COUN 5453 Psychopathology
“Sad and Alone” – Mrs. Upton** – For Study Purposes only!!
“Irene Upton was a 29 year old special education teacher who sought a psychiatric consultation because “I’m tired of always being sad and alone.”
The patient reported chronic, severe depression that had not responded to multiple trials of antidepressants and mood stabilizer augmentation. She reported greater benefit from psychotherapies based on cognitive behavioral therapy and dialectical behavior therapy. Electroconvulsive therapy had been suggested, but she refused. She had been hospitalized twice for suicidal ideation and severe self-cutting that required stitches.
Ms. Upton reported that previous therapists had focused on the likelihood of trauma, but she casually dismissed the possibility that she had ever been abused. It had been her younger sister who had reported “weird sexual touching” by their father when Ms. Upton was 13. There had never been a police investigation but her father had apologized to the patient and her sister as part of a resultant church intervention and an inpatient treatment for alcoholism and “sex addiction.” She denied any feelings about these events and said, “He took care of the problem. I have no reason to be mad at him.”
Ms. Upton reported little memory for her life between ages 7 and 13 years. Her siblings would joke with her about inability to recall family holidays, school events, and vacation trips. She explained her amnesia by saying “Maybe nothing important happened, and that’s why I don’t remember.”
She reported a “good” relationship with both parents. Her father remained “controlling” toward her mother and still had “anger issues,” but had been abstinent from alcohol for 16 years. On closer questioning, Ms. Upton reported that her self-injurious and suicidal behavior primarily occurred after visits to see her family or when her parents surprised her by visiting.
Ms. Upton described being “socially withdrawn” until high school, at which point she became academically successful and a member of numerous teams and clubs. She did well in college. She excelled at her job and was regarded as a gifted teacher of autistic children. She described several friendships of many years. She reported difficulty with intimacy with men, experiencing intense fear and disgust at any attempted sexual advances. Whenever she did get at all involved with a man, she felt intense shame and a sense of her own “badness,” although she felt worthless at other times as well. She tended to sleep poorly and often felt tired.
She denied the use of alcohol or drugs and described intense nausea and stomach pain at even the semi of alcohol. On mental status examination, the patient was well-groomed and cooperative. Her responses were coherent and goal-directed, but often devoid of emotional content. She appeared sad and constricted. She described herself as “numb.” She denied hallucinations, confusion, and a current intention to kill herself. Thoughts of suicide were, however, “always around.”
More specific questions led Ms. Upton to deny that she had ongoing amnesia for daily life, particularly denying ever being told of behavior she could not recall, unexplained possessions, subjective time loss, fugue episodes, or inexplicable fluctuations in skill, habits, and/or knowledge.
She denied flashbacks or intrusive memories but reported recurrent nightmares of being chased by “a dangerous man” from whom she could not escape. She reported difficulty concentrating, although she was “hyperfocused” at work.
She reported an intense startle reaction. She reported repeated counting and singing in her mind, repeated checking to ensure that doors were locked, and compulsive arranging to “prevent harm from befalling me.”
**RIchard J. Loewenstein M.D., in DSM 5 Clinical Cases, Barnhill, J. (Ed.), 2014