The purpose of this case study is to describe the case of a patient known as Ellen Farber. Ms. Farber, an insurance company executive, arrived at a psychiatric emergency room at a university hospital with numerous complaints in regard to her overall well-being. It is apparent that Ms. Farber has been affected by her symptoms to a large degree. This case study will discuss the complaints provided by Ms. Farber and will provide a detailed discussion of how her symptoms fit the criteria provided in the DSM-IV-TR for several disorders such as Major Depressive Disorder, Single Episode; Eating Disorder Not Otherwise Specified; and Impulse-Control Disorder Not Otherwise Specified. This paper will also discuss differential diagnoses as well as co-occurring disorders that may be present. The final portion of this paper will discuss a possible treatment plan as well as an indication of the patients prognosis based on known information about her diagnosis.
Ellen Farber is a 35 year old woman who presented with complaints of depression, the thought of driving her car off of a cliff, and numerous other symptoms. Upon closer evaluation of Ms. Farber’s symptoms it appears that she is suffering from a Major Depressive Episode. The symptoms that she has exhibited that allow for this conclusion are a lack of energy for the past six months; a lack of pleasure for the past six months; increasingly persistent depressed mood for the past six months; oversleeping in amounts of 15-20 hours per day; overeating to the extent that she has gained 20 pounds over the past few months; and thoughts of suicide with a specific plan (Barlow & Durand, 2012, p. 206). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), the presence of a single manic depressive episode in the absence of another disorder, such as schizophrenia, indicates that Ms. Farber can be diagnosed with Major Depressive Disorder, Single Episode. It is also clear that Ms. Farber has never experienced a prior Major Depressive Episode indicating even further that Major Depressive Disorder, Single Episode is the proper diagnosis for her (DSM-IV-TR, 2000, p. 375). It is essential to point out that Ms. Farber is also a candidate for other diagnoses because she has engaged in binge eating and impulsive spending. Ms. Farber has reported that she has engaged in eating binges since she was an adolescent. During these binges she reports that she eats anything that she can find. Although she has engaged in intermittent binge eating since adolescence she has done so without using compensatory methods to rid her body of the excess calories. According to the DSM-IV-TR (2000), Ms. Farber should be diagnosed with Eating Disorder Not Otherwise Specified (Binge-Eating Disorder) because she does not engage in the compensatory behaviors that are typically characteristic of Bulimia Nervosa (p. 595). Finally, Ms. Farber has engaged in shopping sprees that she refers to as buying binges. This excessive and impulsive spending has resulted in a large amount of debt, about $250,000, that has arisen from illegal practices such as unauthorized use of her employers credit cards and over drafting bank accounts to open new accounts, a process she calls check kiting. Since the money was used on impulsive purchases and cannot be accounted for by another disorder, such as substance dependence or a paraphilia, it appears likely that Ms. Farber is also a candidate for a diagnosis of Impulse-Control Disorder Not Otherwise Specified (DSM-IV-TR, 2000, p. 677).
According to the DSM-IV-TR (2000), the following diagnoses are relevant for Ellen Farber:
Axis I: Major Depressive Disorder, Single Episode
Eating Disorder Not Otherwise Specified (Binge-Eating Disorder)
Impulse-Control Disorder Not Otherwise Specified
Axis II: Borderline Personality Disorder
Axis III: Moderately Overweight
Axis IV: Unemployed, financial difficulties
Axis V: GAF = 35 (current)
On Axis II, Ellen received a diagnosis of Borderline Personality Disorder for several reasons. First, she has reported that she has experienced lifelong feelings of emptiness, chronic feelings of loneliness, chronic feelings of sadness, and chronic feelings of isolation. In order to satisfy her feelings of emptiness she has engaged in weekly buying binges which established her current level of debt. Ellen has also engaged in daily episodes of binge eating without compensatory behaviors. She has also experienced chronic uncertainty with whom she wants to be friends and about what she wants to do in life. We also know that she has been in numerous brief and intense relationships with both men and women. In these relationships, Ellen exhibits a quick temper that has frequently led to arguments and physical fights. Based on a comparison of Ellen’s symptoms and the diagnostic criteria for Borderline Personality Disorder provided in the DSM-IV-TR it is clear that Ellen suffers from Borderline Personality Disorder (DSM-IV-TR, 2000, p. 710). Ellen has not presented with any other medical conditions other than the fact that she is moderately overweight. Since this is the only condition of concern it was listed on Axis III. Axis IV includes relevant information about psychosocial and environmental problems that may be affecting Ellen. Since Ellen is unemployed and is experiencing a large amount of debt as a result of her spending binges this information is listed under Axis IV (DSM-IV-TR, 2000, p. 33). On Axis V I have included a GAF score of 35. After evaluating the information provided in the DSM-IV-TR it seemed apparent that Ellen fell within the 40-31 range on the GAF scale. She fell into this range as a result of her suicidal thoughts with a specific plan and because she is currently unemployed but unable to work as a result of her depression. Within the scale it appeared that Ellen’s level of functioning was not severe enough to receive a GAF score of 31 but her functioning was not well enough to receive a GAF score of 40. Based on this scale, it seems that Ellen fits in the middle of the 40-31 scale so I assigned a GAF score of 35 (DSM-IV-TR, 2000, p. 34).
According to the DSM-IV-TR (2000), there are several common differential diagnoses present for Major Depressive Disorder, Single Episode. These disorders include Bipolar I Disorder; Bipolar II Disorder; Mood Disorder Due To a General Medical Condition; Substance-Induced Mood Disorder; Dysthymic Disorder; and Schizoaffective Disorder (DSM-IV-TR, 2000, p. 373). In the process of diagnosing Ellen, I made a differential diagnosis between Dysthymic Disorder and Major Depressive Disorder, Single Episode. The primary way that this differential diagnosis was made was comparing the length of time that Ellen reported experiencing her symptoms and comparing them to the length provided in the DSM-IV-TR. For Dysthymic Disorder, a period of at least two years must be met for depressed mood (Barlow & Durand, 2012, p. 209). Symptoms for Major Depressive Disorder, Single Episode are only required to be present for a period longer than two weeks (Barlow & Durand, 2012, p. 206). From the information that is known about Ellen, it only appears that Ellen’s symptoms have differed from her normal level of functioning for six months. Since Ellen did not meet the minimum two year requirement for depressed mood it seemed apparent that her symptoms only met the criteria for Major Depressive Disorder, Single Episode. Eating Disorder Not Otherwise Specified also presented with a differential diagnosis, Bulimia Nervosa. This was easily distinguished because Ellen did not engage in compensatory behaviors in order to control her caloric intake, and a diagnosis of Bulimia Nervosa requires that a person engage in inappropriate compensatory methods to prevent weight gain (DSM-IV-TR, 2000, p. 589).
It is not uncommon for other mental disorders to co-occur with Major Depressive Disorder, Single Episode. These common mental disorders include Substance-Related Disorders, Panic Disorder, Obsessive-Compulsive Disorder, Anorexia Nervosa, Bulimia Nervosa, and Borderline Personality Disorder. Axis II presents the personality disorders that Ellen has presented with and Borderline Personality Disorder is listed. Ellen has presented with chronic feelings of loneliness, emptiness, sadness, and isolation. She has also experienced chronic uncertainty about what she wants to do in life and with whom she wants to be friends. She has engaged in numerous intense relationships with both men and women that have often resulted in arguments and physical fights as a result of Ellen’s quick temper. In order to cope with her chronic symptoms she has engaged in weekly buying binges and daily episodes of binge-eating. Based on this information, as stated previously, Ellen meets the criteria for Borderline Personality Disorder (DSM-IV-TR, 2000, p. 710). There are no conditions listed in the DSM-IV-TR that co-occur with Eating Disorder Not Otherwise Specified (Binge-Eating Disorder) or Impulse-Control Disorder Not Otherwise Specified.
