Patient Management Exercise A Person-Centered Approach to Treatment

CASE VIGNETTE PART 1

Mark is 24-year-old single employed male who was referred by his psychologist and presented to you with the remark: “Well, I'm here for depression. I'm pretty sure my current medication [fluoxetine 60 mg daily] is no longer working.” Two weeks earlier, his mood had been “abysmal, hopeless;” but today he reported “it's ok now.” He acknowledged that there has been a long-standing cyclical nature to his moods. He reported to you that at bedtime, he usually experiences about an hour of his “mind going going going,” and then he will sleep fitfully for 10–11 hours. He described problems maintaining interests, which were reduced overall at present. Feelings of guilt were also endorsed. Concentration, he was careful to report, was intact, except for a problem making decisions: he described that he “nearly had a panic attack” trying to choose which box of breakfast cereal to buy a few days ago. He reported that he eats mechanically, on a schedule, with little enjoyment; his weight has been stable. When you asked about psychotic symptoms, he reported that in childhood, he occasionally heard a woman's voice call his name. When asked about paranoid ideation, he wondered aloud if “fate is plotting against me.” He described having a passive death wish and admitted to having suicidal ideation in the past, with a plan then to “make it look like an accident” and prevent his body from being found. No homicidal ideation has ever been present. Screening for anxiety, he shared, “I worry mostly about running out of time” and “I have never liked being alone in the dark.” He has been seeing a psychotherapist for 2 years; he is unsure that this is helping him much.

You and he completed a validated Mood Disorder Questionnaire; he endorsed behaviors, suggestive of probable bipolar disorder. When asked about his experience of anger, he noted, “I've never gotten to the point of shouting at someone. … I usually don't express or deal with my upset. … It's hard to tell if I'm angry. I learned not to get angry as a child—it was punished.” He reported his IQ was greater than 140; it was clear that he is intellectually gifted in this conversation. He has never dated regularly, although he has asked some girls out. Caffeine use was described “as little as possible … it makes me feel tense and jittery.” He reported that 6 months ago he had “quite a bit of alcohol,” which resulted in suicidal despair. He reported no other drug use.

Decision Point A:

At this point, what would you offer this patient as your therapeutic relationship starts? (Select all options you might choose.)

CASE VIGNETTE PART 2

Your patient returns sometime later: “I'm doing ok. … I'm cautious to say things are getting better. In the past, things would look good, but then change for the worse sometimes.” Mood was endorsed as “middle of the road.” He reported sleeping better and that his interests were “a little” improved. Some low feelings persist, but they were not as “heavy” as previously. Energy was “unchanged.” Appetite was “the same,” he has lost 13 pounds by not eating refined carbohydrates. He reported he was “hardly irritable anymore.” No auditory hallucinations were endorsed, although he still felt “the fates” were out to get him. An occasional passive death wish was endorsed but no suicidal ideation or plans. He drank once since his last visit: 6–8 shots of tequila one evening, when he was “down;” he expanded that he did this just to “remind” himself that he doesn't like it and it doesn't work to help him feel better. He had been seeing his psychologist weekly, but it has actually been a month since their last appointment

He completed the TCI and at this visit you took the opportunity to review the results with him:

As to Temperament indices, you commented to him that the low Novelty Seeking score matched your impression of his comfort with routine and rules (e.g., eating on schedule). The high Harm Avoidance value was what you might expect in someone with chronic and somewhat refractory depression and anxiety and with problems making decisions. The Reward Dependence in the average range surprised you, given his chosen social isolation, so you looked at the performance-based scores, which were derived from how the individual responds—and found a Reward Dependence score of the 5th percentile.

Shifting your discussion to indices of Character, his low Self-Directedness was recognized as a basis for chronic depression and irritability and hinted at the presence of a personality disorder. This also supported his vulnerability to cycling in his moods. As another instance, you reminded him of how he has had episodes of drinking alcohol without enjoyment. Drinking alcohol without actually liking it fits with having low Self-Directedness. You interpreted the high average Cooperativeness as indicating his capacity to be tolerant and helpful. Low Self-Transcendence suggests that a person is more concrete and materialistic in thinking; you offered as an example how he had once complained that he “didn't see the point” of poetry.

Decision Point B:

With these concepts of who he is as a person and some of the particular difficulties he encounters in his life, he reports that he is somewhat better. Augmentation of fluoxetine with a mood stabilizer has also helped manage symptoms. What would you offer him next?

ANSWERS: SCORING, RELATIVE WEIGHTS, AND COMMENTS

Decision Point A:

Decision Point B: