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PSYCHOTHERAPY IN CLINICAL PSYCHOLOGY

Assignment 3

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TRIPLE WHAMMY

A 27-year-old Hispanic graduate student presents with a chief complaint of depression. The problem began about three weeks ago and seemed related to the news that his evening job was being phased out. He reports that this was the third problem to befall him in as many months. "It started with fall quarter. I never really caught up in Statistics after missing a week with the flu, but I hadn't expected to get a "D" and have to repeat the course. Then about six weeks ago, I found out my wife was pregnant. I tried to act happy for her but I wasn't. We already have three and are just barely making it financially. I was holding up pretty good until I heard about the job. I started crying right in front of the boss. I've just been hopeless ever since. I only go to school about half of the time--I don't like to be around anybody." Further examination reveals no past or family history of depression and no apparent thought or personality disorder. He denies anorexia, low energy, difficulty concentrating, suicide thoughts, or excessive guilt.

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FAILED BUSINESSWOMAN

Ms. D, a 55-year-old business executive, has previously had several relatively brief (up to 1 month) episodes of depression. These episodes each followed a psychosocial stressor but remitted after cognitively oriented psychotherapy without any need for medication or hospitalisation. The current depression also began in the context of a possible business reversal, but, unlike the previous depressions, it did not improve as business did. Instead, the depression gradually deepened and became more severe and pervasive. Within 6 weeks, the patient became unable to work. She spent her day lying in bed facing a blank wall.

Upon evaluation, the patient reports that, although she is usually able to fall asleep easily, she often awakens in the early morning hours and paces. She says that, although she does not feel very good during the day, the worst time for her is shortly before sunrise. Ms. D appears dehydrated and reports that she has lost between 15 and 20 pounds. Her face shows no emotion, and she states convincingly that she finds nothing pleasurable and has even lost her sense of humour, which has always been a mainstay for her. She says that even when her grandchildren arrived on a visit she was able to summon up only a temporary smile. She quickly returned to feeling blank and empty and didn’t have the energy to play with the children as she always had in the past. The patient describes feeling overwhelming guilt but does not have bizarre delusional beliefs. She says that she feels like a failure at work and as a wife and grandmother and is constantly apologising to everyone for not getting better. She feels that she is letting people down and that the business will collapse without her.

Ms. D describes her overall mood as feeling dead inside. Although she has experienced depression before, she says it was never anything like this, not even when she lost her mother to whom she was very close. She says that it is very difficult to describe her feelings and that she has an emotional ache that is “horrid beyond words.”

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BLACK BILE

Mrs. J, a 37-year-old, white, married, housewife and mother of three, nervously presents to your office after referral by her family doctor. His thorough work-up had disclosed no medical cause for her complaint of fatigue. She notes to you that she "just doesn't enjoy anything anymore."

The onset of the problem is vague but appears to have been about six years ago. About that time the family was having some financial stress and she and her husband were having marriage problems. "But that all ended years ago. I don't understand it. Now I have everything, but I just don't enjoy it." Occasionally she will feel a bit better for a few days but that is unpredictable and never lasts. Her past hobbies of oil painting and needlework have been untouched for over five years: "I'm not interested in it anymore. I just don't care. I'm always tired. Even when something good happens, I still feel dumpy."

She is sombre and tearful. Her speech is mildly underproductive, lacks inflection, and is interrupted twice by quiet crying. No psychotic features or significant psychomotor retardation are present, and she denies insomnia, anorexia, difficulty concentrating, suicide thoughts, obsessions, or drug/alcohol abuse.

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DISABLED VET

The patient is a 32-year-old man who admits himself to a mental hospital in 1982, after attempting suicide by taking sleeping pills. He says that nothing in particular prompted this attempt, but that he has been more-or-less depressed, with some fluctuations, ever since he returned from Vietnam ten years earlier.

He describes a reasonably normal childhood and adolescence. “I never in my life felt like this before I got to Nam.” He had friends throughout high school, always got at least average grades, and never was in trouble with the law or other authorities. He has had many girl friends, but has never married. After high school, he went to technical school, was trained as an electrician, and was working in this occupation when he was drafted for military service in Vietnam. He loathed the violence there, but on one occasion, evidently swept away by the group spirit, he killed a civilian “for the fun of it.” This seems to him totally out of keeping with his character, and he is troubled with guilt. He was honourably discharged from the army, and has never worked since, except for three weeks when an uncle hired him. He has been living on various forms of government assistance.

Over the last five years, the patient began to drink heavily and to use whatever drugs he could get his hands on, abusing most of them. He has blackouts, frequent arrests for public intoxication, and injuries from barroom brawls. He has made four suicide attempts in the last seven years. For the month before his latest suicide attempt, he had been living in an alcohol-treatment residence, the longest dry period he can remember. All previous attempts at cutting down on his drinking having failed.

