Tony Stark: Case Study and Psychological Assessment
Tony Stark is a Caucasian male in his early forties. He has a genius level intellect shown by how he built a circuit board at age four, an engine at age six, and graduates from M.I.T. summa cum laude at seventeen (Wake Wiki, 2010). At age eighteen both Howard and Maria Stark, his parents, died in a car crash. Tony was never close to either of his parents because he attended boarding school starting at a young age. Tony hated his father to a certain extent because Tony could never be good enough to impress his father and his father never paid any real attention to Tony. At twenty-one Tony inherited Stark Industries and began to create smarter weapons; he became a billionaire and becomes famous for his partying lifestyle.
Tony did not begin to show any signs of mental illness until he was taken hostage by a terrorist group in Afghanistan and his heart is injured by shrapnel. Tony was tortured for months by the terrorist group in an attempt to force him to build them weapons. Tony eventually manages to escape by building and using a suit of technological armor, however his fellow captive and friend, Yinsen, ends up having to sacrifice his life so that Tony can escape. After his captivity Tony decided he wanted to “do better”; he immediately ceased all weapons development and upgraded the suit of armor he used to escape until it can be used to make him the superhero known as Iron Man. Soon after becoming Iron Man Tony discovered that the terrorists were working with his father figure, Obadiah Stane. Stane stole Tony’s arch reactor, the thing that keeps the shrapnel in his heart from killing him, and left him to die; in the aftermath Tony ended up killing Stane. Tony continued to deal with different traumas on a weekly basis with his decision to become Iron Man and tells the public his identity. Tony has not spoken to anyone about the people he has killed nor the trauma he experienced in Afghanistan.
Tony did not have any apparent signs of serious mental illness until he fought in an all-out war in New York against the Chitauri to protect Earth. During the course of the battle Tony took a nuclear warhead through a wormhole in order to protect the civilians in New York, believing he would not survive. Tony survived the experience, but he began to experience symptoms of Post-Traumatic Stress Disorder (PTSD) which impaired his ability to deal with his next threat, the Mandarin. After defeating the Mandarin Tony sought out a friend of his, Dr. Bruce Banner, to talk to about what has been happening to him since the wormhole. Tony told Dr. Banner about how he was experiencing trouble sleeping and how he would often be awake for more than seventy-two hours before sleeping and, when he did sleep, he would have nightmares of New York. One time Tony subconsciously summoned his suit and it came and grabbed Pepper who was sleeping next to him while he was having a nightmare. Tony also mentioned the fact that when a child asked him how he survived the wormhole he started feeling as if he was having a heart attack; he ran to his suit where his A.I. told him that based on the suit’s scans, Tony was having an anxiety attack.
Tony talks about how each time something reminds him of the wormhole he experiences what he calls an anxiety attack. Tony is also adamant that he does not suffer from Post-Traumatic Stress Disorder and that he does not need any medication to help him with his anxiety attacks. Tony has a very small support network; he only really talks to his girlfriend Pepper, his best friend the Iron Patriot/War Machine Rodney, his A.I. Jarvis, and, occasionally, his friend Bruce Banner. He often uses humor and misdirection to keep those close to him from seeing his pain. He has also said that Pepper moving in with him is one of the few things keeping him sane and describes himself as a “hot mess”.
If Tony Stark was my client. I would diagnose him with Post-Traumatic Stress Disorder based on the DSM-5 code 309.81 (Hsiung, 2013). Post-Traumatic Stress Disorder is “an anxiety disorder in which the individual experiences several distressing symptoms for more than a month following a traumatic event, such as a re-experiencing of the traumatic event, an avoidance of reminders of the trauma, a numbing of general responsiveness, and increased arousal” (Halgin & Whitbourne, 2013, p. 207). The first signs of PTSD in Tony Stark become clear due to his biological, psychological, and social symptoms.
After his near death experience in New York Tony Stark began to have biological, psychological, and social symptoms of PTSD. The biological symptoms Tony experiences could be seen as a sign of PTSD or depression. Tony’s appetite, sleep habits, and activities have changed, which may be due to a change in his Serotonin levels. Since the wormhole in New York Tony often goes over seventy-two hours or longer without sleeping, he does not have regular meals and is not normally hungry, and he no longer goes out to parties or events instead he spends most of his time at home alone or with his girlfriend Pepper. The main psychological symptoms that Tony shows are paranoia and obsession. After his traumatic experience Tony has become obsessed with preventing a repeat for himself and his loved ones by being prepared for anything and everything; this has caused Tony to become obsessed with building an army of Iron Man suits, to the point of neglecting eating and sleeping. Tony’s social symptoms are apparent in how he will not appear in public without his suit or armor to protect himself and in how he avoids social situations so that people do not ask him about the wormhole or the battle. When Tony Stark’s biological, psychological, and social symptoms continued to persist months after his near death experience in New York, I looked at the criteria for PTSD and found that it fit Tony.
For a person to be diagnosed with PTSD they must meet the criteria established by the DSM-5; there are six main criteria, A-F, that the person must meet. Category A states that the person had to have been exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence by direct exposure, witnessing, in person, indirectly, and/or repeated or extreme indirect exposure to aversive details (American Psychiatric Association, 2013). Tony Stark meets the A criteria because when he was held hostage by the terrorists, he was tortured, threatened with death, and his friend Yinsen was killed in from of him; later when he went through the wormhole in the New York battle he fully expected to die (Iron Man 3, 2013).
Category B states that the traumatic event needs to be persistently re-experienced in at least one of the five ways as described in the Diagnostic and statistical manual of mental disorders (American Psychiatric Association, 2013). Tony re-experiences the event in a second way, nightmares; whenever Tony falls asleep he has nightmares about going through the wormhole and then falling to his death. Category C states that the person must show persistent effortful avoidance of distressing trauma-related stimuli after the event in one of two ways, they must either avoid related thoughts and feelings or related external reminders (American Psychiatric Association, 2013). Tony Stark falls into the second area as he persistently avoids people, places, conversations, activities, objects, and/or situations that remind him of the wormhole. He changes the conversation whenever someone mentions the wormhole or the battle of New York and, if the person tries to talk about it again, he leaves.
Category D states that person must experience negative alterations in cognitions and mood that began or worsened after the traumatic event in at least one of seven ways (American Psychiatric Association, 2013). Tony experiences a persistent negative belief about the world after his experience; post-wormhole Tony believes that he needs to build as many suits of armor as he can in order to “protect the one thing he cannot live without”, referring to Pepper, from any harm (Iron Man 3, 2013). Tony also shows a markedly diminished interest in pre-traumatic significant activities such as: drinking, partying, building machines other than his armor, being involved in his company, and going out with Pepper.
Category E states that the person must experience trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event in at least two of the seven ways according to the Diagnostic and statistical manual of mental disorders 5th edition (American Psychiatric Association, 2013). After the wormhole Tony displays hyper-vigilance of all threats to himself, but mainly those towards Pepper; he goes to extreme lengths to be able to spot all threats such as being able to use his suit of armor without being in so that he can be with Pepper and also watch for threats. Additionally, he has shown an increase in aggressive behavior towards threats; when the Mandarin bomb a mall and one of his friends is put into a coma as a result of the explosion, Tony calls the Mandarin a coward and tells him the he is coming for him; he then displays reckless behavior when he tells the Mandarin his home address and challenges the Mandarin to prove he is not a coward (Iron Man 3, 2013).
Category F requires that the person experiences symptoms from category B, C, D, and E for more than one month. It has been months since the wormhole incident and Tony has continued to meet the criteria of categories B, C, D, and E. Category G requires significant symptom-related distress or functional impairment (American Psychiatric Association, 2013). Since the wormhole Tony rarely goes out in public without his suit on for fear of being caught unprepared and he no longer creates gadgets for his company; he instead creates them for his protection. Category H requires that the disturbance is not due to medication, substance use, or other illness (American Psychiatric Association, 2013). Tony’s A.I. scans him for medical problems every time he enters the suit and has not diagnosed him with any physical disorder. Tony has also quit all drinking since the wormhole incident so as to be constantly for any attack. Tony Stark meets all of the required criteria to be diagnosed with PTSD. The recent changes to the DSM-5 have classified arousal as “reckless or self-destructive behavior, sleep disturbances, hyper-vigilance or related problems”; these changes allow for fight responses as well as flight responses to be used in diagnosing PTSD (dsm5.org, 2013). These changes allowed Tony to be diagnosed with PTSD as opposed to an anxiety disorder. The changes have also made it possible for Tony to be treated as a PTSD patient and can provide the help he needs instead of being misdiagnosed and wrongly treated due to being unable to diagnose him as PTSD (Mathew, Largen, & Claghorn, 1979).
