Client Name: Elizabeth Wurtzel Sex: Female
Age: 26
Medical Condition(s): See below
Reason for Referral:
Client Ms. Elizabeth Wurtzel was referred due to the need of serious psychological intervention. For the past several weeks she has been suffering from debilitating modes of depression. These bouts of depression can last from a day to several weeks. Ms. Wurtzel has complained that she cannot seem to get away from this “black wave” that is drowning her. The depression seems to interfere with her daily life and her personal responsibilities. Ms. Wurtzel has been reported to also be suffering from anxiety. These periods of anxiety seem to interfere with her personal relationships with her parents, friends, boyfriends, co-workers etc. The anxiety seems to have taken over her mind and she feels as if it is running her life. Due to these serious episodes of depression and anxiety, Ms. Wurtzel had been recently threatening to commit suicide to almost anyone who would listen. It was the in the past week, however, that Ms. Wurtzel has once again tried to overdose on Mellaril. Due to these consistent threats and attempts, she was referred in order to receive a different form of intervention. Her family feels that something drastic needs to be done, or that a better diagnosis and treatment plan must be reinstated. The purpose of this is to reestablish a regular day to day routine where Ms. Wurtzel can effectively function.
Tests Administered/Test Scores & Interpretation/Behavioral Observations:
As Ms. Wurtzel walked into the office, she refused to sit in the patient chair and instead took a seat at the desk. This was a telling first sign of her rebellious attitude. After warning that this was not acceptable behavior, with much effort and drama, she removed herself from the chair and sprawled out on the couch.
Her body posture was disorganized. She crossed and uncrossed both her legs and arms and could not decide which way to lean her head. While talking to her, she avoided any eye contact, but instead focused on the beige carpet. She constantly fidgeted with her skirt and strummed her fingers on top of her thigh. Her face displayed signs of anxiety: a worried look, tense facial muscles, and a slight sweat on her forehead.
In our discussion, Ms. Wurtzel immediately blamed everyone but herself for her problems. Her utter lack of responsibility was a common theme throughout her whole personal narrative. Her father was the main target. She claimed that if it were not for her poor environment and her dad´s abandonment, she would not be suffering with all these symptoms. And yet, at the same time, she demanded that she needed medication because her body was broken from birth and unable to function without extra chemical input.
Throughout the interview, she would have moments where her mood was elated and happy-go-lucky. These did not last long and after a few minutes, she turned sour, gloom, and unresponsive. Getting her to continue talking was a tremendous effort. At one point in her lows, she asked if she could take a nap on the couch right then and there. Explaining that this nap would cost more than she could afford, she realized that it was necessary to spend the time in counseling actually getting counseling.
The second half of the meeting was interspersed with her constant need to go to the bathroom. After the third time, an explanation of this lack of decorum was in order. She admitted that she needed a break from talking and would go to the bathroom and watch the water run down the sink. This is consistent with other examples of her easy distractibility.
Nearing the end of the interview, Ms. Wurtzel broke out in a fit of crying. Her tears gushed all over her face and at least 12 tissues were used to sop up the downpour. After this incident her eyes became glassy as she drifted off into a trance-like state. After a minute, she reported that she was just flashing back to a memory of staying at her father´s house. Her demeanor suddenly turned angry and she started screaming that this session was the cause of all her problems and that if she only stopped meeting with counselors, all her issues would go away. She reached over to the garbage, filled her arms with the tissues she had previously used, and threw them all over the floor in an act of defiance.
After this outburst, during the last few minutes of our time, she threw herself on to the couch and refused to leave until her problems were all fixed. Since she was beginning to go over time, a firm order that she needed to visit next week was given. She finally obeyed, and strut out of the office. She gave the finger and she turned the corner.
Client/Family Background:
Ms. Wurtzel has a long line of psychological disorders in her family history. We have evidence that her grandfather was an alcoholic the majority of his life and was also abusive to his wife. This gives us proof that there is a history of instability and substance abuse and dependency. Her grandma suffered from melancholia and was forced to stay in an asylum a significant portion of her adult life. The reason she was put into an asylum has not been determined, however, it can be hypothesized that she was critically mentally unstable. Ms. Wurtzel’s father was never tested for mental disorders but his behavior indicates that he was also under its influences. He seems to have a sleeping disorder, has a substance abuse with alcohol and Valium and experiences denial. Ms. Wurtzel’s mother seems to also be quite psychologically unstable. She is extremely emotionally disturbed, digresses to childish behaviors, and suffers from denial and aggressive behavior. When it comes to dealing with her daughter she seems to be flighty and have extremely high expectations.
Ms. Wurtzel has a handful of cousins who have suffered from elaborate episodes of depression and have been intense drug and alcohol users. On various accounts they have also committed various attempts at suicide.
Ms. Wurtzel has been through a lot of stressful situations with her family. She experienced her parents getting a divorce at the very young age of two. Throughout her childhood she was continually pushed between parents, each of them toying with her loyalty. Ms. Wurtzel was forced to go to summer camp every summer, which regularly would not be seen as a traumatic event, however, she felt immensely disserted and abandoned. During her high school years her father disappeared for an extended amount of time without saying goodbye or contacting his daughter for a number of years. This experience furthered her sense of abandonment with her family.
Detailed Case History:
To fully understand Elizabeth Wurtzel’s case, one must first look at where it all started: her childhood. Her parents were divorced when she was two years old and there was continual conflict between her mother and father. She would travel between their homes and as she grew older her parents would push her to choose sides. She showed early signs of anxiety when she would make her father leave his shoes outside of her door in order to assure her that he had not left her alone. As a very young little girl, however, most people viewed her as a chipper, smart, creative child. She was viewed to have a lot of promise and to be headed down a successful path, despite her parent’s issues and the instability of their home life. Her relationship with her mother eventually turned into more of a friendship than a parent-child role. Ms. Wurtzel became her mother’s confidant and was told a lot about their financial issues and the problems Mrs. Wurtzel had with her husband. The small conflicts that Ms. Wurtzel had during early childhood did not amount to anything that seemed considerably peculiar or inappropriate to anyone. As she entered middle school, however, more serious problems arose.
