Clinical case presentation of Susan Marx's depression following workplace termination

Susan Marx is a 31-year-old, right-handed, Caucasian woman who has completed 12 years of education. She was referred for complaints of depressed mood for the past month. When asked why she referred herself she responded, "I am very depressed and cannot motivate myself to do anything." She also reports experiencing feelings of extreme sadness, hopelessness, lack of appetite, difficulty sleeping at night, decreased energy, some suicidal thoughts, and feeling as if everything she does is of no consequence.

Presenting Problem

Marx reported that her depression began following being terminated from her position as a secretary for an attorney. She reported that she had a "romantic" affair with her employer, who decided to end the relationship and then terminated her. Since then she is quite depressed and does not have the energy to clean her apartment which is becoming quite messy. She sits on the couch and watches television all day long. She only gets up to use the bath room or leaves to go to the store and has not bathed, although the morning before the intake was the first time she had showered in two weeks. She lies on the couch most of the day and cries frequently. She reported sleeping on and off a few minutes at a time during the evening and does not have the energy to look for another job or talk to anyone. At the time she had made "a few" calls to her former employer, but her will not return her calls.

Childhood and Family History

Ms. Marx is an only child. She never knew her father and she was raised by her mother and two of her mother's brothers, Tom and Ken. When Tom married he moved out and Ms. Marx was raised by her Uncle Ken, who never married but died of alcohol-related cirrhosis of the liver several years ago. Her mother worked as a waitress and worked long hours in the afternoon and evening. Her mother also had "many boyfriends" but Ms. Marx recalls that most of them were not around for a very long time. Her mother died of breast cancer three years ago at the age of 50. Ms. Marx left the home when she was nearly 18 years-old after graduating from high school and getting a job as a teller in a local bank. She rented an apartment with several high school friends who were attending a local college, but this did not work out as she usually had a boyfriend over after work and her friends wanted to study. Sometimes her boyfriends and she would fight and this would cause tension with her roommates. She got her own apartment when she was 19 years-old and has lived alone since.

Ms. Marx' developmental history is normal the obtainment of age-related developmental milestones. Her history is also remarkable for self-reported sexual and physical abuse at the hands on an uncle (Ken) when she was 12 years-old. She stated he physically abused her and sexually molested her when he babysat for her. These incidents occurred multiple times over a period of three years; however, she stated that no charges were ever filed and that her mother "looked the other way." She reported that she also began to have sex with other boys and men when she was 14 years-old engaging in "too many sexual relations to count." She began cutting herself on the arm when she was 15 years old to deal with the emotional pain of being rejected by men. She stated that most of her relationships with men are sexual and do not last over two weeks. She has not cut herself in several years; however, she began drinking at age 16 three to five nights a week when she is alone. She has never been married.

Educational and Vocational History

Ms. Marx is a high school graduate. She has never been held back any grades and was a "B student" in school. She did not participate in extra-curricular activities.

Ms. Marx' first job was at the age of 18 as a teller in a local bank. She reported that she had a sexual affair while she was a high school student with the branch manager who hired her. She would occasionally have sex with him but the affair "never went anywhere." She worked for the bank until two and a half years ago when she was let go after a new branch manager took over. Ms. Marx then became a secretary at a law firm but was released after a year and after having an affair with her employer. She was then hired as a secretary at the position that she was recently terminated from.

Medical/Psychiatric: SA History

Ms. Marx had a physical examination at the hospital she was admitted following a suicide attempt. She was in the hospital for three days and released. She has had no follow-up appointments but her medical history is unremarkable. She reports that she smokes a pack of cigarettes a day, takes no medications currently, and has no family physician.

Her psychiatric history is remarkable for depression, a previous suicide attempt requiring hospitalization, current but occasional suicidal ideations, reported physical and sexual abuse, unstable personal relationships, sexual promiscuity, and anger management issues. The patient has completed five previous sessions of psychotherapy for depression. She has taken an antidepressant (Zoloft) in the past for three weeks but stopped that as she felt she did not need it.

Ms. Marx began drinking alcohol regularly at age 16. She usually has three to six mixed drinks at local taverns. She occasionally meets men at these taverns and brings them home to have sex with them. She reported that she usually only sees them once or twice because when she starts having feelings for men they reject her and she has gotten "physical" with them meaning that she has struck several of them. She reported that her drinking has not interfered with her ability to work. She has not experienced withdrawal symptoms other than an occasional headache or fatigue in the morning after drinking. CAGE assessment was 1/4 as she reported trying to cut back on drinking. Ms. Marx denied currently using illicit drugs but has smoked marijuana in the past the last time being three years ago.

Family Psychiatric/Medical History

Family medical history is remarkable for breast cancer (mother) and alcoholism (maternal uncle). She is unable to comment on the family history of her father. She knows of no formal psychiatric treatment or history in her family other than her own.

Military and Legal History

Ms. Marx has not been in the military service. She had a PPO filed against her by a previous employer and there currently is a police investigation regarding vandalism of a car (her most recent employer) of which she is a suspect. There have been no formal charges filed.

Religious and Spiritual Issues

Ms. Marx describes herself as an agnostic. She has never attended church except for attending the weddings of friends.

Cultural Diversity Issues

Ms. Marx identifies herself as Caucasian not of Hispanic origin.

Mental Status

Ms. Marx is alert, oriented x 3. She was dressed casually but appropriate for the intake. She was mildly distractible, but otherwise attention and memory were intact. No evidence of hallucinations or delusions was observed during the intake. Affect was flat but she was pleasant and cooperative.

