Case Study
Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few years later, he invested most of his money; with the rest, he bought a small almod farm in northern California. With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing out, it really didn’t make much difference. If he never made a dime, he felt he got “full value from keeping busy and fit.”
When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed.
As his mood blackened, Brian’s body functioning seemed to deteriorate. Although he was constantly fatigued, often falling into bed by 9 P.M., he would invariably awaken at 2 or 4 A.M. Then obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect of “another damn day to get through” seemed overwhelming. In the evenings he usually felt somewhat better, though he’d sit around working out sums on a magazine cover to see how much money they’d have if he “couldn’t work the farm” and they had to live on their savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before.
“Brian just seemed to lose interest,” his wife, Rachel, reported the day he was admitted to the hospital. “He doesn’t enjoy anthing anymore. He spends all his time sitting arounda nad worrying about being in debt. We owe a few hundred dollars on one credit card, but we pay it off every month!”
During the previous week or two, Brian had begun to ruminate about his health. “At first it was his blood pressure,” Rachel said. “He’d ask me to take it several times a day. I still work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop. He’d get up, feel his pulse, pace around the room, like down, put his feet above his head, do everything he could to ‘keep it going.’ That’s when I decided to bring him here.”
“We’ll have to sell the farm.” That was the first thing Brian said to the mental health clinician when they met. Brian was casually dressed and rather rumpled. He had prominent worry lines on his forhead, and he kept feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the bed where he was sitting and pace over to the window. His speech was slow but coherent. He talked mostly about his feelings of being poverty-sricken and his fears that the farm would have to go on the block. He denied having hallucinations, but admitted to feeling tired and “all washed up-not good for anything anymore.” He was fully oriented, had a full fund of information, and scored a perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts about death. Somewhat reluctantly, he agreed that he might need treatment.
Rachel pointed out that with his generous disability policy, his investments, and his pensions from his former company, they had more money coming in than when he was healthy.
“But still we have to sell the farm,” Brian replied
Diagnosis
F32.2 (296.23) Major Depressive Disorder, Severe with Melancholic Features
F41.9 (300.00) Unspecified Anxiety Disorder
Rationale
In order to meet Major Depressive Disorder 5 out of 9 criteria have to be met during the same two week period and present changes in previous function. Brian reports symptoms of depressed mood and loss of interest in previous enjoyable activities. Client reports issues with his mood and loss of interest in his normal activities. His wife also reports his loss of interest. He reports diminished health, and his belt being two notches smaller than normal. Client’s wife has reported signs of psychomotor agitation, that he gets up and paces around the room, consistently checking pulse, and siting around worrying. Client reports constant fatigue. States that he “all washed up-not good for anything anymore”, signs of worthlessness. Client denies thoughts of death. These symptoms are causing distress with his work and in his home. Client does not report any recent losses. He denies hallucinations and there is no evidence of manic episodes. It is unclear that client has a history of depression therefore unable to determine whether single episode or recurrent episode.
Brian also reports signs of melancholic features by his depression being worse in the mornings and in the evenings feeling somewhat better usually. He reports waking up early in the morning and as listed above shows symptoms of psychomotor agitation, weight loss, and excessive or inappropriate guilt. Brian meets criteria for sever major depressive disorder due to meeting more than five symptoms with motor agitation.
Brian also reports symptoms of Unspecified Anxiety Disorder. He reports symptoms of obsessively worrying at night to the point where he cannot fall asleep. He is consistently worrying about health and financial responsibilities even though there is no evidence of imminent threat. Client reports signs and symptoms of anxiety however does not meet three out of six symptoms for generalized anxiety disorder, therefore diagnosed with unspecified anxiety disorder.
Possible Treatment
Possible treatments for major depressive disorder and anxiety disorders are the use of anti-depressants such as SSRIs and SNRIs (selective serotonin reuptake inhibitors and serotonin-neropinephrine reuptake inhibitors). According to a study completed by Dold et al., there was a correlation between augmentation/combination treatment for major depressive disorder and resistance to treatment. This suggest that medication management can be difficult when treating those who suffer from this disorder.
