Question Details

PSYC 430 MODULE 4 CASE STUDY

CASE STUDY 2: DEPRESSION AND SUICIDALITY

Depression and Suicidality 
Patient: Ellen
Written by Elaine Cassel
Marymount University and Lord Fairfax Community College
Worth Publishers, 2004

Presenting complaint:

	Forty-seven-year-old Ellen walked hurriedly to her car. She had just finished teaching a three-hour class in American Literature at the university where she was an Associate Professor and it had gone well. She was able to forget about her depression for a while and stop obsessing about suicide. 

	As Ellen drove down the highway and got onto the interstate for her 45-minute drive home, she felt the pall of sadness that had overtaken most of her life in the past month. In a one-week period her mother, with whom she had not had a close relationship, died after a lingering illness and her latest boyfriend, Harry, a fellow English teacher, began dating one of his students. Clearly, their relationship was over. She felt that the night Harry told her about his “love” for a student that her life had hit rock bottom. She had just gotten back from her mother- funeral and had not even begun to deal with the issues that haunted her - like the guilt she felt for not being more help to her mother (even thought she lived 800 miles away) and the grief she felt because she never was close to her mother. 

	Ellen had found, though, that thinking about suicide helped her feel better. She had a .22 revolver that she liked to shoot at targets, but she had heard that it was not a good idea to attempt suicide with a .22 unless one was a good shot. So Ellen had taken to fantasizing about buying and learning to shoot a bigger gun, maybe a 9 mm or a .38-caliber revolver. Since she and Harry were no longer an item, maybe that is how she could spend her weekends. She lived near a big gun shop that had targets set up and she could practice until she felt she was accomplished enough to turn the gun on herself. Then she would pick a day when Harry had a class scheduled. She would leave a note in his box, go in back of the Humanities Building where the English classes were held, and pull the trigger at a time when it would disrupt one of Harry- classes.

	Yes, Ellen thought, I should go to the gun shop Saturday. Because Ellen was so in touch with her feelings, she noticed that this thought - of buying a new gun - lifted her spirits. She put a Rolling Stones CD into the player and sang with it all the way home. 

Social and Family History:

	Ellen was the third child in a family of four, three girls and a boy. Her older brother, Alfred, and sister, Jean, were 12 and 10 years older than she. Her younger sister, Joyce, was 7 years younger. Ellen did not remember anything related to her brother when she was at home except when he left to fight in the Korean War. She recalls her mother and Jean being distraught, and Alfred- girlfriend and her family being sad. All she remembers about Jean was her wedding, at the age of 19, to her childhood sweetheart. She remembers almost nothing about Joyce, except that her parents seemed to dote on her.

	Ellen- father, Fran, was a binge-drinking alcoholic. About three times a year he went on binges. During such times, he would drink nonstop for several days, get violently ill, have to be sent to the VA Hospital to “dry out” (he was a veteran of World War II), and return home to face the loss of his business and business equipment. Frank was a brilliant man who had lost his own parents when he was 8 years old. He and an older brother literally raised themselves in a dirt-poor rural community. Frank went into the service when he was 16. There he learned to work (and work on) heavy equipment like bulldozers and cranes. He owned some expensive equipment and was self-employed, mainly doing road construction.  But when he went on his binges and was out of work for two or three weeks, the banks often repossessed his equipment and he lost the jobs. Funny thing was that Frank was so good at what he did that he would get new loans for new equipment, new jobs, or would possibly go back to the same job when he “dried out.”

	Frequently the family had to move, as Frank and Ellen- mother, Evelyn, would miss a rent payment or two. Evelyn was the middle child of 13 children. She too, came from an extremely poor family. She and Frank married when she was 16 and he was 18. Evelyn was a quiet, unassuming person, and religious fanatic - involved in a fundamentalist sect. But she never condemned Frank and was long-suffering. 

