Casey is a 25-year-old male who has suffered from bouts of sadness and lack of motivation about every three months for 8 years. He claims to have done all he can to stop this, yet is not strong enough to achieve it. He has several close friends who he has confided this too, but they have also been of little help. He claims to hear diffuse voices that tell him to hurt himself sometimes, which he has done a few times, including one suicide attempt.
The situation in his household has always been complicated. His father and his mother have had many heated verbal battles, which have sometimes lead them not to speak to each other for days and even weeks. He describes his mother as being submissive, while his father was more aggressive, even though he makes emphasis that the latter never physically hurt the former. When he was 14 years old, his father left the household and only sends them a generous paycheck once a month. This separation had a great influence on him, specially seeing his mother continuously crying for many days; he believes that she has still not gotten over this, offering as evidence the fact that she has never had any other romantic bonds. He is the older of two children; his younger sister is currently 18 and has recently left for college. They had a trusting relationship until Casey slowly started to break this bond when his episodes of sadness started; he claims that he did this attempting to spare her from suffering and not to set a bad example.
He claims to have had a relatively happy childhood when his parents were not fighting. He had above-average grades all through school, except for the episodes when his parents were hostile towards each other. Being well liked by both his teachers and his peers, he perceives that he was relatively popular, yet always felt odd and that he did not quite fit in with the rest of his schoolmates. He reports several homosexual episodes with children of his age during this period.
He characterizes his adolescence as being very turbulent, being characterized by his father’s departure and a conflictive adaptation to his sexual orientation. He describes the former, which happened 11 years ago, as the most difficult time of his life. Intense fighting by his parents, until his father left one night preceded this; he has never had contact with him again. After this, his mother constantly cried for about two months, which was only calmed by anti-depressives; the pharmacological adaptation was also difficult due to the side effects. He was encouraged and demanded by the rest of his family to act as the man of the house and be strong, even though this was very difficult for him. A flowering of his homosexual urges, which sometimes lead him to have promiscuous and almost anonymous encounters, immediately followed this. He claims that sometimes the sexual tension was such that he could not control himself; however, he always used protection in the form of a condom. He blames his father’s departure as the cause of his homosexuality, which he has not fully come to terms with. He does not identify himself as a homosexual and claims that he is still sexually attracted to women. He has not told his mother or any of his family members, but he has expressed his sexual orientation to many of his friends.
He began to have a stable romantic relationship with a boy of his age about a year and a half later. He claims he was completely in love and that he would have done anything for his partner. However, after about a year and a half, he was informed of and confirmed that his boyfriend was being unfaithful. He started to feel a strong sense of negative feelings towards himself, thinking that he was unworthy of his boyfriend and of living. After a month of fighting, they decided to end their relationship. Casey did not respond well to this, only leaving his house for high school, where his grades plummeted. He lost interest in most activities, preferring to stay at home in his room. His friends started to worry about him, yet he told them he was fine, that he only felt numb. About a month and a half later, he began experiencing uncontrollable crying impulses and he felt his mind cloudy and was unable to concentrate; both of these lead to a diminishment in his grades, almost having to repeat the year. He described this as being something he had never felt before, not even when his father departed, and that it was regularly worse in the mornings.
As the symptoms worsened, he began to feel strange sensations in his body, anxiety and momentary experiences of depersonalization or despair. He also felt impulses to damage himself, cutting his forearms several times. The hearing of a male voice that enticed him even to commit suicide, which he attempted once by way of pill ingestion, worsened this self-destructive behavior. However, he does not assign too much importance to this hallucination, dismissing it as something he could just have made up, hearing it softly and diffusely. He lost his appetite and the food that he did ingest was not flavorful to him; this made him lose a significant amount of weight. He claims that these episodes last from three to six weeks and usually happen approximately every three to five months. Due to these crises, he decided not to go to college and currently has a minimum-wage job.