By also using individual therapy Mr. Murphy can gain perspective and knowledge to help manage his symptoms. Person Centered Counseling can help the client to self-actualize and become more aware of his own potential. This will help to determine if there are any personal constructs or facades that he is unaware that may be causing any feelings of inadequacies. By using the therapeutic relationship the counselor will build rapport through empathy, genuineness, compassion, and open communication. This is helpful because the therapeutic relationship is the core to developing change within the client. The counselor can do this by actively listening, summarizing, and clarifying what the client is saying. The counselor can also help the client by reflecting any feelings that were expressed during the session. This can be helpful because sometimes the client may not understand what emotion they have associated with a specific situation. The counselor can also use processing questions to help the client be aware of what he may have been feeling during a specific situation or event. By using all of these techniques the counselor can help the client learn to be in the here and now instead of worrying about any unforeseen circumstance that may arise with his farm or his health.
Case Conceptualization
Mr. Murphy has present external concerns for his financial situation and his health. He reports feeling depressed and having loss of interest in previously enjoyable activities. He stated that he is obsessively worrying which interrupts his sleep. His wife also reports his loss of interest and his excessive worrying. He describes weight loss and loss of appetite.
His symptoms are change in appetite. He has trouble sleeping, states mornings are worse and that he feels better in the evening. He has psychomotor agitation during the first initial meeting with slowed speech. He is obsessively checking his blood pressure and worrying about his health. He struggles with feelings of worthlessness. Mr. Murphy was unable to sit still during interview. He denies hallucinations and any suicide ideation.
He has no reported medications or medical treatment. No reported history of mental health issues.
Mr. Murphy’s displays many strengths. He is a hard worker. He is smart with his money. He has strong self-discipline due to being financially stable enough to own his own farm. Before now he had compassion for the work that he was doing. His main resource is his wife.
Mr. Murphy has not yet reached any stage of self actualization. He does not yet experience things in the here and now, trust in himself, feel any sense of control, identified any facades, or being open to his experience. He has expressed some facades that he “has to sell his farm,” however he has not yet identified this on his own.
DO A CLIENT MAP
Diagnosis:
F32.2 (296.23) Major Depressive Disorder, Severe with Melancholic Features
F41.9 (300.00) Unspecified Anxiety Disorder
Objectives of treatment
• Build coping skills for depressed mood
• Build coping skills for anxiety
• Build more outlets
• Cognitive reframing to decrease cognitive distortions
Assessments
• Hamilton Rating Scale
• Structured Clinical Interview for DSM
• Beck Depression Inventory
Clinician Characteristics
• Supportive
• Focused on here and now
• Sincere
• Compassionate
• Understanding
Location of Treatment- In office
Interventions- psychotherapy, Person Centered Therapy
Emphasis- Weekly, focusing on coping mechanisms and cognitive distortions
Numbers- One person, but monthly family
Timing- 1 hour
Medications Needed- Needs to be assessed by psychiatrist
Adjunct Services- Family Therapy
Prognosis
• Increase strengths
• Decrease depressive thoughts
• Decrease obsessive behaviors
Formal Treatment Plan
1. Long Term Goal: Mr. Murphy will decrease experience of overwhelming low mood and sense of worthlessness to reduce depression.
a. Short term: Mr. Murphy will identify 7 outlets that he can use to cope with his low moods and loss of interest.
i. Use unconditional positive regard Genuineness, and Empathy
ii. Help the client identify, won, and accept emotions.
iii. Help client develop a competent sense of self.
2. Long Term Goal: Mr. Murphy will increase his ability to recognize authentic self without facades to reduce obsessive thoughts about financial situation.
a. Short term: Mr. Murphy will recognize and identify 10 personal strengths
i. Process questions
ii. immediacy
Assess through
• Client report
• Therapist observation
o Verbal and nonverbal responses
• Burn’s Depression Inventory
• Burn’s Anxiety Inventory