There is no evidence of delusions, and no history of hallucinations except during several bouts of Alcohol Withdrawal Delirium in the past. He has trouble falling asleep or staying asleep without medication. He is not psychomotorically slow. He complains of “absentmindedness.” Testing revealed impaired immediate and long-term memory, apraxias, agnosias, and constructional difficulties; his IQ measured 66.

The patient has not responded to any form of antidepressant medication. He is sorry that his suicide attempt did not succeed, and he says that if things aren’t going to get any better, he definitely wants to die.

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A WOMAN WITH DEAD PARENTS

During her initial evaluation, Ms. C, a 38-year-old mother of three, has a look of dread on her face. Her hands pick restlessly at the enlarging scores on her arms. For several weeks before this consultation, she has become increasingly withdrawn, and during this interview responds only with grunts and nods. Ms. C’s husband, who accompanied her for this visit, is extremely alarmed by his wife’s symptoms. He reports that she says she is “hearing voices” of her dead parents. Her mother, who has been dead for 5 years, is insisting that she kill herself so that they can be reunited. Her father is calling her a “freaking, dumb whore” and threatening to kill her if she doesn’t kill herself first. In addition, a medley of unrecognisable and tormenting voices are mocking the patient, voices which she told her husband she could silence only by banging her head sharply against the wall, although she usually doesn’t have the energy to do this. Ms. C also believes that she has cancer and that her children are also gravely ill. She told her husband that she feels a mission to kill everyone in her family so they can all be together after death.

This episode of depression began insidiously with a feeling of increasing despair and emptiness. At night, Ms. C could not fall asleep because of the painful, recurring thought that she was a damaged and damaging creature. She blamed herself for her mother’s death and felt that she was a witch who deserved burning. After awakening early each morning, she would sit shivering on the bathroom floor so that she would not disturb her husband. She wished that she had the will and courage to kill herself and played listlessly with razor blades. Ms. C felt hopeless about herself, and she was also convinced that nuclear war would soon end all live on the planet. She was retarded in her thoughts and actions and looked like a lifeless shell of a person.

Ms. C had been hospitalised five times during the previous 9 years. One hospitalisation 6 years ago was characterized by symptoms very much like her current ones. Her other hospitalisations were necessitated by severe depression and suicidal thoughts but were not accompanied by psychotic symptoms.

Ms. C does not function very well between her major episodes, and her functioning before her first episode was also poor. There are only brief periods – days or occasionally weeks – when she finds life worth living and feels that she can approach responsibilities with reasonable energy and confidence. For the most part, she is a withdrawn and despairing person who spends many hours alone, feeling empty and sad. Because she only occasionally feels up to preparing meals or shopping, her husband employs a housekeeper to run the house and care for the children. Ms. C has only one friend, whom she sees rarely. The patient loves her children but also avoids them. Close contact with them often infuriates her, and she worries that someday she may lose control and kill them.

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NOWHERE MAN

Mr. A, a 28-year-old unmarried accountant, seeks consultation because “I feel I am going nowhere with my life.” Problems with his career and girlfriend have been escalating and are causing him increasing distress. Mr. A recently received a critical job review. Although he is reliable and his work accurate, his productivity is low, his management skills are poor, and he has conflicts with his boss over minor issues.

The patient’s fiancée recently postponed their wedding date. She said that, although she respects and loves him, she is ambivalent, because on many occasions he tends to be remote and critical and he is often uninterested in sex.

Mr. A describes himself as a pessimist who has difficulty experiencing pleasure or happiness. He says that, as far back as he can remember, he has always been aware of an undercurrent of hopelessness, feeling that his life is hard and not worth living. Mr. A grew up in a suburban community and attended public schools. His mother is a quiet person, periodically “moody,” remote, and depressed. Mr. A’s father, now deceased, was successful in business but was also overbearing, critical, and intimidating and drank to excess. Mr. A says that he respected him but never felt they were close.

Although he is usually depressed, he has never been suicidal or had prominent suicidal ideation and has not experienced significant problems with weight loss, insomnia, or psychomotor activity. For months at a time, however, Mr. A’s energy levels are diminished and his ability to concentrate impaired. He views himself negatively, feeling he has little to offer. He is always surprised when others like and respect him. When he is depressed, his sex drive is reduced and he has difficulty maintaining an erection, which frightens him.

Mr. A has periods when he withdraws from friends and social activities, but with effort he always goes to work. Some weekends, he stays in bed in a state of profound inertia. In the past, he would sometimes drink excessively but now has only an occasional glass of wine. He does not recall ever having periods of excessive energy or elation. Mr. A says that he recognizes his strong need to please others, to obtain approval, and to avoid conflicts. He feels extremely anxious when forced to deal directly with a hostile situation. He takes pride in his acknowledged perfectionistic traits: he is extremely controlled, highly conscientious, generally “uptight.”

