleeping, if need be, replacing previous antidepressants.
Psychotherapy is a priority for Emily, and her first session is scheduled to begin Friday, and then once a week for the next month, and then every two weeks thereafter. The main goal of these sessions should be to help her process trauma and learn grounding strategies for coping with such. It’s still unknown the full extent of what she’s experiencing, although psychotherapy to help uncover these things and change behaviors is the best course of action. She does display general fear, dismay, and anxiety at being prescribed a label she feels doesn’t fit her, as well as surrounding abuse, so a slightly less direct and more cautious approach might be necessary.
Her guardians have been assigned classes in proper parenting to help Emily’s treatment at home. While they’re in that training, Emily will be placed in a group home, to be returned to her parents’ guardianship once the classes are finished. Stronger, healthier parenting will go a long way with helping her.
Given Emily’s age and understanding, a degree of hopefulness about her case can be had. I believe that with proper care and healthier relationships, she’ll be able to work past her current issues as she continues into the future.
-Doctor Ivory Spark