	Evelyn worked menial jobs for as long as Ellen could remember. By the time Ellen was 8 years old, she was coming home from school to an empty house that she had the obligation to clean. She cooked dinner and did the laundry. She recalls no affection from either parent, but she does remember harsh physical punishment for “talking back” to them or complaining about going to church. Ellen hated the church her mother dragged her to.

	In order to escape from her miserable home life, her father- drunken binges, and her mother- religious fanaticism, Ellen turned to a life of books, school work, and, when she was old enough, taking jobs herself. She excelled in school and was admired by her teachers. She had a couple of close friends whose parents “adopted” her. They felt badly that Ellen was so mistreated by her own parents. Ellen- mother resented Ellen- involvement in school, for she thought that she should be doing “the Lord- work” and not concerning herself with books and learning - the so-called “tools of the devil.” Neither of Ellen- parents ever went to any of the school functions that Ellen was involved in, nor did they recognize or praise her academic accomplishments.

	When Ellen graduated from high school as class valedictorian, she turned down scholarships at local colleges and literally ran away from home. She moved to Washington, DC and got a low-paying job with the government. When she became pregnant, she married a man 18 years older than she. After having the child, she began college.

	From college she went on to graduate school in English. By then her marriage was floundering. The older man she had hoped would be nice to her turned out to be controlling and aloof -somewhat like her father. Though she was a good mother, Ellen was also selfish. One day, while still in graduate school, she walked out on her husband and 10-year-old daughter.

	Over the years, Ellen kept in touch with her daughter and eventually had a good relationship with her, but she had no luck with men or relationships. She obtained a Ph. D. in English Literature from a prestigious institution and eventually landed the job she now held at a well-respected state university. Ellen had been totally successful in her professional life. She worked hard and got what she went after. She was admired in her field.

	But, as she got older and hit her late 40s, she suffered frequent bouts of depression due mainly to her loneliness. She had a good relationship with her daughter and her colleagues, but she had no other social support. She had no close friends. She was always working but she also felt out of place since she was not married. She refused to hang out with her married friends and felt like an “old-maid” or social misfit. Work served two purposes - it increased her professional success and gave her an excuse not to have a social life.

	Ellen had little contact with her mother during her adult life. Her father had died right after Ellen had gotten married, and though Ellen went home for the funeral she recalled feeling no emotion about his death. When Ellen- child was still a baby, Ellen- mother made an effort to re-establish contact, but Ellen was pretty cool to the idea. However, as Ellen got older she visited her mother once a year and tried to connect with her and her sisters. But somehow Ellen never quite felt as if she belonged, and though polite and cordial, she felt “disconnected,” as she would say, from her mother and sisters.

	That it why it caught Ellen by surprise that she was so taken aback by her mother- death - somewhat after the fact. As with her father- funeral, she hadn’t felt much grief. It is as if she dissociated from the events surrounding the funeral. But when she got home - once Harry “dumped” her, as she put it - her mother- death hit her, and hit her hard.

	By the time Ellen had begun fantasizing about killing herself, she had been seriously depressed for almost a month. She had just about stopped eating (which was not hard to do, since Ellen was obsessed with being thin and at 5’ 5’’ weighed 110 pounds) and rarely slept. She worked all the time - working on a new textbook for which she had a contract and working on her class lectures.

	Ellen actually wanted to try psychotherapy because she wanted someone to talk to. But she figured that no one would really understand her, so why spend the money? She was adamant that she would never take medication. For one thing, she thought that she could control her state of mind - if she wanted to. If she wanted to “snap out of it” Ellen felt that she could. But frankly, she did not want to feel better, or feel happy. The way she saw it, she had nothing to live for anyway. She didn’t think her daughter would care a whole lot if she “checked out,” since she had a happy married and two nice kids (whom Ellen adored) and would inherit Ellen- savings and belongings. 

	Yes, living had gotten to be a burden - and far more trouble than it was worth. Talk therapy, medication - they would just mask the underlying issue. Ellen had nothing to live for and the sooner she could do herself in, the better.

