Case Vignette 1

Scenario
Ms. P is a 17 year-old high school senior. She is referred for
evaluation after attempting suicide with an overdose of pills. Just prior to her
suicide attempt, she had a fight with her stepmother after she told her she
did not feel well and did not want to babysit her younger stepbrother that
evening. Ms. P stated that her stepmother told her she would be glad when
she left for college because she was a worthless person who didnt deserve
the family she had. Ms. P indicated that her biological mother died when
she was 8 years of age and she has a rocky relationship with her
stepmother. Her father works long hours and her stepmother is the primary
disciplinarian in the family.
Over the past month, Ms. P has been sad, crying frequently, and has
lost interest in her friends, school, and family activities. She mentions that
she is looking forward to a visit from her boyfriend, who attends college in
another state. Ms. P has difficulty sleeping, and she reported that there were
a couple of nights when she never went to sleep at all. In addition, she has
lost 8 pounds in the last month and she reported she is not ever hungry.
Upon further evaluation, Ms. P reported that she occasionally hears
voices telling her that she is worthless. At times, she thinks it sounds like her
mothers voice.
Symptoms: suicide attempt, anhedonia, lack of a strong father-figure, poor
relationship with primary caretaker (mother), daily depressed mood
(frequent crying), insomnia, weight loss, loss of hunger, feelings of
worthlessness, hearing voices
Differential Diagnosis
Major Depressive Disorder (Unipolar)

Has severe depressive episodes indicated by the presence of at least

five major symptoms of depression including: feelings of sadness
(emotional), anhedonia (motivational), weight loss & insomnia
(physical), and feelings of worthlessness (cognitive). These symptoms
have all occurred recently and within a close timeframe, likely less
than a month apart judging from the context of the information.
Attempt of suicide major distinguishing factor from other depressive
disorders is the presence of suicidal thoughts and attempts. Ms. P had
already attempted suicide, which is why she was referred for
evaluation.
Lack of mania or hypomania no mood swings or manic episodes. This
indicates that the disorder must be unipolar in nature.

Persistent Depressive Disorder (Dysthymia)

Has persistent depressed mood. The scenario indicates that the poor
relationship between Ms. P and her stepmother, which is likely a
catalyst for many of the other symptoms, has been an ongoing one.
Ms. P consistently demonstrates significant distress/ impairment with
her behavior.
Other key symptoms include poor appetite, insomnia, low self-esteem,
and feelings of hopelessness (with her situation at home). The
description says that Ms. P is looking forward to a visit from her a
boyfriend, so that is probably her only and last source of comfort.
Lack of mania or hypomania no mood swings or manic episodes. This
indicates that the disorder must be unipolar in nature.

Schizophrenia

Ms. P may find herself in an active state of schizophrenia, one where

the symptoms are present and may likely be triggered by a stressor
(her step-mother). This makes sense due to her age (late teens) and
presence of positive schizophrenic symptoms.
According to the information, Ms. P recorded that sometimes she would
hear voices in her head which sounded like her mothers voice. This is
an auditory hallucination which is classified as a positive symptom of
schizophrenia. Additionally, it may be likely that Ms. P has delusions of
persecution from her unsupportive step-mother. Presumably, after
several years of having a poor & maybe even abusive (information
says the step-mother was primary discipliner) relationship with her
step-mother, Ms. P may see her mother as a threat instead of a
caretaker.
Functioning in regular aspects of life has fallen to a lower level of
achievement. This can be seen in Ms. Ps weight loss, lack of desire to
babysit her brother, and loss of interest in her friends & school.

Assessment Plan
For my assessment plan, I would first administer a projective test, attempting
to uncover unconscious conflicts and motivations. Specifically, I would
choose to administer the TAT test because it reveals the subjects habitual
patterns of thought and emotional responses. Though projective tests often
lack validity and reliability, I believe that administering one will provide great
supplementary observations in conjunction with more concrete assessments.
Next, I would give Ms. P a clinical interview (unstructured) so that I can see
her conscious thoughts and emotions and whether they could be linked/ a
result of the unconscious factors unraveled by the projective test. By giving
the interview after, I believe that Ms. P will have less bias during the
projective test. I will use these two as the primary assessment tools.

Primary Diagnosis
Considering all the symptoms and factors, I believe the cause of Ms. Ps
abnormality is a case of Major Depressive Disorder.
Treatment Plan
Treatment for Major Depressive Disorder can be done in multiple ways. I
believe that the source of Ms. Ps depression stems from the loss of her
biological mother, the absence of her father, and her adverse relationship
with her stepmother. You could appropriately administer both psychodynamic
and behavioral treatment in this scenario. However, I think unconscious
factors are much more influential than conscious conflict, so I will use
psychodynamic treatment. One method I believe would be very effective is
therapeutic transference. It is obvious that Ms. P lacks the presence of a
strong father figure in her life. Her older boyfriend has become the source for
her sense of security. I will ask Ms. P to elaborate on her feelings towards her
boyfriend to determine whether they are congruent to feelings one would
typically have for their parents. Additionally, I will ask Ms. P to do this with
her feelings for her biological mother. Hopefully, this will unravel unconscious
emotions for her mother and father that would not have been apparent
otherwise.