medication consultation

Case Study 4
Still a Student
Ellen Waters’s psychotherapist referred her for a medication consultation
because of her continuing depressed mood and panic attacks. She is a 37-yearold, part-time graduate student who lives along and supports herself by working
as a home health aide. She completed course work for a Ph.D. in sociology 3
years ago, but has not yet begun her thesis.
Ellen is indeed an unhappy-looking woman, and describes being unhappy
through much of her life, with no long periods of feeling really good. Her father
had a history of alcohol problems, and there was always a great deal of strife in
her parents’ marriage. She denies sexual or physical abuse, but feels that her
parents were “emotionally abusive” of her. She was first referred for treatment
after she made a suicide attempt at age 14, and there have been many times
over the years during which her usual low-level depression has become
considerably worse, but she has not sought treatment.
Two years ago, when she had been seeing her current boyfriend for about 4
years, it finally became clear that he was unwilling to marry her or live with her.
She began to get more depressed and to experience acute panic attacks, and it
was at that time that she entered psychotherapy.
In the month before the consultation, she says she was depressed most of the
time. She had gained about 10 pounds because she was constantly nibbling on
chips or cookies or making herself peanut better sandwiches. She often
awakened in the middle of the night, was unable to go back to sleep for hours,
and then overslept the following day, often sleeping up to 18 hours. She says she
feels like dead weight, her legs and arms are heavy, and she is always tired. She
ruminates about her own failures and cannot concentrate on any serious reading,
although, she has not made any recent suicide attempts.
Ellen’s mood is clearly reactive to favorable events. Small attentions from her
therapist or her boyfriend can cause her to feel really good for hours at a time.
She has an equally extreme reaction to any sort of rejection. If a friend does not
return a call, or if someone appears romantically interested and then withdraws,
she feels devastated to the point where she cannot work. She then stays at
home, overeats, and avoids people.
Ellen’s academic and vocational history have been erratic. She has a mater’s
degree in psychology, and worked as a counselor for a while, but found this too
upsetting. She then began a Ph.D. program in sociology, completed her course
work, but interrupted this to train in physical therapy. She has never worked in
one job for more than a few years, and has spent much of her adult life as a
student. Her current romance is the longest she had sustained. She lived with a
man once previously, but this was a brief and tumultuous relationship. Boyfriends have described her as “needy and clinging,” and it appears her current boyfriend
fears her neediness.
Although Ellen reports chronic depression, when she is asked about “high”
periods, she describes many episodes of abnormally elevated moods that have
lasted for several months. During these times she would function on 4 or 5 hours
of sleep a night, run up huge telephone bills, and feel that her thoughts were
racing. She was able to get a lot done, but her friends were obviously concerned
about the change in her behavior, urging her to “slow down” and “calm down.”
(She has never gotten into any real trouble during these episodes.)