Case study of Tina's work attendance and employment challenges

¶ … MDD: Tina's Case Study…"

Tina's Case Study MDD

"MDD: Tina's Case Study.."

Major Depressive Disorder: Tina's Story

Tina's Story- Case Study

Tina is a 23-year-old black female. She is currently separated from her husband of five years. She is currently employed by two companies, one at which she works Monday- Thursday mornings, and the other on Wednesday -- Friday evenings, and all day Saturday and Sunday. However, she hasn't shown up for work on a consistent basis for the last four weeks, and not at all in the last two days.

Once an energetic, active, healthy female who loved to exercise at the local gym three days a week, Tina now spends most of her time in her apartment. She hasn't been to the gym in over four weeks, and her body movements that used to be quick and marked are now slow and sluggish. Even though she hasn't changed her eating habits, Tina has been losing weight.

Joe, Tina's husband, left her for another woman approximately four weeks ago. When she found out, Tina immediately locked herself in her room and cried herself to sleep. That night, she slept for about twelve hours straight, but that was the last time she had a long stretch of true sleep. Since then, Tina's sleep habits have been very erratic; sometimes she will sleep for a few hours in the day, some in the evening. She finds herself unable to sleep longer than four hours at a time; as a result, she is constantly fatigued.

When she is awake and able to think clearly, which isn't 100% of the time, Tina is fixated on where she went wrong in her marriage. She feels that if Joe left her for another woman, it must be because she must not be good enough, just like she wasn't good enough for her own father to stay at home when she was seven…he left her and her mother, so she must not have been good enough back then, either.

Tina thought that when she married Joe right out of high school, it would be so wonderful. She had such great plans for the two of them...they would both work their way through college and be successful. But it didn't work out that way, and Tina had to work two jobs just to keep food on the table and the rent paid, because Joe felt it more important to hang out with his friends all day long. If only she had worked harder, or been prettier, or sexier. That must be a lot of it, Tina thinks. She isn't pretty enough, or hard working enough, or good enough, or sexy enough, which is why Joe left her. She was always so tired from working so much, that it was all she could do to crawl in the bed to sleep, much less give Joe the sex he wanted so often.

Tina believes that because of whom she is and what she has done, no one will ever love her and she will never have a relationship again. She keeps saying over and over how worthless she feels, and that her working all the time must have contributed to the downfall of the marriage. The company kept telling her that if she did just a little more, stayed a little longer, worked a little harder, that she would be promoted, which is why she kept pushing herself as she did. Unfortunately, Tina couldn't balance the roles, and lost her husband as a result. She feels like a failure, and that she will always be a failure at life and at love.

Tina thought that she and Joe had many friends, but when Joe left, the friends stopped calling and coming to visit, leaving her alone with her sadness. Shortly after Joe left, she called a few girlfriends, but they eventually tired of her constant complaining and wanting sympathy and stopped answering her calls. As a result, Tina has no one to talk to. It would have been nice to talk to her sister, but her sister committed suicide four years ago after becoming deeply depressed over a broken relationship. Tina has thought about suicide too, but she isn't at the point to do anything about it…yet.

Major Depressive Disorder: Tina Case Study

Introduction

Major depressive disorder is a difficult disorder to identify, deal with and treat, especially when a single episode of symptoms is the only diagnostic criteria. There is a social tendency to see MDD as a singularly and normal event when its episodic symptoms are associated with real life stressors and therefore something someone will likely work through on their own if they do the right work. This social view of MDD symptoms (especially in singular) episodes often leaves people suffering from MDD with ideation about further inadequacies and social isolation as there is little social support demonstrated by people for the affect of the symptoms of MDD and other depressive disorders, which creates a vacuum for the patient and a challenge for clinicians who seek reasonable and effective treatment intervention (Hybels, Blazer, Steffens & Judith, 2006). Major life stressors can trigger major depressive disorder in a single episode and with appropriate grief work a major depressive disorder can result in resolution or in the diagnostic sense remission. So, finding a balance between action and inaction on the part of the clinician and/or the client is essential as working together to find a resolution for a disorder that can seriously impair an individual's ability to function is crucial to recovery and a return to prior normal and productive living. One of the most essential aspects of major depressive disorder is a lack of ability to feel joy, even when good things happen in one's life. This experience of lack of joy is persistent and devalues one's life, affecting everything about their desires and drives. Tina, in the case study above demonstrates symptomology of a major depressive episode and would likely be helped with diagnosis and intervention. This work will review Tina's case with regard to the diagnostic criteria for Major Depressive Disorder, offer a possible multi-axial diagnosis, discuss theories associated with her possible MDD and finally close with a discussion of possible treatment options for Tina, given her diagnosis and theoretical indices for intervention.