Mr. A appears early for his appointment, is conservatively dressed, and initially appears outgoing and affable. As the interview progresses, however, he becomes tearful as he discusses his problems and acknowledges his depressed mood. There is no evidence of a thought disorder or of hallucinations or delusions. His insight is impaired by his tendency to avoid emotionally laden material. His judgment is intact, as are his orientation and recent memory. His intelligence appears to be high-average.

Please answer the following multiple choice questions for each of the cases on the answer sheet provided. Include your name and ID number for computer scoring.

Triple Whammy

1. Preliminary diagnostic impresssion:

a. Major depressive disorder

b. Dysthymia

c. Adjustment disorder with depressed mood

d. Melancholia

2. Further diagnostic considerations:

a. Anxiety disorder

b. “Double depression”

c. Antisocial personality disorder

d. None of the above

3. Psychotherapeutic considerations

a. None

b. Stress management

c. Behavior therapy

d. Psychoanalysis

4. Further therapeutic considerations

a. Benzodiazepines

b. Antidepressants

c. Birth control

d. None of the above

Failed Businesswoman

5. Preliminary diagnostic impression:

a. Major depressive disorder, non-melancholic

b. Major depressive disorder, melancholic

c. Adjustment disorder with depressed mood

d. Schizoaffective disorder

6. Which of the following is most likely to be prescribed?

a. Antidepressant medication or ECT

b. Antipsychotic medication

c. Both antidepressant and antipsychotic medication

d. None of the above

7. Immediate psychotherapeutic considerations:

a. Cognitive therapy

b. Stress management

c. Other psychotherapy

d. None of the above

8. Future psychotherapeutic considerations:

a. Cognitive therapy (“rational restructuring”) regarding delusions

b. Cognitive behavior therapy regarding depressive relapse

c. Behavior contracting regarding suicide risk

d. Paradoxical intervention (e.g. “de-reflection”)

Black Bile

9. Preliminary diagnostic impression:

a. Major depressive disorder (MDD)

b. Adjustment disorder with depressed mood

c. Dysthymia

d. None of the above

10. Further diagnostic considerations:

a. “Double depression”

b. Manic depression

c. Sexual dysfunction

d. None of the above

11. Based on features in this case, which of the following is most likely to be prescribed?

a. Antidepressant medication

b. Antipsychotic medication

c. Antianxiety medication

d. Medication other than the above

12. Psychotherapeutic considerations:

a. Psychoanalysis

b. Client-centered counseling

c. Cognitive and behavioral interventions

d. Sex therapy

Disabled Vet

13. Preliminary diagnostic impression:

a. Substance-induced mood disorder

b. Major depressive episode, with secondary Alcohol Dependence

c. Primary dysthymia with secondary Alcohol Dependence

d. Adjustment disorder and/or Post-traumatic Stress disorder

14. Further diagnostic considerations:

a. Melancholica

b. Personality disorder

c. Dementia associated with alcohol abuse

d. None of the above

15. Based on features in this case, which of the following is most likely to be prescribed?

a. Antidepressant medication

b. Antipsychotic medication

c. Antianxiety medication

d. Alcoholism treatment

16. Initial psychotherapeutic considerations:

a. Psychoanalysis

b. Client-centered counseling

c. Cognitive therapy

d. Behavior therapy

A Woman with Dead Parents

17. Preliminary diagnostic impression:

a. Major depressive disorder (MDD) with melancholic features

b. Adjustment disorder with depressed mood

c. MDD without melancholic features

d. Schizophrenia

18. Further considerations:

a. Manic-depressive disorder

b. Schizophrenia

c. Mood-congruent psychotic features

d. Delusional psychosis

19. Which of the following is most likely to be medically prescribed?

a. Antidepressant medication

b. Antimanic medication

c. Antianxiety medication

d. No biomedical treatment

20. Immediate psychotherapeutic considerations:

a. Psychoanalysis

b. Client-centered counseling

c. Cognitive-behavioral

d. None of the above

Nowhere Man

21. Preliminary diagnostic impression:

a. Major depression disorder

b. Adjustment disorder with depressed mood

c. Dysthymia

d. None of the above

22. Further diagnostic considerations:

a. Anxiety disorder (obsessive-compulsive)

b. Personality disorder (obsessive-compulsive)

c. Sexual dysfunction secondary to substance abuse

d. None of the above

23. Based on modern medical practice, which of the following is most likely to be prescribed?

a. Benzodiazepines

b. Antidepressants

c. Antipsychotics

d. Medication other than the above

24. Psychotherapeutic considerations:

a. Client-centered counseling

b. Cognitive therapy

c. Sex therapy

d. Behavior therapy

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