At age eleven Ms. Wurtzel started showing deviant and threatening behavior. When her parents “forced” her to go to summer camp she felt the range of emotions from anger, fear, abandonment, and then on into being depressed. While at summer camp she attempted to overdose on allergy medicine. She claimed that it was not a suicide attempt, but she was hoping that by overdosing people would see that there was something wrong with her. She wanted her parents to come pick her up. It was that same year that Ms. Wurtzel was found cutting her legs with a pack of razor blades in the girls locker room at school. She claimed that this was not a suicide attempt either, but that she simply wanted to know that if things became bad enough that she could in fact inflict harm on her body. Because of the amount of time she spent with the school psychologist, it was recommended that she see Dr. Isaac, a professional psychiatrist. This is also when her negative self body images started. She became certain that she was fat and because of the emotional drain she felt would cry for hours at night because she felt pressured from others to be perfect. She felt like she must act like her old self and became anxious and whelmed when she realized she could not hide who she really was. She continued going to camp during the summer. During these trips, she would obsessively call her parents and distant relatives, several times a day, to make sure someone would be there to pick her up. She was constantly anxious and worried that she would be forgotten and left behind.
When her therapy started, Ms. Wurtzel cooperated and actually claimed that she liked talking with Dr. Isaac. She eventually began making excuses so she could skip school and spend more time talking with him. Due to this, her grades began to slip considerably and she concluded that the daily routines and things people did in life were all pointless because everyone was going to die anyway. At this point, she feels like the happy girl she once was is already gone and that the only true pleasure she can experience is causing others pain. One thing she had an extreme interest in, however, was boys. She seems to attract the attention of older boys and men even at the young age of twelve. She has her first sexual encounter with a boy who is 17 when she is 12. (She does not have complete sexual intercourse at this time). At this point, she feels like this physical activity is the most wonderful thing and that it brings her true happiness. She knows that it is wrong, however, she mentions that she just wants to be doing sexual activity like this all the time. At age thirteen, she manages to convince her parents to let her leave summer camp and go spend time with her cousins at her aunt and uncles. She smoked an insane amount of pot and went to keg parties.
These tendencies continue and become more serious as Ms. Wurtzel enters high school. She goes through different stages where she enjoys school and tries to be sociable, and then diverts back to being antisocial, depressed, and unmotivated. For the most part, Ms. Wurtzel feels unaccepted at school and that everyone judges her and thinks she is a complete mess. Throughout all of these stages, especially the major depressive ones, Ms. Wurtzel’s mother forced her to still participate in real life in order to prevent her from completely wallowing in her self-pity. Nevertheless, Ms. Wurtzel still manages to find more reasons and evidence that she is worthless and that she in fact is a failure. It was because no one could tell her what was really wrong with her, or how to treat it, that Ms. Wurtzel began wishing she had some sort of addiction to alcohol or drugs. She began to create a belief system that would last for years, that if she could only have a “real” problem, like a substance addiction, that she could be put into rehab and be “fixed”.
The situation with her parents continued to worsen, and the belief that her father truly did not love her unconditionally became more influential in how Ms. Wurtzel responded to her dad and how she functioned in her day to day relationships. Her father was consistently disappointing her, not following through, and eventually really disappeared at the end of her freshman year in high school. She began to try and fill that void with dating. While in the beginning of relationships she was able to remain pretty stable, things became quite complicated as time went on. She would wallow in her depression and continually talk about it, crying and would constantly need reassurance that the boy loved her and would never leave her. She became obsessive with planning their futures together and making sure that they would stay together, rather than focusing on the present and simply enjoying the relationship. Through these habits she lost various boyfriends and became even more frustrated with men and her feelings.
When things worsened for Ms. Wurtzel, things with her mother also seemed to become more complicated. Her mom would often times blame Ms. Wurtzel for causing her so much pain and being too much of a burden. She would threaten her that she was going to die because of all of the stress she was put through. Ms. Wurtzel stopped going to therapy because her father would not pay for the bills, and her mother could not afford it.
As Ms. Wurtzel started college at Harvard she developed the habit of drinking large quantities of alcohol at continuous parties, taking various drugs such as cocaine, pot and Ecstasy, and chasing and running from hookups with boys. Because of the late nights and the intense intoxication, she spent a lot of time holed up in her dorm room, too afraid to socialize, unless under the influence. She took a liking to becoming involved in risky situations, like sleeping with her best friend’s boyfriend, and taking so many drugs that she is incoherent and doesn’t remember what she did the night before. She is aware that she is not addicted to the drugs in the sense that she is dependent on them, however she continually abuses them and wants to be high or on a “trip” in order to escape her mind. Throughout college she is checked in and out of Stillman Infirmary due to hysterical breakdowns, overdosing on drugs and alcohol or depression medicine. She occasionally sees the psychiatrist or psychologist at the college, but cannot undergo continual therapy because her father still would not pay the bill. She had occasional contact with her father but they tended to end up fighting and blaming each other for the way their relationship was.
Throughout her entire time at college she battles major depressive episodes, where she cannot leave her room and stays in bed. She has days where she does not sleep at all, but is able to do all of her schoolwork in the middle of the night and somehow do well. Other days she completely blows off school and her assignments and exams and manipulates her professors into accepting her excuses. She is also incredibly manipulative of her “friends”. She is constantly complaining of how bad her life is and how they need to take her seriously and get her help or she will kill herself. She has the inability to follow through with commitments she makes. When she does get a boyfriend she becomes obsessive and constantly wants to be with them or be reassured that they care about her and will not leave her. She feels the need to always talk about how she feels and how messed up she is. It is very evident that she has a lack of concern for others. She has flighty behavior, disregarding others feelings and needs and becomes quite hypersexual She has numerous partners and finds that sex is one of the only times she feels real sensation.