Tina's Possible MDD

The occurrence of MDD is in definite need of review with regard to Tina, her behaviors and feelings indicate a need for appraisal and intervention as the depression she is experiencing is affecting her ability to function both at work and at home and if it continues without treatment may further impair her functioning. Major depressive disorder as described by the multi-axial system includes the presence of a single episode of the mood disorder, Major Depressive Disorder on the Axis I table as the patient has not reported having such an episode prior to this time and the episode is not better explained by any other psychotic disorder nor does she exhibit signs of having mixed episodes including mania. It is also clear that Tina's Major Depressive Disorder episode is linked with the melancholic features as a modifier. The criteria for this modifier, experienced by Tina include loss of pleasure in all or most activities coupled with several of the secondary qualifiers, including distinct quality of depressed mood, as this is a novel reported experience for Tina, early awakening at least two hours before regular time, marked psychomotor retardation (reported sluggishness and inability to move rapidly), significant weight loss, and excessive or inappropriate guilt. The likely diagnosis for Tina would be Major Depressive Disorder Single Episode with Melancholic Features. Axis II does not apply to Tina as she does not report any marked personality disorder. Axis III is also non-applicable as she does not seem to be experiencing any underlying medical or neurological condition that could affect her outward presentation of diagnosis. Axis IV is appropriate to explore as Tina is and has experienced several life changing psychological stressors over her lifetime and is presently experiencing an abandonment. First she still has demonstrative feelings of loss with regard to her father's abandonment of her and her mother when she was a child. Her only sister committed suicide as a result of a depression brought on by a breakup, just a few years prior to Tina's acute period of depressed symptoms and finally she is experiencing the acute feelings of loss and grief associated with a very recent divorce, which is likely at the root of this particular episode of MDD. On an Axis V code Tina would likely code between 41-50 as she is experiencing serious impairment in social and occupational functioning that has gotten worse over the last few weeks, where she was previously able to attend work spottily and now is not attending work at all and she previously was able to reach out to friends and loved ones but is currently nearly completely isolated. (APA, DSM-IV-TR, 2000, pp. 348-350)

Other diagnostic tests may need to be conducted, beyond the fact finding case study that is repeated above. One possible quantitative assessment tool the: The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; Endicott, Harrison, & Blumenthal, 1993) may be a needed and important tool for the development of a clear picture of the scale of Tina's affect with regard to her symptoms. As quality of life and related melancholic features are clearly at the core of her symptomology, etiologically and globally the need for scaling, coding and address is significant in this case. The Q-LES-Q is described as:

…a self-report measure of the degree of enjoyment and satisfaction an individual experiences in various areas of daily living…[a] 15-item overall satisfaction and enjoyment summary subscale of the Q-LES-Q, that includes items covering domains such as physical health, mood, work, household activities, relationships, daily functioning, sexual issues, economic status, living/housing situation, and overall life satisfaction. Scores on this scale are reported as percentages, with higher scores indicating increased satisfaction. The Q-LES-Q has been shown to have sound psychometric properties when compared to similar measures, and an internal consistency of .74 (Craigie, Saulsman & Lampard, 2007, p. 1150).

Tina's responses on this questionnaire might help a clinician determine the scope and scale of her present MDD episode as well as her levels of overgenerality (discussed further later in this work) and looking for the possibility that this is not a singular episode and could be an exacerbated example of previous episodes of MDD. That may have occurred in or around the subsequent periods of serious loss in her life, i.e. desertion by her father and suicide of her sister or could correspond to other periods in her life.

