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CASE WRITEUP EXAMPLE
December 2, 1998
I. CASE HISTORY [actual word count: 774] (suggested # of words: 750)
A. Identifying Information: Ann is a 44-year-old, twice-divorced, Caucasian woman who has no children, lives alone, and has been working full-time as a Spanish teacher for the past 22 years.
B. Chief Complaint: Ann sought treatment due to an escalation in her depression which started in October, 1996. She reported that she was also binge eating and overusing and abusing laxatives at least once a week, though she was much more concerned by the depression than the eating/laxative problem.
C. History of Present Illness : In October, 1996, Ann divorced her second husband and began to develop depressive symptoms (sadness, crying, social withdrawal, severe self-criticism). The depression worsened until it reached the severe level in March, 1997. At intake (May, 1997), her symptoms included the following: emotional symptoms: sadness, anxiety, lack of interest in almost all activities cognitive symptoms: difficulty concentrating, believing she was worthless and unloveable behavioral symptoms: crying, social isolation
physiological symptoms: difficulty falling asleep, tiredness She developed subclinical symptoms of bulimia nervosa in April, 1997. At intake, she reported that she binged, felt out of control of this behavior, and overused laxatives about once a week; she was (and is) intermittently preoccupied with a misperception that she is fat and is highly self-critical. The major stressors in Ann’s life are social ones. Since her divorce she has withdrawn from friends, family, and co-workers. She has dated several times since her divorce but each date has been a “one-night stand,” which leaves her feeling rejected and defective. She used to derive significant satisfaction from relationships but has isolated herself and now feels sad, lonely, and rejected by others. While she finds it more difficult to do her job, work does not appear to be a significant stressor. Ann restarted Prozac about 2 weeks ago (prescribed by her family physician) but thus far sees no change in her depressive symptoms.
D. Psychiatric History: Ann’s first episode of major depression occurred in 1977 when her first husband divorced her. She was hospitalized for three weeks and was given Elavil. She discontinued the medication (against medical advice) at discharge but initiated psychological treatment (cognitive therapy) for the first time. Her depression remitted after four months of this outpatient psychotherapy, though she remained in therapy on a biweekly basis for another year, working on Axis II issues.
Ann remarried in 1989. Her second husband reportedly spent a lot of time with young men and Ann suspects he was bisexual. He ceased having any sexual relations with her about three years after their marriage. Though they tried marriage counseling briefly, her husband was unwilling to work on modifying the situation and they divorced in October of 1996.
F. Medical History: Ann did not have any medical problems which influenced her psychological functioning or the treatment process.
G. Mental Status Check: Patient is fully oriented, with depressed mood.
H. DSM IV Diagnoses: Axis I: Major Depressive Episode, Recurrent, Severe Rule out Bulimia Nervosa Axis II: Avoidant Personality Disorder Axis III: None Axis IV: Divorce, Multiple Relationship Failures Axis V: GAF Current—68. Best in Past Year—80.
**II. CASE FORMULATION: [actual word count: 403] (suggested # of words:
A. Precipitants:** Ann’s second divorce probably precipitated a recurrence of depression. Although it was she who initiated the divorce, she nevertheless felt
rejected, believing that if she were more loveable, her husband would have fought to save the relationship. Feeling not only unloved by and unloveable to her husband but also unloveable in general, she began to isolate herself. She was no longer getting much positive input from her friends, family, and co-workers because of her lack of contact with them—but, like the divorce, she perceived this self-initiated reduction of contact as their rejecting her, instead of her withdrawing from them. She became increasingly sad and lonely and other depressive symptoms began to develop.
B. Cross-Sectional View of Current Cognitions and Behaviors: A typical current problematic situation is that Ann has just had sex on the first date with a man. Lying in bed with him she has the automatic thoughts, “I’m so ugly, what does he see in me, he’ll never call, I might as well get up and leave now.” Emotionally she feels sad and her behavior is to leave abruptly (probably appearing unfriendly, at best, to her date). A second typical situation is that she’s reflecting on how a man has not called her back after a date. Her automatic thoughts are, “I’m too fat. No one wants me.” She then feels sad, binges, and takes laxatives. A third situation is attending a family dinner where she perceives her father as being critical about her and her mother as lacking affection. She thinks, “No one cares about me; there’s something wrong with me, I’m unimportant.” She feels sad and becomes monosyllabic, speaking only when spoken to.
will dislike me.” To operationalize her assumptions, she has developed the following behavioral compensatory strategies: submission, avoidance, and acquiescence. **III. TREATMENT PLAN: [actual word count: 195] (suggested # of words:
A. Problem List:**
- “Ann bashing”--hating self (ugly and unlovable)
- Depression; especially loneliness, sadness, crying
- Avoidance and isolation: wanting to be loved but fearing rejection
- Anxiety: fearing serious consequence of unrelenting depression
- Binge eating and abuse of laxatives
- Resentment towards parents for lack of affection and love B. Treatment Goals:
- Reduce dysfunctional behaviors: Verbally berating herself Bingeing and purging Isolation
- Reduce negative distorted thinking.
- Increase self worth, self-value and self-image. (Modify unloveability and not-good-enough (defective) schemas).
- Find healthier ways to have fun.
- Gain confidence to go out alone and take risks in pursuing intimacy again.
- Build assertiveness skills and reduce subjugation.
C. Plan for Treatment: The treatment plan was to reduce Ann’s depression through helping her respond to her automatic thoughts (especially those connected with unloveability) and activity scheduling (especially to increase socializing). We also worked on alternative behaviors to bingeing when she was upset. Next, we tested her assumptions about being rejected if she displeased people and then worked on assertiveness skills. We are currently working at the belief level, modifying her view of herself as unloveable and defective.
IV. COURSE OF TREATMENT [actual word count: 300] (suggested # of words: 500) A. Therapeutic Relationship: Treatment was facilitated by Ann’s eagerness to please (“If I please others, they’ll like me”) but the counterpoint to this assumption (“If I disagree with people, they won’t [like me]”) did interfere slightly. Ann was too eager to please in therapy; she quickly agreed with me, sometimes without really stopping to reflect on the hypotheses or alternative perspectives I presented to her. I was able to elicit from her another belief (“If I tell someone I disagree, they’ll take it as criticism”), helped her test these beliefs with me, correct her thinking, and then she became more willing to tell me when she didn’t fully understand or agree with what I had said.
B. Interventions/Procedures:
