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THE CASE OF EMILY 1 Running head: THE CASE OF EMILY Foundations of Psychopathology Michelle Pavlick Touro University Worldwide MFT 611

THE CASE OF EMILY 2 Introduction In this case assignment I will briefly discuss Emily’s presenting concerns and psychological history, including current level of functioning and providing a final diagnosis with z-codes. I will also discuss the theoretical orientation I will use, develop a treatment plan for Emily and explore potential interventions to help alleviate Emily’s symptoms of depression. Assessment Emily is a 41 year old Caucasian woman who is currently unemployed (since 2010) and presents with symptoms of depression. Emily reports a family history of Bipolar Disorder and a mother who was verbally and physically abusive toward her, and attempted to kill her father during childhood. She states that her mother tried to make her life difficult, constantly put her down, and did not allow her to feel good about herself. Emily reports that she had bulimia from ages 15-18, but was able to recover on her own. She denies current suicidal ideation, but reports a suicide attempt when she was 8 years old. Although the method was not lethal, she perceived ingesting the ink in board pegs as a lethal means. Emily is currently unemployed. She states that she is easily bored and has had numerous careers over the last few years. She struggles with relationships and describes feeling “invisible.” She states that she has few friends (mostly acquaintances). Emily says that she is having difficulty moving forward in her life and tends to “sabotage” anything good that happens. She is currently seeking therapy for feelings of depression. In therapy Emily is often tearful, makes self-deprecating remarks, and expresses anger and resentment toward her mother. Emily appears to be struggling with a prolonged period of depression, as evidenced by her negative view of herself, limited social relationships, and tearfulness observed during

THE CASE OF EMILY 3 sessions. While Emily does not specifically state that she is experiencing anhedonia, she does not report finding enjoyment in activities, daily life, or in relationships. She describes increasing symptoms of depression since she became unemployed in 2010 and Bennett (2011) states that people with low incomes experience 10 times the rate of depression compared to those with high incomes. Emily’s depression may likely have been present during her childhood. She describes a volatile relationship with her mother, reporting verbal and physical abuse in childhood. Bennett (2011) indicates that childhood neglect and abuse are strong predictors of depression. Additionally, exposure to non-supportive family environments, including high levels of conflict, and angry interactions are associated with depression in children (Hudson, Rapee & Rapee, 2005, pp. 152, 156). While Emily does not directly state the presence of depressive symptoms when she was a child, she reports a suicide attempt at age 8 and bulimia from ages 15-18. It is important to note that bulimia often being co-morbid with a diagnosis of depression (Levinson et al., 2017, pp. 341). Taken together, Emily appears to have a personal history that is suggestive of significant periods of depression since childhood. Final Diagnosis F34.1 Persistent Depressive Disorder (Dysthymia), Late Onset, with Pure Dysthymic Syndrome, With Persistent Major Depressive Episode, Moderate Intensity Given the symptoms that Emily presents with, I believe the diagnosis of Persistent Depressive Disorder (Dysthymia) is warranted. This disorder presents with a depressed mood for most of the day, more days than not, and has lasted for at least 2 years (Criteria A). Individuals with Persistent Depressive Disorder (PDD) must have the presence of two symptoms from Criteria B, as well as symptoms of Criteria C-H. Emily meets Criteria B4- low

THE CASE OF EMILY 4 self-esteem, as the clinician noted her making self-defeating remarks in therapy. Emily also meets Criteria B6- feelings of hopelessness, as evidenced by her statement that she is not able to move forward and tends to “sabotage” anything positive. Additional information would be needed to determine if Emily meets Criteria B1- poor appetite or overeating, Criteria B2- insomnia or hypersomnia, Criteria B3- low energy or fatigue, and Criteria B5- poor concentration and indecisiveness. It also appears that Emily meets Criteria C- where she has not been without her symptoms for more than 2 months at a time, Criteria E- no manic or hypomanic episodes, Criteria F- symptoms not better explained by another disorder, Criteria G- symptoms not attributable to another physiological disorder, and Criteria H- symptoms cause clinically significant impairment in functioning. The specifier of Late Onset was given, since Emily reports her depressive symptoms starting in 2010, which would have meant she was 34 at that time. When considering the differential diagnosis of MDE and PDD, I focused on the length of time Emily had been experiencing her symptoms. Because she indicated that the onset of her depression was in 2010, I think a diagnosis of PDD with the specifier Persistent Major Depressive Disorder better explains Emily’s experiences. I also specified that her current severity was of Moderate Intensity because I felt that her symptoms were between being distressing, but manageable (Mild) and seriously distressing and unmanageable (Severe). Her depression is negatively impacting her ability to function in many aspects of her life, however her symptoms are not so distressing that she isn’t able to function at all.

THE CASE OF EMILY 5 Z Codes Z 62.810- Personal history (past history) of physical abuse in childhood. Emily reported that her mom was physically abusive toward her when she was a child. Z 62.811- Personal history (past history) of psychological abuse in childhood. Emily reported that her mom was verbally abusive toward her when she was a child. Z 91.5- Personal history of self-harm. Emily reports a previous suicide attempt when she was 8 years old. Z 56.9- Other problems related to employment. Emily reports that she has been unemployed since 2010 (7 years). Theoretical Model The primary theoretical model that I would use to work with Emily is Cognitive Behavioral Therapy (CBT). CBT is an empirically supported treatment for mood disorders, including depression in adults (Springer, Rubin & Beevers, 2011, pp.1). In addition to being an effective treatment for clients during the therapeutic process, CBT has also been shown to be effective in teaching clients to develop techniques that they can use once treatment is completed (Glassman, Finlay, & Brock, 2004, pp. 336). A therapist working from a CBT model believes that negative actions or feelings are directly related to an individual’s distorted beliefs and thought patterns. It focuses on the client’s mood and thoughts, as well as his/her behaviors. The therapist will work with the client to identify negative thought patterns and how the client’s thinking affects his/her mood, behaviors, and physiological experiences. When working from a CBT theoretical framework, the therapist focuses on helping the client learn to recognize negative thought patterns, challenging their validity, and replacing with healthier and more adaptive thoughts (Sudak, 2012, 100-101). A CBT therapist sees biological

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