Diagnostic Impressions

DSM-IV-TR Multiaxial Assessment:

Axis I: 296.30 Major Depressive Episode/Recurrent

305.00 Rule out Alcohol Abuse Disorder

Axis II: 301.83 Borderline Personality Disorder

Axis III: Tobacco use.

Axis IV: History of suicide attempt; current suicidal thoughts; currently unemployed; problems with isolation; unstable sexual and interpersonal relationships; anger management issues; history of physical and sexual abuse; potential legal issues.

Axis V: GAF = 20 at intake (History of suicide attempt and current suicidal ideation at intake)

Prognosis at Intake

The patient is given a score of 20 on the GAF due to her history of suicide attempt, self-injurious behavior, current suicidal ideations, self-reported failure to maintain personal hygiene, and termination of previous psychotherapy which suggests she may not be agreeable to help or to engaging in therapy. Her prognosis is guarded at best and while she denies a current plan to hurt herself, but required close monitoring. Her intake presentation did not allow for involuntary commitment and she was not amenable to voluntary commitment. She was followed by a psychiatrist in conjunction with therapy and completed a suicide contract. Long-term treatment was deemed necessary given the nature of the characterological dysfunction displayed by this patient.

Conceptualization and Treatment Formation

Based on Ms. Marx's presentation it appears that her psychological functioning has been compromised by the presence of long-standing characterological dysfunction. However, there are also other numerous sensitive psychosocial factors to consider such as her early relationships with her mother and uncles, history of sexual abuse, and her sexual promiscuity which operates on several levels in people with BPD. It is important to understand these aspects of life from a functional level and not to explain them in terms of the diagnostic category ("She's borderline so that's why she has all these relationships and is unstable"). Moreover, she does not see herself as the problem and views her depression as a reactive response to being treated unfairly ("dumped") by men. Her feelings on loneliness, hopelessness, etc. may reflect a core theme of feeling lonely or abandoned by others and her need to define herself in terms of relationships with men. In part we can understand this by way her early attachments.

People are dependent on social support in order to develop a sense of meaning, feelings of safety, and a sense of control in their lives. The presence of caregivers can help children in modulating their physiological arousal in times of a threat, but when the same people who are supposed to be the sources of safety concurrently become sources of extreme danger or trauma, children or adolescents will move in a direction to restore their sense of safety. Instead of turning against their caregivers they tend blame themselves. Later they can become fearfully and keenly attached to caregivers and significant others, but at the same time can be anxiously obedient. This situation can lead to a pattern of avoidance that competes with the desire for closeness. Such internal conflicts can lead to fears of abandonment but at the same time the need or closeness. Significant persons in such people's lives can be either idolized or demonized and these people frequently tend to engage in personal relationships that are often unstable and unsatisfying. It is not a coincidence that she refers to men that reject her as pigs like her uncle Ken who abused her.

Reliving dissociated sexual trauma is often the motivation for engaging in and seeking the types of relationships as well as leading to chronic the fears of abandonment, loneliness, and the suicidal ideation that Ms. Marx has described (Chu, 1991; Van der Kolk, 1989). Recently this notion has been applied in cases of PTSD (Nishith, Mechanic, & Resick, 2000). From a cognitive standpoint this may be associated with dysfunctional schema regarding what constitutes healthy relationships held by the victim. While Ms. Marx does not appear to currently meet diagnostic criteria for PTSD the notion of revisiting dissociated trauma and a faulty relationship schema can help us understand the past self-mutilation and current suspected alcohol abuse disorder. This is a very sensitive case that will require long-term remediation and will be handled in conjunction with a psychiatrist. Ms. Marx believes that she needs help for depression because of being fired and being "dumped" by her lover. In true personality disorder form she does not realize that: 1) her tendency to seek relationships that are doomed to fail is the source of her discomfort (she is the problem not other people); 2) she may be reliving trauma from the past; and 3) that her depression is not something than can be treated without addressing deeper personal issues. These deeper issues include the aspects of her characterological dysfunction. Ms. Marx demonstrates significant feelings of abandonment and rather immature defense mechanisms such as splitting and most likely projection and denial.

We must also not think of Ms. Marx as simply a victim, but her pathology also is also one of manipulation. Often individuals with personality disorders maintain pathogenic belief systems are complicated and characterized by conflict and are seemingly inconsistent (McWilliams, 1999). In the case of the borderline patient it is often assumed that the core underlying belief system is one of being abandoned or unsupported. While this is often a central core belief of borderline patients, an often overlooked and competing belief is one of manipulation or "I can manipulate people into being there for me." These beliefs of being able to manipulate others are often, like the core fear of abandonment, not explicit beliefs, like " The world is round" but more implicit beliefs that a manifest in intrapersonal behavior. Thus, the borderline patient is often known for their tendency to play people against one another in order to get them to take sides. The motivation for this is always to get someone, usually an easy target, to side with them and buy into their pathology. In Ms. Marx case she appears to try to get men attached to her by using sex and this can be a powerful tool in keeping them close to her. These core conflicting beliefs, that one can manipulate others into siding with them and at the same time believing that others are unconcerned about them, must both be addressed in order for treatment to be successful.

Ms. Marx demonstrates the tendency of many borderline patients to experience a dilemma based on the aforementioned core beliefs, when they get close to a person they will often become very anxious and panic because of fears of control or being engulfed by another; however, when they feel separated from others they experience anxiety and panic because of fears of abandonment. This often leads to a series of brief and intense relationships wherein Ms. Marx does not feel comfortable being close or apart.

Another issue with borderline patients is often with identity integration; borderline patients are