Case Digest

Presenting Problem
Paula is a 27-year-old white female who lives in a large city. Paula is single and has never been married.
She works as a securities and bond trader for a major financial institution and has done so since she
graduated from college. "I got my BA in Economics, and the economy was doing really welL This
company sent recruiters to campus, we had a good match, and so here I am." Paula has "shown loyalty to
this firm; I've worked for them since I graduated. The hours can be nuts at times but look at what I have to
show for it! They're great in that they're going to pay for me to get my MBA. I was all set to go for it
when the problems started getting worse." Paula was 5'6" tall, wore glasses, and was somewhat thin. She
made good eye contact and had a blunted affect but often appeared tense in the sessions. For example, she
would have a frightened look in her eyes at the start of each session, similar to the "look a deer has when
it's caught in the headlights. I know how I look when I'm scared." She did not smile much and always
seemed on edge. We noticed that her hand would often go to her neck to check her pulse, or over her
heart. She would perform these behaviors about four times each session. Paula wore no jewelry except for
a Phi Beta Kappa Key attached to a small wrist chain. We asked Paula for some clarification, and for the
reason(s) she came in. "Well, if you thought you were having constant heart attacks and dizzy spells,
you'd look for help also. Lately my heart beats so fast, I get dizzy, have chest pains, and I'm short of
breath. I feel like I'm dying and the world is ending. I've gone to the emergency room a number of times
and each time they tell me it's in my head and nothing is wrong. I went to a cardiologist for a sonogram
and echocardiogram and he found nothing wrong at all with my heart. He also told me that the problem
was psychological He told me to get some hypnosis and relaxation training, cut out caffeine, and maybe
exercise and do yoga or Tai Chi. He also suggested that I try and not spend as much time at home with
mom." "1 got a bit worried and of course I went to another doctor when I got the next attack. He told me
the same thing and told me to relax more. He also gave me some Xanax (alprazolam*) to help me relax. I
used it a lot and it really zonked me out. I was like the walking dead. It helped, but once I stopped taking
Xanax because I couldn't work while on it, the attacks came back. My mom and my best friend at work
got worried and told me to see someone. My general practitioner recommended you, so that's why I came
in. I need to get this thing under control and over, and I'm afraid to not use Xanax, since it worked before.
I can't drive while taking it, so hopefully there are some logical answers to this."

Background Information

Paula's mother is a homemaker, and her father owned a car dealership. He died "shortly after I graduated.
He knew I had a job so at least he lived to see that. He died from congestive heart failure; I hope that
doesn't run in the family. My dad had a huge insurance policy, and when we sold the business, my mom
was set for life. She does painting as a hobby and sells it to a store in the neighborhood. She's really good
at it." Paula is an only child, but there is a story behind that. "1 had a younger brother who was very sick
when he was born. He had a heart defect and other birth defects that! really don't wish to discuss. He died
when he was three. The doctors tried everything but it was basically hopeless. The defects were not
picked up while he was in the womb, so we were upset and thought about suing the doctors. My dad, who
was too soft, said to forget it and move on. They tried to get pregnant again but it didn't happen. They
were still too devastated by his death to consider adoption, and they didn't want to wait at least five years.
My mom is still affected by this." Paula reached all of her developmental milestones at the ageappropriate
levels with one exception. "I was reading when I was four; they considered this early. They put me in a
special program at school and I was always the best reader. I still love to read. I guess that's why my eyes
are so bad. My dad was a math whiz and my mom, well, she's the intuitive one in the family." Paula lives
at home with her mother "to take care of her and watch out for her." Paula was unattached at the start of
the sessions and said "it's probably because of three things: I work too hard and too many hours, I live at
home, and my problems prevent me from going out a lot. They come and go, but they've really gotten bad
lately. I'm not sure what's happening. I stopped using caffeine, but that gave me the shakes and it made
me tired all the time. It's hard to give that up. I also stopped smoking, figuring that might help. It did, a
bit." At this point Paula appeared on the verge of tears but none were noticed. We then asked Paula for
some more family background. "My mom has had health problems, but nothing psychological that I know
of. Her father's father, who was from Poland, had a bad drinking problem. Other than that, nothing. My
dad was the same way, no psychological stuff. His health was quite bad. Here was a man who was never
sick when I was young. He hits 50 and bang! All of a sudden everything breaks down. He got cancer, then
emphysema, and then the heart failure. He always said that the cigarettes caused his troubles, but cancer
also ran in his family. His mother died from breast cancer, and his father from colon cancer. I have a lot
to look forward to. That's one reason I stopped smoking, and I don't drink. I have enough bad seeds in
me." Paula was reluctant to continue at this point and said she needed "some air. I'll come back next week
if that's okay." We were about to answer when she flew out of the office. She called later that day to
confirm her appointment for the following week.

Thought Questions
1. What is going on with Paula?
2. What other physiological possibilities might explain Paula's behavior?
3. Paula seems like a very bright woman. How could someone so bright possibly have a mental illness?
4. How important is Paula's family history?
5. Paula works in a high-pressure job. How might that be related to her symptoms?
6. Are there any predisposing and/or precipitating factors to her condition?

Presenting Problem
Sarah is a 14-year-old white female who is in the eighth grade at a local public junior high schooL Sarah
has an 18-year-old stepbrother from her father's second wife. "My dad divorced when I was very young, 6
years old. My mom was an alcoholic, a really really bad drunk. My dad is 38 and is as straight as they
come. He finally divorced her and he got custody. My mom's on welfare and couldn't take care of me. I
have no relationship at all with my mom. I tolerate my stepmother. I only listen to my dad, and he's very
strict with me. It pisses me off." Sarah had a hardened look to her. She had a blunted affect and rarely
smiled. Her demeanor was not depressive; rather it was angry. Sarah was short (5'1"), had long blonde
curly hair, and wore a short skirt and "my Go-Go boots" to the first session. She wore bracelets on both
wrists and wore an oversized watch on her right wrist. Sarah wore a lot of makeup on her face, including
blue eye shadow. She made fair eye contact. Sarah never cried during any of the sessions and appeared
angry most of the time. Regardless, she was candid with us. Sarah's grades are okay in schooL She's
getting low Cs but does not seem too concerned about it. "What are grades anyway? I ain't going to
college, so as long as I graduate, it's cool. I like to hang and stuff. School doesn't interest me much. I do
like history though, but the rest, no way." Sarah's guidance counselor first referred Sarah to the school
social worker. He was concerned that Sarah was falling asleep in class more often lately. Her guidance
counselor was not overly concerned about Sarah's grades since they remained consistent throughout her
junior high school years. A rule of thumb: If a child's behavior changes suddenly, or his/her grades drop
significantly, investigate the possibility of alcohol/substance abuse. Do you think that will be the case
here? Keep reading. Sarah's school social worker had a few sessions with Sarah, at which time he
discussed her case with the school principal. He noted that Sarah had been cutting many classes and on
many days had not come in at all. Her father had been notified and was not "too concerned," according to
Sarah. "My dad always worries about me, but the most important thing for him is his work. I forged the
absence notes and no one knew a thing. Dad is cool as long as I call and tell him where I am. If I'm
spending the night at a friend's house he's okay with that. He's very careful with me as I said, but he really
doesn't pry into my life a lot. He's a strict, yet nonprying dad." We called the principal since he was the
one who referred Sarah to us. He noted as well that she was missing a lot of classes and they could not
figure out why her father was unconcerned. He verified that her grades had indeed remained stable this
year. Sarah's teacher was more concerned with her falling asleep in class so often. Sarah told them she has
a job after school, but they discovered this was not true. They figured that she was out all night long, or
staying up with friends. Sarah's eyes were also quite red a number of times during the past month in
school (she appeared like this twice in the clinic). The principal was not sure if this was because Sarah
was so tired, or was due to something else such as substance abuse (he presumed she was smoking
marijuana).