Ms. Wurtzel is extremely impulsive. When she comes up with an idea of something she wants to do, somewhere she wants to go, or someone she wants to sleep with, she will attempt it. She goes on random stints to work in Dallas even though she doesn’t really know anyone there or have anything set up. When she was not working she was constantly drinking, partying, dating over a dozen men at the same time and using caffeine to make up for the lack of sleep. There was a complete lack of recognition of those who cared about her or needed her to be stable. She dismissed her obligations to her family and when stressed or nervous would turn to alcohol. She often times is seeking something that will give her life meaning and jumps to decisions without much contemplation, to realize later that she really did not want to do what she did. This, as well as her involvement in unwise behavior seems to be a means to try and drown out her feelings of desperation, loneliness and anxiety.
Eventually, it is apparent that Ms. Wurtzel can no longer function without seeing a therapist. Dr. Diana Sterling is recommended. At the beginning of the sessions, things seemed to have settled down in Ms. Wurtzel’s life. After a month or so, she starts to have a mental breakdown and feel like she cannot handle life again. A few days later, Ms. Wurtzel had a miscarriage. Prior to waking up to a bed full of blood, however, she was not aware that she was pregnant. When she initially found out she was hysterical and was given a series of Xanax, Valium, and Thorazine to calm her down. She ended up using the miscarriage as an excuse to be depressed and used it to make her friends and strangers feel sorry for her.
Ms. Wurtzel has another break down, however, she becomes obsessed about getting her school work done. She felt that if she could get her work done that everything would be okay and she could maybe make it through another day. She becomes so hysterical, however, and irrationally talking about suicide that she is brought back to Stillman Infirmary for an extended stay. She is given Dalmane and encouraged to sleep between interviews with her doctors. These stays at the infirmary become routine and Ms. Wurtzel has an increase in extreme episodes where she cannot function and becomes hysterical. While she has the desire to become better, she has completely resigned herself to being depressed and really must push herself to consider that she could become better if she tried. She becomes obsessive compulsive with calling Dr. Sterling, every five minutes, in order to be reassured that she will come out of this depression one day. To her it feels like nothing sticks in her mind, nothing is truly real to her unless it is right in front of her or if someone continually reassures her. At this point she states that she considered suicide more seriously than she ever had before. This pushes Dr. Sterling to decide that she will try a chemical treatment on Ms. Wurtzel. Dr. Sterling claims that her main symptoms are anxiety and agitation. She had an extremely negative reaction to Xanax, and then is put on Mellaril which seems to work initially. After awhile though, the Mellaril ends up just making her feel blank and taking away all emotions, to the point where she doesn’t experience any feeling.
These patterns continue, in and out of Stillman, off and on medication, traveling to random places in order to try and escape what she is feeling. She ends up not having enough energy to go to therapy, eat, and not even enough to sleep. She decides to do an independent study semester so she can go to London and hopefully escape her life in the U.S. The trip ends up being a disaster where she feels taken advantage of by men, becomes even more depressed and completely alone in the world. It furthers her dependence on her therapist, who she calls over twenty times a day. She eventually comes home and tries to get back into a routine. Because her mother is mugged, she is forced to take responsibility and try to help her mother and family out. This sort of puts things into perspective for her and somewhat pushes her to think of someone but herself. There is a pivotal movement of their time together, when her mother says that she understands that Ms. Wurtzel cannot deal with anything because she is depressed. Ms. Wurtzel is surprised and grateful to realize that her mother understands her and why she is the way she is. She realizes that depression is something that must be dealt with on its own terms and that it is something she could overcome.
When she returns once again to school, things seem to be fine, however, she is overcome with the desire to kill herself. She tells Dr. Sterling her well thought out plan and Dr. Sterling tells her that she is going to take her to the hospital. Before she can, however, Ms. Wurtzel goes into the bathroom and finds the bottle of Mellaril and takes all of the pills in the bottle. She goes through a wide range of reactions; laughing hysterically, crying, hating life, wanting to go home and jump on the bed and enjoy life to the fullest. She later explains that she simply wanted to know what it felt like to go that far, she wanted to know if she really wanted to die, and she realized she didn’t. She admitted that she had somewhat fallen in love with her depression and believed that it is was all she had and it was what made her worthwhile.
Diagnosis
Reasons for Diagnosis of Dysthymic Disorder:
First off, Ms. Wurtzel meets enough criteria for the Axis I diagnosis of Dsythymic disorder. In general, and in regards to Criterion A/1 she feels depressed most, if not every, day for years on end. Friends and family claim that she has always been a down-in-the-dumps person. Ms. Wurtzel has days where she can hardly get out of bed, eats too much or nothing at all, is not able to move around with adequate energy, and does not value herself, but instead sees herself as worthless.
With Criterion B/2, she goes days where she does not think she has enough time to eat. Her sleep cycles are not the most stable. She complains of tiredness and lethargy often, makes poor choices, and feels that she is a meaningless, insignificant creature.
Ms. Wurtzel meets Criterion C/3 by not having gone more than two months without a significant amount of the above symptoms. Where Ms. Wurtzel differs is that she has overlapping periods of more intense lows, which qualify her for Occasional Major Depressive Episodes.
Those incidents that seem manic in nature are best related to her Axis II, Borderline Personality Disorder. The diagnosis of psychotic features is distant from her overall issues. Although she does use a vast majority of substances, these are in reaction to preexisting conditions and not the cause of her problems. Ms. Wurtzel even self declares that she uses drugs so people will know that she has a real underlying problem. Her disorder causes immense difficulties in societal, career related, academic, and personal functions in life.