There are certain ethical issues that come into play for the treatment of Tony Stark. For one, since Tony is Iron Man, he has to deal with a level of danger at all times and even if he was to give up Iron Man there would still be people who would want him dead. This makes it difficult to treat his paranoia and high vigilance level because removing his need to search for threats could end up getting him hurt or killed. Also the fact that he is suffering from PTSD may impair his ability to help save people, but client confidentiality would not allow for informing anyone of his condition without breaking his trust.
I would recommend a combination of different therapies without any medication to treat Tony because of his life as Iron Man, if he had a negative reaction to medication it could result in harm to himself or someone else. The first therapy I would recommend would be exposure therapy. Exposure therapy is when a person is exposed to their fears and then they talk about it with a therapist in order to gain control of their own reactions towards stimuli that remind them of their fear (Lauterbach & Richard, 2007, p. 2-3). In exposure therapy Tony could gain control over his reaction when the New York battle and the wormhole are mentioned; if Tony can get his reaction to the trauma under control then the rest of his symptoms should follow. I would also suggest the use of cognitive-behavioral therapy to help Tony to understand how his thoughts affect his moods and to enable him to work on positive thinking in order to improve his mood (Greenlaw, 2014). The final therapy I would recommend is family therapy. Tony has said that Pepper is the one thing he cannot live without; I believe it would be a good idea to have Pepper involved in his therapy as it would help them both to understand each other, help Tony understand that his PTSD is affecting other people, and it would make Tony feel more comfortable talking about the wormhole and New York if he has someone he trusts there to support him.
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More information on PTSD
- PTSD At Home: The Forgotten Soldiers
An article about soldiers who have PTSD that never deployed.
- The Brain, Brain Chemistry, And PTSD
Understanding the part that the brain plays in PTSD for the layman. The more information a survivor has about their PTSD, the better chance they have in recovery.
- DBT Therapy for PTSD
Though DBT therapy was designed to be used for people with borderline personality disorder, I found it to be the best therapy for PTSD. DBT therapy for PTSD gave me skills to use to overcome PTSD.
- Signs and Symptoms of Post Traumatic Stress Disorder (PTSD)
The public tends to think of PTSD as an extreme condition suffered by soldiers who were traumatized by war. In actuality, more people suffer from it than the public may think.
- PTSD and suicide among law enforcement officers
Law enforcement officers can be victims of a silent killer. Learn the signs and symptoms of PTSD and how to help the men and women who suffer.
The Psychopathology and Treatment of Anxiety: Edna Foa
"1. How did you become interested in psychology?
>> I think I became interested in psychology in high school so a long time ago. And I suppose because [inaudible] and like everybody else and I was really fascinated by the Freudian theory, by interpretation of dreams and then as I grew up and I actually went to study psychology, I became kind of going into behavioral therapies which is very, very far from Freud and kind of maybe in the opposite direction, different concept, different theories and different treatments.
2. What is your current area of research?
>> Yeah, my result is anxiety disorders, and its covers trying to understand the psychopathology of anxiety disorders, how the theology, the maintenance why people-- some people have anxiety disorders and other people do not. Both maintains the anxiety disorders. How people retain like, you know, panic attacks or obsessive compulsive disorder. And what it mean the mechanisms by which, you know, why don't they stop being obsessive compulsive or still being panic disorder and just become normal overtime, and that doesn't happen usually without treatment. My specific research areas now, obsessive compulsive disorder and most so even posttraumatic stress disorder.
3. What do we think of when we hear the word “phobia”?
>> Specific phobia would be the one that everybody's think about like a spider phobics, dog phobics, cat phobics, height phobics. So it's specific that these people are not afraid in general, they are not--they are not very anxious in general. But when they are confronted ways, the specific things that they are afraid off, they become very upset. They try to avoid confronting those specific situations or specific objects and it can disturb the life quite a bit. Like, if you're a dog phobic and you're so afraid that you're going to see dogs in the street and you'll be attack by the dogs, you may even decide almost not to go out of the house. Or you park your car just near the entrance through your home, so you could jump straight from your home to the car and then drive quickly as even 5 minutes away. So, those are specific phobias.
4. What is panic disorder? How are panic attacks different from pain disorder?
>> And then we go to panic disorder. And those are people, they get frequent panic attacks. Panic attack is defined as kind of a crescendo of anxiety. And anxiety is described by these people if heart rate fast, heart rate palpitation, sweating, and sense of suffocation, dizziness, etcetera. And those symptoms are kind of going as a crescendo up then stay for about 10 minutes or so and then gradually go down. But the--what characterized these to people who get--that get panic disorder is that they are afraid that something tell what will happen from the panic attack. So, like, for example, they are afraid they are going to have a heart attack or they are going to go crazy, or they will behave in such a ways that would shame them in public. So, they avoid situations not because the situation them self are dangerous like in specific phobic and you avoid a dog, you avoid a height 'cause you don't want the dog to bite you, or you don't want to fall of a high place. By the panic disorder patient, avoiding situation that they think may cause in panic disorder. And then, if they have panic disorder, it's the panics that is dangerous not the situation it's safe. So, pleasures where they are stuck like one way streets, you know, if they're making a mistake they could--they can go big. Or sitting in the front of the theater, if they get a panic attack, then, you know, they have a long way to go in order to get out. And plus, if it's in the middle of the theater and they have to go out, it would shame them and you know, they'd be ashamed of it, you know, their behavioral. So they usually would seat near the door, you know, kind of at the back of a seat or back of a [inaudible] chair. Now, a lot of people have panic attacks and do not have panic disorder. So those people just have panic attacks, they feel bad about it but they don't usually think that something terribly is going to happen. So they don't develop this feel of fear that panic disorder patient.
5. Please talk about obsessive-compulsive disorder.
>> Then we have obsessive compulsive disorder, and that's kind of complicated because there are a lot of many station of OCD. Some patient with obsessive compulsive or OCD are mainly feeling contaminated but can feel contaminated by seeing that are naturalistically really [inaudible] or naturalistically dirty. In order to feel better they wash or they take showers, and they may wash 80 times, 100 times a day. They may use Lysol in, you know, in order to clean themselves. And--but some others not washing but checking because they are afraid they'd--you know, they would forget something or they are afraid to make a mistake and they want to kind of present themselves as inappropriate, inadequate, and so they will check again and again and again. They may take--takes them hours to check. Also afraid that because of their responsibility something terrible happen. Like, if they leave the door open when they leave the house and a burglar will come and will take everything they own, or if they don't check the doors before they go to sleep and somebody come and may kill their children and the wife and its all gonna be their fault. So, they check repeatedly and it's not enough for them to check once and to say, "Okay, I checked it like normal people do." But it's as if they don't remember that they checked, they said, "Well, I'm not sure that I checked enough, you know, maybe I'll check another time." And then it can go for hours and they always late to places, you know. Or they will check light or they will check faucet and make sure that the faucet is not leaking because if its leaking then there might be a flood in the house and its all going to be their fault because they did not take responsibility and did not check enough. And then there are people who order, you know, and they have to have everything clean and neat. And, you know, they will reorder and reorder until it feels right. And there are people who are hoarding, so all of us hoard a little bit but people who just could not throw anything. And some of them even rent another apartment for overflow because their apartment is already full with junk and then they need to, you know, hoard. So those are the major type of obsessive compulsives and some people have two of those manifestations. Some people have 3, some people have everything and some people have only one.
6. What can you tell us about your research with people who have post-traumatic stress disorder?
>> And so, then we go to posttraumatic stress disorder and those are people that have been traumatized. And most people after the trauma they have symptoms like nightmares, like flashbacks, into [inaudible] about the traumatic event, they avoid situations that reminds them of the trauma, they feel numb. So, they feel detached from other people, unable to show love to other people, feeling alienated and indifferent from other people. And also, they have sleep disturbances, difficulty concentrating, hyperarousal in general, and they feel that the world is entirely dangers. And that, it happen to people immediately after the trauma many times. But some people, a minority of people, do not recover and they continue to have these symptoms, and they continue to feel that they incompetent to deal with stress and that the world is a dangerous place. And together being in a dangerous place and being incompetent, you know, it's very dangerous. So even say need to take care of them, [inaudible]. And the--and this, they feel hyperaroused because, you know, in a dangerous world you supposed to be a little [inaudible], you know, all the time.
7. What is social phobia?
>> Then we have social phobias. And those are people that feeling very anxious with other people. They feel inadequate, they feel that they are stupid or they feel that other people would think they are stupid, they feel that other people would think that they are boring, and then they avoid social situations. So there are people who are more like general social phobia. Well, you know, they're afraid of so many things that has to do with people. And that people that have specific social phobia like they'll okay with people being with people but they are terrified of giving a speech for example. Or they feel that embarrassed when they eat because maybe their hands will shake and they would spill whatever they eat. But those are specific when in another situation they are feeling very fine. And then I think the last one is generalized anxiety disorder which is kind of tendency of people to worry a lot, to exaggerate into worry. But they worry some stage maybe normal worries like being worry that once a child is going to be dressed warm enough in the winter once they go out, or eat, they like food, or not being sick, you know, making sure that--or if they are sick, you know, call the doctor, but GAD people are exaggerating and then they worry about every little thing.
8. Can you talk about some common treatments for anxiety disorders?
>> The treatment for anxiety disorder, especially, you know, except maybe from GAD, from general anxiety disorder, are based on the same premises. On exposal therapy, which is really confounding people with situations or object that are known to [inaudible], that have low probability of generated danger threat, and confounding them again and again, making sure that the, the situation will be save and then changing people cognations and, and perceptions about the situation. So our dog phobia, for example. If you confound a dog phobic with several kinds of dog, you know, several times, and his findings [inaudible] dogs are sweet and kind and, and, you know, very friendly, then he's going to lose the fear of, of dogs because what he is expected that will happen, you know, the disasters, you know, being, being a, a, bitten by the dog didn't happen. Right. On the other hand, if you do exposure and to a dog, and the dog bite the person, then it's not a good treatment because the, then the person will, will say, alright, I always knew that dogs are danger within now I can prove for it [inaudible]. So you do exposure with a, with most, you know, with, with specific phobic. With panic disorder, you put them in situation where they, either they, they're afraid they could panic attack. Even if they do get panic attack, they are finding out that they don't need to run away from the situation. The panic will go down, and nothing bad will happen, OK. So the idea even OCD, you know, you treat them, you make them sit on the floor. You don't make them, but you work with them, and, you know, they agree to sit on the floor even though they think that they're going to get sick from germs on the floor. And then they find out, you know, they, they don't get sick. So, you know, they, they're not, they, they, they're not afraid anymore from, you know, [inaudible], or they don't need to wash their hands because when they sit on the floor, you don't, you know the treatment is sit on the floor but don't wash after it. So if they don't wash, and they still sick that they really don't really have to protect themselves because the situation they're afraid of really, you know, not dangerous.
9. Do you have set programs based on each of these anxiety disorders, or are the treatment programs tailored toward the individual?
>> Now, the way we're doing exposure therapy is a little different from, you know, one anxiety disorder to another. And if we're doing--if we're not taking into consideration what's special about the disorder and we're not tailoring the treatment to the disorder, we are going to get some good results but not optimal results. So, it depends on the treatment, of course it depends some on how good the therapist is, you know, what expertise. But less so in CBT, less so than maybe in other kind of treatment we don't find that the therapist effect is so great on in cognitive behavior therapy techniques. And another kind of therapy is cognitive therapy. In there you kind of talk to the patient and you identify what are the cognitions, the negative cognitions that are underlying their fears like, you know, people think I'm stupid, or I want, you know, if I give a speech I will black out and I would not--I would forget what I need to speak about.