Diagnosis:

DSM-IV Checklist

Major Depressive Episode:
1. The presence of at least five of the following symptoms during the same two-week period: 
	-depressed mood most of the day, nearly every day
	-markedly diminished interest or pleasure in almost all activities most of the day,
	 nearly every day
	-significant weight loss or weight gain, or decrease or increase in appetite nearly 
	 every day
	-insomnia or hypersomnia nearly every day
	-psychomotor agitation or retardation nearly every day
	-fatigue or loss of energy nearly every day
	-feelings of worthlessness or excessive guilt nearly every day
	-reduced ability to think or concentrate, or indecisiveness, nearly every day
	-recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for 
	 committing suicide.
2. Significant distress or impairment

Major Depressive Disorder:
1.	The presence of a major depressive episode
2.	No history of a manic or hypomanic episode

Dysthymic Disorder:
1.	Depressed mood for most of the day, for more days than not, for at least two years
2.	Presence, while depressed, or at least two of the following:
	-Poor appetite or overeating
	-Insomnia or hypersomnia
	-Low energy or fatigue
	-Low self-esteem
	-Poor concentration or difficulty making decisions
	-Feelings of hopelessness
      3. During the two-year period, symptoms not absent for more than two months at a 
           time.
       4. No history or a manic or hypomanic episode.
       5. Significant distress or impairment. 

Based on APA, 2000, 1994


Schneidman- Taxonomy of Suicide
Death Seeker	A person who clearly intends to end his life or her life at the time of a suicide attempt.
Death Initiator	A person who attempts suicide believing that the process of death is already under way and that he or she is simply hastening the process.
Death Ignorer	A person who attempts suicide without recognizing the finality of death.
Death Darer	A person who is ambivalent about the wish to die even as he or she attempts suicide.


Common Predictors of Suicide:
1.	Depressive disorder and certain other mental disorders
2.	Alcoholism and other forms of substance abuse
3.	Suicide ideation, talk, preparation; certain religious ideas
4.	Prior suicide attempts
5.	Lethal methods
6.	Isolation, living along, loss of support
7.	Hopelessness, cognitive rigidity
8.	Being an older white male
9.	Modeling, suicide in the family, genetics
10.	Economic or work problems; certain occupations
11.	Marital problems, family pathology
12.	Stress and stressful events
13.	Anger, aggression, irritability
14.	Physical illness
15.	Repetition and combination of factors 1 to 14
Source: Adapted from Maris, 1992 


CASE STUDY: DEPRESSION ANSWER SHEET
Ellen: Depression and Suicidality
Student Name:

Diagnosing Ellen
1a. Refer to the DSM-IV checklist and list all symptoms that Ellen has that match the criteria for major depressive episode. Which of Ellen's symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

1b. Can Ellen be said to be suffering from a major depressive disorder?

1c. Explain and defend your diagnoses or lack thereof.

2. Where does Ellen fit with Shneidman- taxonomy of people who intentionally end their lives?

3. What factors are present that may trigger a suicide attempt by Ellen?


Explaining Ellen- Depression and Suicidality
1. What genetic factors might play a role in Ellen- depression?

2. What biochemical factors might play a role in Ellen- depression?

3a.What would a psychodynamic theorist say about the origins of Ellen- depression?

4. How might Freud- concept of symbolic or imagined loss help explain Ellen- depression?

5. What evidence is there that Ellen is engaging in the cognitive triad and automatic thoughts?

6. How might the hormone theory help explain Ellen- depression?

7. How would the body dissatisfaction explanation lend to understanding Ellen- depression?

8. With regard to Ellen- wish to commit suicide, which of Durkheim- categories does Ellen belong and why?


Treating Ellen
1. Explain how a psychodynamic therapist would treat Ellen for her depression and suicidal tendencies.

2. Explain how a behavioral therapist would treat Ellen for her depression and suicidal tendencies.

3. Explain how a cognitive therapist would treat Ellen for her depression and suicidal tendencies.

4. Explain how an interpersonal therapist would treat Ellen for her depression and suicidal tendencies.

5. Explain what biological treatment might be appropriate for Ellen.