Reasons for Diagnosis of Occasional Major Depressive Episodes:
Her Dysthymic symptoms become increasingly severe at times.
Reasons for Diagnosis of Borderline Personality Disorder:
Overall, in confirmation of the diagnosis of BPD, Ms. Wurtzel has extreme difficulties in relating to other people and herself, and makes hurried, rash decisions. Fulfilling symptom one, she constantly feels that abandonment is right around the corner and that the people important to her could leave at any moment. (Remember the shoes of her father outside of her door). She also goes back and forth between calling her relations great and horrible influences in her life. Ms. Wurtzel has extreme issues in regards to her unique identity. She is unable to figure out who she is no matter how hard she tries.
Item four is directly applicable in that she participates in possibly dangerous activities, including having numerous sex partners and using not just one illegal drug at a time, but multiple illicit substances concurrently. Ms. Wurtzel´s entire history is dotted with incidents of suicidal feelings/tendencies/half-hearted attempts. Hours of intense anxiety attacks are not uncommon. Object seven fits accurately in describing her feelings of hollowness. Ms. Wurtzel does have some incidents of anger, namely all out battles on the phone with her father. Criterion nine establishes that she has temporary, stress-related, paranoid formation of crazy ideas. It also explains her severe inability to separate her thoughts, emotions, and experiences from one another purposely and effectively. This is extremely evident throughout her entire college career.
Treatment Plan:
For Dysthymic Disorder
The first plan of action is to introduce Ms. Wurtzel to some type of Selective Serotonin Reuptake Inhibitor (SSRI), possibly Cymbalta, Paxil, Effexor, Celexa, Wellbutrin or others.
These drugs are more reliable than older forms of drugs used against depression. If necessary, combination of the above medications could be prescribed. This process will inevitably be trial and error, to see how Ms. Wurtzel´s brain chemistry responds to changes.
The above biomedical treatment will be combined with biweekly intense therapy sessions in which Ms. Wurtzel will be retrained to correct her thinking and behavior based off of studies on patients who have had success with these therapies. The focus of this treatment will be to establish a positive self image for Ms. Wurtzel and give her the tools to learn self control, as well as beneficial and constructive thinking and behavior.
For Borderline Personality Disorder
A potpourri of care is available to choose from. This clinic is recommending the following:
Ms. Wurtzel simply needs more people in her life who can sit down and truly listen to her. One possibility for this would be joining support groups. These would provide Ms. Wurtzel with a network of people who understand her struggles and can lend listening ears on a regular basis. In the few instances where her parents listened without bringing themselves into the situation, Ms. Wurtzel felt relieved and comforted in the fact that she had connected in some way with another human being. Family therapy is also being advised. Ms. Wurtzel should become involved with some sort of relaxation therapy, such as yoga and meditation. A colleague is offering a discount on a five year plan of psychoanalysis; this is strongly encouraged, as Ms. Wurtzel has many deep childhood issues to work through. Finally, it can be asserted that some of the drugs used to treat her Dysthymia may leach over and help treat her BPD.
Overall:
The major goal for Ms. Wurtzel is for her to regain a stable life, functioning in the world as a productive and happy individual. The minor goals include her ability to effectively communicate her emotions to appropriate people in a manner so as to relieve her symptoms without increasing their severity. Furthermore, it is hoped that Ms. Wurtzel will develop the skills necessary to interact with her friends, classmates, and family in a harmonious manner.
Also, Ms. Wurtzel´s regulated mood is of utmost importance. Boosting the lows, and capping off the highs is expected to take a significant amount of work, but is highly possible. These goals are to be reached in a manner so as to produce immediate beneficial effects while working on longer term problems simultaneously. Ms. Wurtzel would refuse further treatment if we did not provide some type of instant gratification. Practical ways to reach these goals include Ms. Wurtzel applying herself to a process of recording her life as she lives it and then summarizing it for the practitioner to evaluate and use to better understand Ms. Wurtzel´s patterns of behavior.
Any and all types of therapy are worth a try in the case of Ms. Wurtzel. Extreme behavior modification is planned, replacing her negative actions, such as drugs, sex, and drinking, with activities such as gardening, hiking, and caring for a pet. Immediate implementations of certain changes are required, but constant new behaviors are the goal.
Prognosis:
This is a very intensive treatment plan that is being suggested. Ms. Wurtzel is hoped to establish a sense of stability in her life. Together we can help Ms. Wurtzel achieve constant and mellow relationships. Through this therapy she will be able to acquire a sense of security that will reassure her that she will not be abandoned. She will hopefully achieve self-actualization, forming her own identity. We will help her control her impulsivity, giving her the confidence to say no to unsafe habits, such as multiple sex partners and drug and alcohol abuse. These therapies will also help her value life, instead of desiring to end it. She should be able to decrease her frequent outbursts of temper, thus controlling her anger. She will personally have the tools to separate her experiences from her past from the choices she is currently making.
She will learn how to regulate her eating and sleeping habits, and stabilize her energy levels. She will comprehend how to make informed and wise decisions without depending solely on others input. All of this together will ultimately be able to give her a sense of hope and a sense of meaning in her life.
Multiaxial Evaluation Report Form
Name: Elizabeth Wurtzel
Date: February 20, 2009
AXIS I: Clinical Disorders
300.4 Dysthymic Disorder, Early Onset, Typical Features with
Occasional Major Depressive Episodes
AXIS II: Personality Disorders
301.83 Borderline Personality Disorder
AXIS III: Relevant General Medical Conditions
AXIS IV: Psychosocial/Environmental Problems
1) Divorce of parents.
2) Financial Difficulties. Not enough money for full treatment.