10. What type of anxiety disorder is the most difficult to treat or disconfirm?
>> So, you know, with--in social phobia, there is a special problem because it's not so easy to disconfirm what these patients are afraid it will happen. But even if they are talking to people and nobody tells them that they are stupid or boring they may still think that the other person thinks that they are boring or stupid, but they are just polite enough not to tell them. So, it's not that easy to disconfirm and therefore you need, you know, different techniques. We, using video tapes to, you know, when they are actually talking to a confederate to somebody else. And then we show them the tape and in a way you were afraid that you are going to red and, you know, and then you are afraid that you look really terribly anxious, you know, how--what are you think you're looking. So you really need to give them more evidence, whereas, you know, the panic disorder patient you sent them to the supermarket, afraid of getting a heart attack and they don't get a heart attack, so that's easy to disconfirm.
11. What kind of therapy do you use for treating PTSD? Does the nature of the treatment depend on the time that has elapsed since the event?
>>The treatment for PTSD does not differ according to the type of a disaster or the type of trauma. It differs from let's say treatment of social phobia in someone because we are using a lot of imaginary exposure or revisiting in imagination the traumatic memories. And you know we don't do it you know in other disorders because in other disorders there's no traumatic memory that you are going to revisit. So a lot of the treatment is really focused on asking the patient to close their eyes and reliving or revisiting the traumatic memory and recount them aloud. And when they do it, several things happen. First of all, they organize the story because in PTSD patients, the memory is very fragmented and it's not kind of organized because they are people who are trying to avoid thinking about the trauma and so when the thought of trauma comes in, they push it away. And so they really don't have a kind of a story with a beginning, a middle, and an end. And they also if...you know they may not even remember what happened in the traumatic...during the trauma and they may have...they may have memories that were not there or may have forgotten that were there and so it's important too for them to revisit the memory and see what really happened there as much as they can remember. So it collects there in a negative...a negative cognition; negative perceptions about what happened. For example, one of our rape victims, that when she imagined the traumatic memory...she was raped by four men. And 20 years before she came for treatment and she...all these years she felt very ashamed that she never told them...she never fought them; she never told them to stop and it's all her fault. And when she was actually recounting the memory and remembering what happened, after several...two sessions, or three sessions, she came out with the idea; when I hear myself saying, "Why didn't I stop them," and "Why didn't I fight," and I realize today I didn't fight because I was scared. There were four and one of them had a gun. So now you know the shame and guilt are you know kind of dissipating because she allowed herself to go back and actually reexperience; revisiting and remembering what exactly the situation was. So that's really an important component of treatment that does not exist in other treatment because of the nature of PTSD.
12. What types of therapies do you use in training other anxiety disorders? Is any common element often used, regardless of the condition?
>> What is common to all the treatment of anxiety disorder is that we're doing exposure in vivo, what is called. So what I like that the--the example that I gave about the dog phobic, you know, you prevented them with dog is call exposure in reality. And that pretty common to all the anxiety disorders. So if you're afraid of elevators that the treatment is to get you into elevators. And go there, you know, again and again until you realize that [inaudible] happen in elevator. If you are claustrophobic, you know, you're put in small rooms. And of course, you know, the patient has to accept it, it's not your put, you know, you agree that for your own sake, for your own good you would do those exposures in order to kinda get better later. So the in vivo exposure is common really to all anxiety disorder. But other component may differ in among the anxiety disorder.
13. What research findings have surprised you most?
>> I think that when I started to work with people with PTSD, I do realize that how chaotic the life was. They really are--they can't focus, they don't remember and the life really is a lot more chaotic than life of other people with anxiety disorder. But that was kind from the surprise about life and about how dysfunctional they are even compared to people with obsessive compulsive who are also very dysfunctional. What surprise me, you know, positively is that they are getting better in amazingly in 8 session. They can get really, really much better and many of them just have no symptom. They lose their symptoms. Well, in OCD patients it takes longer, and rarely in OCD patients looses the symptoms totally. They get better, the symptoms get much reduced. But they still have residual symptoms. So, I thought that I was surprised that, you know, how easy it is to treat people with PTSD"(Foa, 2013).