Background Information

The principal met with Sarah and her father before she was referred to us; Sarah related the conversation.
"So Mr. Adler told us that I had to come in to this clinic to get psychobabbled or something. Like there's
something wrong with me. I'm just a 14-year-old girl who's having fun. Give me a d$#@ break here. But
it was either come here or get suspended, so guess which one I chose? Mr. Adler was worried about my
ditching classes and school. Well, my grades are okay, so what's the diff what I do? Look at me: Is this
college? But my dad will throw me out or put me in foster care or something if I get suspended or
expelled." Sarah's father came in with her to the second session. Sarah was clearly uncomfortable with
this but she agreed to his presence. We asked Sarah a few questions and she looked at the floor and
responded with one word answers. When we asked open-ended questions, she would tell us she did not
know the answers. It appeared as though Sarah was withholding information while her father was present.
He was curious as to what might be occurring with Sarah. We explained to him that he was more than
welcome to stay if we saw the need for his presence (and if Sarah agreed), and we praised him for being
so concerned. However, we asked him to remain in the waiting room while Sarah spoke to us. We also
explained that even though Sarah was a minor, she still had confidentiality rights. He was upset by this
but understood. Sarah then became more candid once he left the room, and we began to learn the reasons
behind her recent actions as the sessions progressed. "I guess I've been spending too much time out the
past few months, so I'm really wiped in the morning. My dad doesn't know any of this ... you won't tell
him, will you? (We said we would not, without her permission, unless we legally had to violate
confidentiality.) He'd get really pissed at me if he found any of this stuff out. Well, one of the reasons I've
been blowing off school and stuff is that I've been out partying with friends a lot this year. I met these
cool people from the private high schooL We get together, sometimes go to raves, and sometimes just
hang. We drink and stuff. I like vodka and beer. Sometimes I pass out at Joe's place, sometimes on the
street. But I'm always safe. Someone's always watching over me. Are you okay hearing this? I feel
comfortable here, so I can spilL" So far it seems like we have some key information. Sarah may have an
alcohol abuse problem that is causing all of these other problems to occur. It makes sense, since she
claims that her mother is an alcoholic and alcohol dependence seems to have a familial component. We
asked Sarah some more questions. "One thing I do want to fix is my sleep problems. I keep having these
nightmares that won't stop, and I need you to tell me what's up. They are so wrong. You guys do the
dream stuff ... I read about it. That's one reason I fall asleep in class so much, as I'm not able to sleep
much. I keep getting the nightmares and when I wake up I'm afraid to fall asleep again. They seem so
reaL So okay, that is a problem." Alcohol abusers sometimes have sleep problems. However, when
someone is drunk to the point of passing out, REM sleep (the dream stage) does not occur. We then
brought Sarah's father back in and told him that the clinic wished to see him alone for a few sessions.
Sarah was then asked to leave and she agreed, heading to the waiting room. He complained about the cost
and about us taping Sarah's sessions but agreed to let Sarah continue. He told us that he was friendly with
some of the police, and they told him that on at least four occasions they found Sarah asleep on the street
or in the gutter. She appears to be drunk and possibly stoned or high. He was very worried about this and
wanted some answers. However, he did not wish to confront Sarah since he feared she might run away
"and she's the only child I'll ever have. I have a physical problem that makes producing another child
impossible." We asked him to join Sarah in the next session, hoping that he would be candid with her. At
that point the session ended

Thought Questions
1. What is going on with Sarah? Do you have enough information yet?
2. Sarah's father was not being honest with her. Discuss your views on this. What would you do in that
situation?
3. Discuss some of the possible causes of Sarah's nightmares.
4. Should Sarah be seen individually or together with her father? Justify your answer.
5. Are there any predisposing and/or precipitating factors to her condition?