AXIS V: Global Assistant of Functioning Score:
Varies from 20 to 35
Age: 26
Medical Condition(s): See below
Reason for Referral:
Client Ms. Elizabeth Wurtzel was referred due to the need of serious psychological intervention. For the past several weeks she has been suffering from debilitating modes of depression. These bouts of depression can last from a day to several weeks. Ms. Wurtzel has complained that she cannot seem to get away from this “black wave” that is drowning her. The depression seems to interfere with her daily life and her personal responsibilities. Ms. Wurtzel has been reported to also be suffering from anxiety. These periods of anxiety seem to interfere with her personal relationships with her parents, friends, boyfriends, co-workers etc. The anxiety seems to have taken over her mind and she feels as if it is running her life. Due to these serious episodes of depression and anxiety, Ms. Wurtzel had been recently threatening to commit suicide to almost anyone who would listen. It was the in the past week, however, that Ms. Wurtzel has once again tried to overdose on Mellaril. Due to these consistent threats and attempts, she was referred in order to receive a different form of intervention. Her family feels that something drastic needs to be done, or that a better diagnosis and treatment plan must be reinstated. The purpose of this is to reestablish a regular day to day routine where Ms. Wurtzel can effectively function.
Tests Administered/Test Scores & Interpretation/Behavioral Observations:
As Ms. Wurtzel walked into the office, she refused to sit in the patient chair and instead took a seat at the desk. This was a telling first sign of her rebellious attitude. After warning that this was not acceptable behavior, with much effort and drama, she removed herself from the chair and sprawled out on the couch.
Her body posture was disorganized. She crossed and uncrossed both her legs and arms and could not decide which way to lean her head. While talking to her, she avoided any eye contact, but instead focused on the beige carpet. She constantly fidgeted with her skirt and strummed her fingers on top of her thigh. Her face displayed signs of anxiety: a worried look, tense facial muscles, and a slight sweat on her forehead.
In our discussion, Ms. Wurtzel immediately blamed everyone but herself for her problems. Her utter lack of responsibility was a common theme throughout her whole personal narrative. Her father was the main target. She claimed that if it were not for her poor environment and her dad´s abandonment, she would not be suffering with all these symptoms. And yet, at the same time, she demanded that she needed medication because her body was broken from birth and unable to function without extra chemical input.
Throughout the interview, she would have moments where her mood was elated and happy-go-lucky. These did not last long and after a few minutes, she turned sour, gloom, and unresponsive. Getting her to continue talking was a tremendous effort. At one point in her lows, she asked if she could take a nap on the couch right then and there. Explaining that this nap would cost more than she could afford, she realized that it was necessary to spend the time in counseling actually getting counseling.
The second half of the meeting was interspersed with her constant need to go to the bathroom. After the third time, an explanation of this lack of decorum was in order. She admitted that she needed a break from talking and would go to the bathroom and watch the water run down the sink. This is consistent with other examples of her easy distractibility.
Nearing the end of the interview, Ms. Wurtzel broke out in a fit of crying. Her tears gushed all over her face and at least 12 tissues were used to sop up the downpour. After this incident her eyes became glassy as she drifted off into a trance-like state. After a minute, she reported that she was just flashing back to a memory of staying at her father´s house. Her demeanor suddenly turned angry and she started screaming that this session was the cause of all her problems and that if she only stopped meeting with counselors, all her issues would go away. She reached over to the garbage, filled her arms with the tissues she had previously used, and threw them all over the floor in an act of defiance.
After this outburst, during the last few minutes of our time, she threw herself on to the couch and refused to leave until her problems were all fixed. Since she was beginning to go over time, a firm order that she needed to visit next week was given. She finally obeyed, and strut out of the office. She gave the finger and she turned the corner.
Client/Family Background:
Ms. Wurtzel has a long line of psychological disorders in her family history. We have evidence that her grandfather was an alcoholic the majority of his life and was also abusive to his wife. This gives us proof that there is a history of instability and substance abuse and dependency. Her grandma suffered from melancholia and was forced to stay in an asylum a significant portion of her adult life. The reason she was put into an asylum has not been determined, however, it can be hypothesized that she was critically mentally unstable. Ms. Wurtzel’s father was never tested for mental disorders but his behavior indicates that he was also under its influences. He seems to have a sleeping disorder, has a substance abuse with alcohol and Valium and experiences denial. Ms. Wurtzel’s mother seems to also be quite psychologically unstable. She is extremely emotionally disturbed, digresses to childish behaviors, and suffers from denial and aggressive behavior. When it comes to dealing with her daughter she seems to be flighty and have extremely high expectations.
Ms. Wurtzel has a handful of cousins who have suffered from elaborate episodes of depression and have been intense drug and alcohol users. On various accounts they have also committed various attempts at suicide.
Ms. Wurtzel has been through a lot of stressful situations with her family. She experienced her parents getting a divorce at the very young age of two. Throughout her childhood she was continually pushed between parents, each of them toying with her loyalty. Ms. Wurtzel was forced to go to summer camp every summer, which regularly would not be seen as a traumatic event, however, she felt immensely disserted and abandoned. During her high school years her father disappeared for an extended amount of time without saying goodbye or contacting his daughter for a number of years. This experience furthered her sense of abandonment with her family.
Detailed Case History:
To fully understand Elizabeth Wurtzel’s case, one must first look at where it all started: her childhood. Her parents were divorced when she was two years old and there was continual conflict between her mother and father. She would travel between their homes and as she grew older her parents would push her to choose sides. She showed early signs of anxiety when she would make her father leave his shoes outside of her door in order to assure her that he had not left her alone. As a very young little girl, however, most people viewed her as a chipper, smart, creative child. She was viewed to have a lot of promise and to be headed down a successful path, despite her parent’s issues and the instability of their home life. Her relationship with her mother eventually turned into more of a friendship than a parent-child role. Ms. Wurtzel became her mother’s confidant and was told a lot about their financial issues and the problems Mrs. Wurtzel had with her husband. The small conflicts that Ms. Wurtzel had during early childhood did not amount to anything that seemed considerably peculiar or inappropriate to anyone. As she entered middle school, however, more serious problems arose.