Diagnosis
Casey diagnosis is that implied by code 293.34: Major Depressive Disorder, Recurrent, Severe with Mood-Congruent Psychotic Features, With Melancholic Features. His episodes are depressive in nature, which will be posteriorly justified, and happen every one to two months and he does not suffer from Psychotic Disorders nor has never had any other episodes of altered mood. Also, he did not use any altering substances nor was suffering from any physiological diseases. Moreover, while he associates the beginning of his condition with the loss of his boyfriend, it does not fit the limits of Bereavement. The social, academic and work inhibitions that he suffers during these periods justify the severity of the disorder; he was a promising young man with many friends and now lives in a low-income job without having furthered his studies. The criticalness of the situation may be complemented with the hallucinations, which reflect the depressive mood that Casey suffered, as they enticed him to damage and kill himself. The preponderance and intensity of his losing pleasure in all activities; his signaling out these episodes as being the worst that he had ever felt, including the loss of his father; his signs and symptoms being worse in the morning; and the loss of appetite and subsequent weight loss all justify the classification of the disorder as having melancholic features.
His periods of suffering may be classified as Major Depressive Episodes. He suffers a depressed mood, as evidenced by his constant crying and feelings of sadness. His loss of interest and pleasure in everyday activities significantly affected his social bonds and academic goals. Partly due to this loss in interest, especially in food and eating, he lost an important amount of weight. His intellectual activity was also impaired, not being able to concentrate, which also contributed to detriments in his scholarly activities. Finally, the persistent thoughts of death and damaging himself may be one of the most important aspects of this case, as may be evidenced by his attempt and the hallucination that tempted him to do it.
Etiology
The etiology of Major Depressive Disorder has not been exactly discovered. Many studies evidence that there are many factors in play, especially biological, psychological and sociocultural ones. While some believe that it is a result of the summation of these factors, other investigations have found that there is usually a biological foundation, which may be triggered by external factors. As such, these threes aspects of the source of Major Depressive Disorder will be examined with relation to this particular case, not so that the cause may be determined, but so that their analysis may serve to better understand the patient and to better explore treatment options.
Biological
There are many biological theories that help explain depression through many approaches. While some point to abnormalities in monoamine and serotonin, others explain the disorder through the use of circadian rhythms and sleep patterns, among other theories. Nevertheless, as this case does not contemplate these factors, the most important biological aspect is the genetic one. “In this large, nationally representative twin sample, when the parameters were constrained to equality in men and women, the heritability of major depression was estimated to be 38%” (Kendler, Gatz, Gardner & Pedersen, 2006). As his mother suffered was diagnosed with and treated for depression, heredity could have played a major factor in his syndrome.
Psychological
There are various psychological aspects that should be taken into account with regards to the cause of Major Depressive Disorder in this case. First, the only evaluations he makes of his parents are negative in nature. They were both absent in different ways: while his father was not present physically, his mother’s depression also made her not take care of Casey adequately. This unhealthy attachment produced consequences in the conformation of his self-perception. One can see that this caused a representation of the self as being unlovable, which is reflected in the feeling of unworthiness that accompanies the romantic rupture that begins the syndrome.
Furthermore, his parents did not allot him with sufficient cognitive strategies to be able to affront this disease. Both father and mother retreated and severed ties with others when they found that they were not able to keep sustaining the marriage, instead of finding the tools within themselves and others to better the situation and its management. As such, one may see that Casey’s most affected component during his depressive episodes is the cognitive one, especially through the loss of concentration that made studying impossible and the mental impulses to do himself harm. If his were able to better combat these intellectual elements, the disorder could be countered in a more efficient manner.
Sociocultural
The sociocultural aspect of this case could be the most important, particularly in relation to his family, his romantic rupture and his sexual orientation. As was briefly mentioned before, his parents turmoil and their subsequent rupture had a profound impact on Casey. These social factors contributed to his syndrome, as he did not have stable and loving role models to rely on. Furthermore, their separation marked the point of culmination in their rejection of Casey, as the latter did not receive attention from either of them. His sister was also a burden on him, as his love for her made him separate himself so as not to make her suffer.