The treatment of Ms. Farber is complicated by her thought of driving her car off a cliff. This indicates that she possesses suicidal desire, capability, and intent. As a result, she should be asked to agree to, or sign, a no-suicide contract. This contract is essentially a promise that she will not attempt suicide without contacting the mental health professional overseeing her case first. If she declines to agree to the terms, or if there is doubt about her sincerity, hospitalization may be required (Barlow & Durand, 2012, p. 251). Considering that Ms. Farber has presented with several co-occurring conditions, treatment for her Major Depressive Disorder would be most effective if she undergoes combined treatment. The first aspect of her treatment should be a medication based treatment, particularly treatment with a selective-serotonin reuptake inhibitor (SSRI). This medication functions by blocking the presynaptic reuptake of serotonin causing a temporary increase in the levels of serotonin at the receptor site. All antidepressant therapies provide some form of benefit to about fifty percent of the patients who receive them (Barlow & Durand, 2012, p. 236). In combination with the prescription for SSRIs, I would also recommend cognitive-behavioral therapy. A cognitive-behavioral approach, such as Lynn Rehm’s self-control therapy, could assist Ellen in gaining control over her moods and daily activities while incorporating cognitive therapy to assist her in identifying and correcting errors of thought, shifting her thought pattern from a depressive thinking pattern to a more realistic thinking pattern (Barlow & Durand, 2012, p. 240). Ms. Farber should also undergo treatment for her diagnosis of Eating Disorder Not Otherwise Specified (Binge-Eating Disorder). The most appropriate treatment for Ms. Farber would be a technique that involves therapist led treatment. It seems appropriate that she should undergo guided self-help therapy in which she would meet with a therapist periodically to review a self-help manual. This approach would be the most effective for her because she presented with several diagnoses (Barlow & Durand, 2012, p. 375).
The prognosis for Ms. Farber appears to be relatively positive in regards to the alleviation of her Major Depressive Episode; however, there are some risks within the first two years following her diagnosis of Major Depressive Disorder, Single Episode that may alter her prognosis level to fair. Approximately 67%, or two-thirds, of patients experiencing a Major Depressive Episode may experience complete remission of their symptoms. One-third, or 33% of individuals suffering from a Major Depressive Episode may only experience partial remission of their symptoms or may not experience any alleviation of their symptoms at all. At least 60% of individuals with Major Depressive Disorder, Single Episode will experience a second episode and 5%-10% will subsequently develop a manic episode, meeting the criteria for Bipolar I Disorder (DSM-IV-TR, 2000, p. 372). In the first year following an episode there is a 20% risk of reoccurrence. In the second year the risk of reoccurrence increases as high as 40% which would qualify Ms. Farber for a diagnosis of Major Depressive Disorder, Recurrent (Barlow & Durand, 2012, p. 208). By undergoing combined treatment for her depression her chances for remission may increase slightly over receiving medicinal treatment alone (Barlow & Durand, 2012, p. 243). At this point it is impossible to determine the exact course of Ms. Farber’s symptoms. At best we can expect a more positive prognosis with treatment than without any treatment at all.
Ellen Farber presented with several co-occurring conditions and psychosocial and environmental problems that have potentially affected the onset and severity of her symptoms. The purpose of this paper was to discuss Ms. Farber’s symptoms, provide diagnoses based on the DSM-IV-TR, and discuss the appropriate means of treatment for her conditions. Ms. Farber has been affected immensely by her symptoms and requires appropriate treatment immediately in order to prevent her condition from worsening. In the end, her prognosis ranges between fair and relatively positive based on the available knowledge about her diagnosis. It appears that if Ms. Farber receives the appropriate treatment she is at a greater likelihood for remission of her symptoms and continuing treatment may reduce the risk of a reoccurrence of her symptoms. Only time can definitively show how Ms. Farber will be affected by the course of her co-occurring disorders.