At age eleven Ms. Wurtzel started showing deviant and threatening behavior. When her parents “forced” her to go to summer camp she felt the range of emotions from anger, fear, abandonment, and then on into being depressed. While at summer camp she attempted to overdose on allergy medicine. She claimed that it was not a suicide attempt, but she was hoping that by overdosing people would see that there was something wrong with her. She wanted her parents to come pick her up. It was that same year that Ms. Wurtzel was found cutting her legs with a pack of razor blades in the girls locker room at school. She claimed that this was not a suicide attempt either, but that she simply wanted to know that if things became bad enough that she could in fact inflict harm on her body. Because of the amount of time she spent with the school psychologist, it was recommended that she see Dr. Isaac, a professional psychiatrist. This is also when her negative self body images started. She became certain that she was fat and because of the emotional drain she felt would cry for hours at night because she felt pressured from others to be perfect. She felt like she must act like her old self and became anxious and whelmed when she realized she could not hide who she really was. She continued going to camp during the summer. During these trips, she would obsessively call her parents and distant relatives, several times a day, to make sure someone would be there to pick her up. She was constantly anxious and worried that she would be forgotten and left behind.
When her therapy started, Ms. Wurtzel cooperated and actually claimed that she liked talking with Dr. Isaac. She eventually began making excuses so she could skip school and spend more time talking with him. Due to this, her grades began to slip considerably and she concluded that the daily routines and things people did in life were all pointless because everyone was going to die anyway. At this point, she feels like the happy girl she once was is already gone and that the only true pleasure she can experience is causing others pain. One thing she had an extreme interest in, however, was boys. She seems to attract the attention of older boys and men even at the young age of twelve. She has her first sexual encounter with a boy who is 17 when she is 12. (She does not have complete sexual intercourse at this time). At this point, she feels like this physical activity is the most wonderful thing and that it brings her true happiness. She knows that it is wrong, however, she mentions that she just wants to be doing sexual activity like this all the time. At age thirteen, she manages to convince her parents to let her leave summer camp and go spend time with her cousins at her aunt and uncles. She smoked an insane amount of pot and went to keg parties.
These tendencies continue and become more serious as Ms. Wurtzel enters high school. She goes through different stages where she enjoys school and tries to be sociable, and then diverts back to being antisocial, depressed, and unmotivated. For the most part, Ms. Wurtzel feels unaccepted at school and that everyone judges her and thinks she is a complete mess. Throughout all of these stages, especially the major depressive ones, Ms. Wurtzel’s mother forced her to still participate in real life in order to prevent her from completely wallowing in her self-pity. Nevertheless, Ms. Wurtzel still manages to find more reasons and evidence that she is worthless and that she in fact is a failure. It was because no one could tell her what was really wrong with her, or how to treat it, that Ms. Wurtzel began wishing she had some sort of addiction to alcohol or drugs. She began to create a belief system that would last for years, that if she could only have a “real” problem, like a substance addiction, that she could be put into rehab and be “fixed”.
The situation with her parents continued to worsen, and the belief that her father truly did not love her unconditionally became more influential in how Ms. Wurtzel responded to her dad and how she functioned in her day to day relationships. Her father was consistently disappointing her, not following through, and eventually really disappeared at the end of her freshman year in high school. She began to try and fill that void with dating. While in the beginning of relationships she was able to remain pretty stable, things became quite complicated as time went on. She would wallow in her depression and continually talk about it, crying and would constantly need reassurance that the boy loved her and would never leave her. She became obsessive with planning their futures together and making sure that they would stay together, rather than focusing on the present and simply enjoying the relationship. Through these habits she lost various boyfriends and became even more frustrated with men and her feelings.
When things worsened for Ms. Wurtzel, things with her mother also seemed to become more complicated. Her mom would often times blame Ms. Wurtzel for causing her so much pain and being too much of a burden. She would threaten her that she was going to die because of all of the stress she was put through. Ms. Wurtzel stopped going to therapy because her father would not pay for the bills, and her mother could not afford it.
As Ms. Wurtzel started college at Harvard she developed the habit of drinking large quantities of alcohol at continuous parties, taking various drugs such as cocaine, pot and Ecstasy, and chasing and running from hookups with boys. Because of the late nights and the intense intoxication, she spent a lot of time holed up in her dorm room, too afraid to socialize, unless under the influence. She took a liking to becoming involved in risky situations, like sleeping with her best friend’s boyfriend, and taking so many drugs that she is incoherent and doesn’t remember what she did the night before. She is aware that she is not addicted to the drugs in the sense that she is dependent on them, however she continually abuses them and wants to be high or on a “trip” in order to escape her mind. Throughout college she is checked in and out of Stillman Infirmary due to hysterical breakdowns, overdosing on drugs and alcohol or depression medicine. She occasionally sees the psychiatrist or psychologist at the college, but cannot undergo continual therapy because her father still would not pay the bill. She had occasional contact with her father but they tended to end up fighting and blaming each other for the way their relationship was.
Throughout her entire time at college she battles major depressive episodes, where she cannot leave her room and stays in bed. She has days where she does not sleep at all, but is able to do all of her schoolwork in the middle of the night and somehow do well. Other days she completely blows off school and her assignments and exams and manipulates her professors into accepting her excuses. She is also incredibly manipulative of her “friends”. She is constantly complaining of how bad her life is and how they need to take her seriously and get her help or she will kill herself. She has the inability to follow through with commitments she makes. When she does get a boyfriend she becomes obsessive and constantly wants to be with them or be reassured that they care about her and will not leave her. She feels the need to always talk about how she feels and how messed up she is. It is very evident that she has a lack of concern for others. She has flighty behavior, disregarding others feelings and needs and becomes quite hypersexual She has numerous partners and finds that sex is one of the only times she feels real sensation.