Nevertheless, it was not this household situation that triggered the syndrome but his own romantic rupture. While the childhood situation may have set the ground for what happened afterwards, the feelings of self-worth and the depressive episodes started after he caught his boyfriend being unfaithful to him, causing them to terminate the relationship. “The main finding from these analyses is that, on average, TR [Targeted Rejection] events are associated with a significantly quicker onset of depression than non-TR events, even after adjusting for history of depression” (Slavich, Torres, Monroe, & Gotlib, 2009). He suffered the ordeal as if his boyfriend was rejecting him and that he was not worthy of an adequate life. The biological and childhood events paved the way so that this targeted rejection event advanced the onset of the disease.
Finally, his sexual orientation also played an important role in this case as a catalyzer. While it was not the cause of the condition per se, the influence that it had on the rapid development of the disease is not negligible. His decision to keep this a secret, even though he sustained a romantic relationship, made him further retreat from his social circles. The rejection that he felt from society as a whole, including his classmates, should be taken into account when affronting this case. It served to further retreat him from his friends, who could have helped him overcome or counter this syndrome.
Treatment
Medication
Medication would probably be an appropriate course of action, as part of the disease may be genetic and is severe in this case. Selective Serotonin Reuptake Inhibitors (SSRIs) are the predominant pharmacological treatment options for Major Depressive Disorder. “[T]reatment with SSRIs is associated with symptomatic improvement in depression by the end of the first week of use” (Taylor, Freemantle, Geddes, & Bhagwagar, 2008). However, studies have linked them to an augmentation of suicidal tendencies, which should be evaluated for this case. These and other side effects should be taken into account to adjust the substance and the dosage to be taken. The beneficial consequences that the use of antidepressants had on his mother could also be used in a favorable way.
Psychotherapy
As Casey is very intellectually and socially resourceful, he would also benefit from psychotherapy. Even though there are many different currents in this discipline, many times this has not been an important factor. “There were no significant differences in percentage symptom reduction based on psychotherapy type” (Khan, Faucett, Lichtenberg, Kirsch, & Brown, 2012). Therefore, instead of indicating the specific techniques and philosophy behind a proposed therapy, Casey’s particular life situations and resources will be explored to propose a guideline for this modality of treatment.
One of the main aspects of the therapy would have to be impulse control, so that he may stop hurting himself and putting his life in danger. One can build this on top of how accomplished he was as a child and the hope that he may regain those achievements through therapy. The suicidal thoughts should also be explored and diminished or eradicated.
His social relations should also be analyzed so that he may have a better life. He should be continuously encouraged to regain contact with his friends and make new ones. Similarly, his relation to his mother and his sister, who seem to be sources of defeat and protection, respectively, should also be retaken. This would improve his self-esteem, as he would see that others also value him.
Finally, his relation to his own sexual orientation should be explored, so that he may come to terms with it. Without prejudices, this should be examined and accepted so that he may accept himself as a whole. For others to accept him for who he is, he must first accept himself with all his benefits and downsides.
Prognosis
Reference List
Kendler, K. S., Gatz, M., Gardner, C. O., & Pedersen, N. L. (2006). A Swedish National Twin Study of Lifetime Major Depression. The American Journal of Psychiatry, 163, 109-114. doi: 10.1176/appi.ajp.163.1.109.
Khan, A., Faucett, J., Lichtenberg, P., Kirsch, I., & Brown, W. A. (2012). A Systematic Review of Comparative Efficacy of Treatments and Controls for Depression. PLos One, 7. doi: 10.1371/journal.pone.0041778
Slavich, G. M., ThorntonT., Torres, L. D., Monroe, S. M. & Gotlib, I. H. (2009). Targeted Rejection Predicts Hastened onset of Major Depression. Journal of the Society of Clinical Psychology, 28, 223-243. doi: 10.1521/jscp.2009.28.2.223
Taylor, M. J., Freemantle, N., Geddes, J. R., & Bhagwagar, Z. (2008). Early Onset of Selective Serotonin Reuptake Inhibitor Antidepressant Action. Arch Gen Psychiatry, 63, 1217-1223. doi: 10.1001/archpsyc.63.11.1217