The experience that Tina is having is also indicative of a causal or suspected linked factor in MDD, overgenerality in autobiographical memory. In the case of Tina her depressed thoughts surround the idea that she must not be good enough, work hard enough, be sexy enough for her husband to continue to stay with her, and she uses overgenerality to support this as evidenced by her voicing that she must not be good enough because her father also left her when she was seven, probably because she was not good enough then either.

The overgenerality in autobiographical memory retrieval aroused a great deal of interest because of its 'downstream' clinical implications. There is a large amount of evidence that OGM has powerful and maladaptive effects on other functioning. First, many studies have found OGM to be associated with impairment in social problem solving & #8230; Second, patients who are more overgeneral find it difficult to imagine the future and are more hopeless & #8230; Third, not only is increased OGM associated with depression it may also be implicated in delayed recovery from episodes of affective disorders, (Aglan, Williams, Pickles & Hill, 2010, p. 361).

Tina attributes her father's desertion as a reoccurring theme, given that her sister and her husband have both deserted her, her core belief through overgeneralization is that this desertion will reoccur throughout her life, that no one will ever love her enough to stay and she sees this as a barrier to her future life of happiness and security. She holds on to dysfunctional levels of guilt regarding her relationship with both her father and her husband feeling that the desertion was the result of some lacking in her and therefore since she is the seat of the problem she will likely never be happy again and most importantly no one will ever love her again because she is not good enough. In the various theories associated with the root cause of overgenerality in autobiographical history is one that seems to correlate with Tina's feelings well. The theory proposed by Williams is that overgenerality is employed as a result of early trauma (the desertion of her father) to attempt to mitigate the affect of the event and that this then becomes the major global point-of-view of the individual with regard to thinking about additional trauma (Aglan, Williams, Pickles & Hill, 2010, p. 361). Yet, in this case the overgenerality is actually manifesting as a major symptom of her MDD and without counseling intervention will likely continue to plague her in relationships and elsewhere for her whole life. The feeling of not being good enough is persistent and prevailing and takes no accounting of the actions or inactions of other or their particular point-of-view in the situation.

She places very little emphasis on the faults of the individuals who deserted, even though she notes that her husband seemed disinterested in working toward the her perceived idea of their common goals, i.e. both working their way through an education, instead allowing her to overwork herself to support his own lack of productivity. Tina feels trapped in her former decisions as she feels like she worked very hard to try to maintain their lives and that she was not supported in this and that working as much as she did was in fact the root cause of the breakup and subsequently her failure. The inability to reconcile the reality of her commitment to work and the fact that working too much impaired her social and emotional connection to her husband is an essential aspect of Tina's conundrum. Tina felt forced to work harder because of external and internal pressures but working harder simply made her life worse. Tina's dysfunctional beliefs about her own inadequacies with no accountability on the part of the "other" is indicative of a trend in many major psychiatric disorders including mood and personality disorders (Jones, Burrell-Hodgson, & Tate, 2007)

Tina's treatment recommendations would likely be a combination therapy associated with some sort of cognitive behavioral therapy and pharmacological intervention (Spijker & Nolen, 2010, p. 181). The course of treatment should be short-term with regard to pharmacology, given that this is reported to be a singular episode, different than any other she has experienced (Craigie, Saulsman, & Lampard, 2007, p. 1155). Though in cognitive therapy it may be found that symptoms of MDD in less sever forms and previous episodes may be present which could change the need for pharmacological treatment length. The pharmacological treatment regimen associated with MDD is usually a prescription for one of several anti-depressant (AD) medications, yet it has been recently proposed, changing the clinical recommendations that people with suicidal ideation and anxiety related thought processes, clearly evident in Tina, may need collaborative treatment of one or more medications, one to mitigate the anxiety and anxiety driven thoughts (anxiolytic) that will likely increase with the introduction of therapeutic levels of an anti-depressant medication (at least at the onset of treatment) and the AD medication as well. The co-prescription of Anti-anxiety medication and AD medication may be indicated for the first few weeks of treatment with the reduction and then elimination of the anti-anxiety medication by 6 weeks at maximum. As noted by one set of researchers looking at the co-prescription of anti-anxiety and AD medications indicates that anti-anxiety mediation should be co-prescribed in the early treatment of MDD in situations with suicidal ideas and/or high anxiety levels are present (Verger, et. al., 2008) .