Ms. Wurtzel is extremely impulsive. When she comes up with an idea of something she wants to do, somewhere she wants to go, or someone she wants to sleep with, she will attempt it. She goes on random stints to work in Dallas even though she doesn’t really know anyone there or have anything set up. When she was not working she was constantly drinking, partying, dating over a dozen men at the same time and using caffeine to make up for the lack of sleep. There was a complete lack of recognition of those who cared about her or needed her to be stable. She dismissed her obligations to her family and when stressed or nervous would turn to alcohol. She often times is seeking something that will give her life meaning and jumps to decisions without much contemplation, to realize later that she really did not want to do what she did. This, as well as her involvement in unwise behavior seems to be a means to try and drown out her feelings of desperation, loneliness and anxiety.
Eventually, it is apparent that Ms. Wurtzel can no longer function without seeing a therapist. Dr. Diana Sterling is recommended. At the beginning of the sessions, things seemed to have settled down in Ms. Wurtzel’s life. After a month or so, she starts to have a mental breakdown and feel like she cannot handle life again. A few days later, Ms. Wurtzel had a miscarriage. Prior to waking up to a bed full of blood, however, she was not aware that she was pregnant. When she initially found out she was hysterical and was given a series of Xanax, Valium, and Thorazine to calm her down. She ended up using the miscarriage as an excuse to be depressed and used it to make her friends and strangers feel sorry for her.
Ms. Wurtzel has another break down, however, she becomes obsessed about getting her school work done. She felt that if she could get her work done that everything would be okay and she could maybe make it through another day. She becomes so hysterical, however, and irrationally talking about suicide that she is brought back to Stillman Infirmary for an extended stay. She is given Dalmane and encouraged to sleep between interviews with her doctors. These stays at the infirmary become routine and Ms. Wurtzel has an increase in extreme episodes where she cannot function and becomes hysterical. While she has the desire to become better, she has completely resigned herself to being depressed and really must push herself to consider that she could become better if she tried. She becomes obsessive compulsive with calling Dr. Sterling, every five minutes, in order to be reassured that she will come out of this depression one day. To her it feels like nothing sticks in her mind, nothing is truly real to her unless it is right in front of her or if someone continually reassures her. At this point she states that she considered suicide more seriously than she ever had before. This pushes Dr. Sterling to decide that she will try a chemical treatment on Ms. Wurtzel. Dr. Sterling claims that her main symptoms are anxiety and agitation. She had an extremely negative reaction to Xanax, and then is put on Mellaril which seems to work initially. After awhile though, the Mellaril ends up just making her feel blank and taking away all emotions, to the point where she doesn’t experience any feeling.
These patterns continue, in and out of Stillman, off and on medication, traveling to random places in order to try and escape what she is feeling. She ends up not having enough energy to go to therapy, eat, and not even enough to sleep. She decides to do an independent study semester so she can go to London and hopefully escape her life in the U.S. The trip ends up being a disaster where she feels taken advantage of by men, becomes even more depressed and completely alone in the world. It furthers her dependence on her therapist, who she calls over twenty times a day. She eventually comes home and tries to get back into a routine. Because her mother is mugged, she is forced to take responsibility and try to help her mother and family out. This sort of puts things into perspective for her and somewhat pushes her to think of someone but herself. There is a pivotal movement of their time together, when her mother says that she understands that Ms. Wurtzel cannot deal with anything because she is depressed. Ms. Wurtzel is surprised and grateful to realize that her mother understands her and why she is the way she is. She realizes that depression is something that must be dealt with on its own terms and that it is something she could overcome.
When she returns once again to school, things seem to be fine, however, she is overcome with the desire to kill herself. She tells Dr. Sterling her well thought out plan and Dr. Sterling tells her that she is going to take her to the hospital. Before she can, however, Ms. Wurtzel goes into the bathroom and finds the bottle of Mellaril and takes all of the pills in the bottle. She goes through a wide range of reactions; laughing hysterically, crying, hating life, wanting to go home and jump on the bed and enjoy life to the fullest. She later explains that she simply wanted to know what it felt like to go that far, she wanted to know if she really wanted to die, and she realized she didn’t. She admitted that she had somewhat fallen in love with her depression and believed that it is was all she had and it was what made her worthwhile.
Diagnosis
Reasons for Diagnosis of Dysthymic Disorder:
First off, Ms. Wurtzel meets enough criteria for the Axis I diagnosis of Dsythymic disorder. In general, and in regards to Criterion A/1 she feels depressed most, if not every, day for years on end. Friends and family claim that she has always been a down-in-the-dumps person. Ms. Wurtzel has days where she can hardly get out of bed, eats too much or nothing at all, is not able to move around with adequate energy, and does not value herself, but instead sees herself as worthless.
With Criterion B/2, she goes days where she does not think she has enough time to eat. Her sleep cycles are not the most stable. She complains of tiredness and lethargy often, makes poor choices, and feels that she is a meaningless, insignificant creature.
Ms. Wurtzel meets Criterion C/3 by not having gone more than two months without a significant amount of the above symptoms. Where Ms. Wurtzel differs is that she has overlapping periods of more intense lows, which qualify her for Occasional Major Depressive Episodes.
Those incidents that seem manic in nature are best related to her Axis II, Borderline Personality Disorder. The diagnosis of psychotic features is distant from her overall issues. Although she does use a vast majority of substances, these are in reaction to preexisting conditions and not the cause of her problems. Ms. Wurtzel even self declares that she uses drugs so people will know that she has a real underlying problem. Her disorder causes immense difficulties in societal, career related, academic, and personal functions in life.
Reasons for Diagnosis of Occasional Major Depressive Episodes:
Her Dysthymic symptoms become increasingly severe at times.
Reasons for Diagnosis of Borderline Personality Disorder:
Overall, in confirmation of the diagnosis of BPD, Ms. Wurtzel has extreme difficulties in relating to other people and herself, and makes hurried, rash decisions. Fulfilling symptom one, she constantly feels that abandonment is right around the corner and that the people important to her could leave at any moment. (Remember the shoes of her father outside of her door). She also goes back and forth between calling her relations great and horrible influences in her life. Ms. Wurtzel has extreme issues in regards to her unique identity. She is unable to figure out who she is no matter how hard she tries.
Item four is directly applicable in that she participates in possibly dangerous activities, including having numerous sex partners and using not just one illegal drug at a time, but multiple illicit substances concurrently. Ms. Wurtzel´s entire history is dotted with incidents of suicidal feelings/tendencies/half-hearted attempts. Hours of intense anxiety attacks are not uncommon. Object seven fits accurately in describing her feelings of hollowness. Ms. Wurtzel does have some incidents of anger, namely all out battles on the phone with her father. Criterion nine establishes that she has temporary, stress-related, paranoid formation of crazy ideas. It also explains her severe inability to separate her thoughts, emotions, and experiences from one another purposely and effectively. This is extremely evident throughout her entire college career.
Treatment Plan:
For Dysthymic Disorder
The first plan of action is to introduce Ms. Wurtzel to some type of Selective Serotonin Reuptake Inhibitor (SSRI), possibly Cymbalta, Paxil, Effexor, Celexa, Wellbutrin or others.
These drugs are more reliable than older forms of drugs used against depression. If necessary, combination of the above medications could be prescribed. This process will inevitably be trial and error, to see how Ms. Wurtzel´s brain chemistry responds to changes.
The above biomedical treatment will be combined with biweekly intense therapy sessions in which Ms. Wurtzel will be retrained to correct her thinking and behavior based off of studies on patients who have had success with these therapies. The focus of this treatment will be to establish a positive self image for Ms. Wurtzel and give her the tools to learn self control, as well as beneficial and constructive thinking and behavior.
For Borderline Personality Disorder
A potpourri of care is available to choose from. This clinic is recommending the following:
Ms. Wurtzel simply needs more people in her life who can sit down and truly listen to her. One possibility for this would be joining support groups. These would provide Ms. Wurtzel with a network of people who understand her struggles and can lend listening ears on a regular basis. In the few instances where her parents listened without bringing themselves into the situation, Ms. Wurtzel felt relieved and comforted in the fact that she had connected in some way with another human being. Family therapy is also being advised. Ms. Wurtzel should become involved with some sort of relaxation therapy, such as yoga and meditation. A colleague is offering a discount on a five year plan of psychoanalysis; this is strongly encouraged, as Ms. Wurtzel has many deep childhood issues to work through. Finally, it can be asserted that some of the drugs used to treat her Dysthymia may leach over and help treat her BPD.
Overall:
The major goal for Ms. Wurtzel is for her to regain a stable life, functioning in the world as a productive and happy individual. The minor goals include her ability to effectively communicate her emotions to appropriate people in a manner so as to relieve her symptoms without increasing their severity. Furthermore, it is hoped that Ms. Wurtzel will develop the skills necessary to interact with her friends, classmates, and family in a harmonious manner.
Also, Ms. Wurtzel´s regulated mood is of utmost importance. Boosting the lows, and capping off the highs is expected to take a significant amount of work, but is highly possible. These goals are to be reached in a manner so as to produce immediate beneficial effects while working on longer term problems simultaneously. Ms. Wurtzel would refuse further treatment if we did not provide some type of instant gratification. Practical ways to reach these goals include Ms. Wurtzel applying herself to a process of recording her life as she lives it and then summarizing it for the practitioner to evaluate and use to better understand Ms. Wurtzel´s patterns of behavior.
Any and all types of therapy are worth a try in the case of Ms. Wurtzel. Extreme behavior modification is planned, replacing her negative actions, such as drugs, sex, and drinking, with activities such as gardening, hiking, and caring for a pet. Immediate implementations of certain changes are required, but constant new behaviors are the goal.
Prognosis:
This is a very intensive treatment plan that is being suggested. Ms. Wurtzel is hoped to establish a sense of stability in her life. Together we can help Ms. Wurtzel achieve constant and mellow relationships. Through this therapy she will be able to acquire a sense of security that will reassure her that she will not be abandoned. She will hopefully achieve self-actualization, forming her own identity. We will help her control her impulsivity, giving her the confidence to say no to unsafe habits, such as multiple sex partners and drug and alcohol abuse. These therapies will also help her value life, instead of desiring to end it. She should be able to decrease her frequent outbursts of temper, thus controlling her anger. She will personally have the tools to separate her experiences from her past from the choices she is currently making.
She will learn how to regulate her eating and sleeping habits, and stabilize her energy levels. She will comprehend how to make informed and wise decisions without depending solely on others input. All of this together will ultimately be able to give her a sense of hope and a sense of meaning in her life.
Multiaxial Evaluation Report Form
Name: Elizabeth Wurtzel
Date: February 20, 2009
AXIS I: Clinical Disorders
300.4 Dysthymic Disorder, Early Onset, Typical Features with
Occasional Major Depressive Episodes
AXIS II: Personality Disorders
301.83 Borderline Personality Disorder
AXIS III: Relevant General Medical Conditions
AXIS IV: Psychosocial/Environmental Problems
1) Divorce of parents.
2) Financial Difficulties. Not enough money for full treatment.
AXIS V: Global Assistant of Functioning Score:
Varies from 20 to 35
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