Clinical Psychology Case Report

on

Persistent Depressive Disorder

Submitted in the Partial Fulfilment
for the award of a Degree of

Master of Art – Psychology

Submitted to the

Department of Psychology

Rabindranath Tagore
University
Submitted by

Swati Tiwari
 R’s Clinical Psychology Case
Record

Date: XX/XX/XXX Trainee’s Name: Swati

Tiwari

Client’s Identifying Data

Name: Mrs. R Age: 44

Sex: Female Education: Post Graduate
Occupation: Housewife Marital Status: Married
Socioeconomic Status: Middle-Class Residence: Urban

Informant: Though R mostly came alone for follow-up sessions, an

informant who is R’s husband was present for the first meeting.

Informant Present Absent

If the informant is present, then specify the relationship with the

client: Husband.

Reliability of Information: Reliable Not Reliable

Adequacy of information: Adequate Not Adequate

Given Information is satisfactorily Reliable and adequate.

Chief Complaints/Client’s reason for seeking
treatment

R claims that she has been experiencing low mood, and feeling
depressed for the past several years. (after marriage)

She is seeking treatment due to a fear that she would lose everything.
(more than 4 years)

The onset of symptoms/problems

The onset of symptoms is Early and Insidious.

R and her husband claim that all this started when she was pregnant
and she first started feeling depressed after she gave birth to her
daughter 20 years ago. Her husband also mentioned that she is
experiencing mood swings since then. They also mentioned that the
symptoms are worsening with every passing year for the past 4-5
years.

The course of symptoms/problems

The course of symptoms is gradual and continuous for the past few
years.

R claims that she has been experiencing feelings of depression. She

claims she is always sad, tired, and angry and feels hopeless. For her,
everything seems gray. She reports that she lost interest in activities
that she was interested in before, and is upset about the fact that she is
not doing justice with raising her child. R claims that she experienced
Postpartum depression, which her gynecologist never noticed, and
about 3 weeks after her child's birth, her mood lifted again, but her
symptoms worsened the past year or so. In addition, she claims she
experiences abnormal sleep patterns. Somedays she would sleep for 12-
14 hours other days she could hardly get a 4-hour sleep. She mentioned
that the onset of the condition was about 7 months ago and which is
considered being concurrent with depression.

Duration of symptoms/problems

The duration of the symptoms is more than 24 months.

R complains that these symptoms have been coming and going for the
past 20 years but now the frequency of episodes has increased in the
last year.

Precipitating Factors/Stressors

Present Absent

If Present, specify: Undiagnosed Postpartum Depression can be a

precipitating factor.

History Of Mental Health Problems

Associated Disturbances
(E.g., sleep, appetite, socio-occupational functioning):

R claims that she is experiencing a sleep disorder. She is always fearful

and has a feeling of helplessness. She is optimistic about life and feels
hopeless.

Negative History
(absence of organic causes)
Other than untreated postpartum depression, she has experienced her
brother’s addiction and death. Strained relationship with her husband
and his family. A habit of comparing and contrasting with others from
childhood.
Past History

Past psychiatric history – Not Applicable

Medical and surgical history

C-Section childbirth in 2002. Thyroid medication since 2010.

Family History

*Addict and died of a cardiac arrest at 38

Family history of major physical illness

Mother and Father are both diagnosed with high blood pressure.
Mother has diabetes. The elder brother, who was an addict, died of a
cardiac arrest at the age of 38.

Family history of psychiatric illness

Brother was an addict and had some psychological issues which were
never addressed.
Current living arrangement

Living in a nuclear family with husband and daughter.

Interpersonal relationship

Not in a very healthy relationship with her husband, but has a strong
bond with her daughter. She also has a good friends network.

Family’s knowledge of the client’s illness/problems

Husband and daughter both are aware of the issues with R but deny
that it is a psychological issue.

Family’s attitude towards the client’s illness/problems

The family mostly feels that all the problems are attention-seeking
tactics and do not require intervention.

Personal History

Birth History – Normal

Behavior during childhood

Was the second of three children in a conservative family. Eldest was a

brother, then R, and a younger sister. As reported, R started feeling
neglected and a kind of burden after her younger sister was born.

School History – Nothing unusual.

Occupational History – Housewife

Menstrual History – Menstrual cycles were normal before the onset of

the pre-menopausal phase in 2020.
Sexual History – Has not indulged in any sexual activity for several
years.

Marital and Relationship History – R’s was an arranged marriage. Her

relationship with her husband has always been strained. She never
found a partner/soulmate in her husband. Her relationship with her
husband and family was damaged further after her giving birth to a
daughter (family was expecting a boy). Her decision of not to have
another child was one more nail in the coffin.

Substance Use History: No substance use.

Premorbid Personality
(i.e., before the onset of mental health problems):

Social relations – She has always been a likable person. She is always
on her toes to help others.

Intellectual activities – She was an average student and did her

Masters.

Mood – Happy.

Character – Ethical. Compare and contrast with others has always been
her character.

Attitude to work- She takes care of her house well. Cleaning, cooking,
and laundry is her usual day.

Interpersonal relationships – Baring compare and contrast, she was

good with people.

Energy and Initiative- Energy was Enthusiastic and futuristic. She

always was a rebel and wanted to change the stereotypes.
Habits – Normal.

Mental Status Examination

General Appearance and Behaviour

● Alertness: OK.
● Appearance: Dull.
● Nutritional status: Ok.
● Dress and grooming: Good.
● Eye contact: Appropriate.
● Posture: Slouch. Lack of confidence.
● Motor activity: OK.
● Any involuntary or abnormal movements: No.
● Attitude toward the examiner: Positive and cooperative.
● Rapport: Established.

Speech

● Tone: Dull.
● Tempo: Non-Stop.
● Volume: Mostly Low. Sometimes whispering.
● Prosody: Very dramatic.
● Coherence: Coherent but very impatient. Sometimes even start
without listening to the question completely.
● Relevance: Relevant but undertones are mostly negative.

Emotion

● Mood: R’s mood is mostly sad. No excitement. Pessimistic. She

feels hopeless and insecure about the future. She also feels
helpless, as if she is trapped in this marriage and cannot escape
this situation.
 ● Affect (quality, range, reactivity, intensity, mobility,
appropriateness).
o As reported by the client:
o As observed by the Psychologist: Sad and tearful. She has
no control over her tears. She could not help crying during
the sessions.

Thought

● Form: Mostly over-inclusive. A very detailed conversation with a

lot of unnecessary information.
● Stream: Derails often. Most arguments are irrational, with no
justification.
● Possession (obsessions and compulsions): Shows signs of OCD.
● Content (phobia/homicidal or suicidal ideas/delusions): Had
planned and unsuccessfully executed, running away from the
house several times.

Perception (hallucinations/illusion)

● She has an overvalued idea of a bad marriage. She believes that

her husband does not love and care for her and her daughter.
● She has another overvalued idea that her only goal in life is her
daughter’s safety. So much so that she needs to protect her
daughter from everyone (including her father and close family)
and everything.

Cognitive functions:

● Consciousness: Intact.
● Orientation (time, place, person): Intact.
● Attention and concentration: Easily Aroused and sustained. All
her focus is on her daughter only.
● Memory (immediate, recent, remote): Intact. Extremely sharp.
● Intelligence (general information, comprehension,
arithmetic/calculation, abstraction): Average.
● Judgment (personal, social, test): Satisfactory.
Insight about Illness (Present/absent/partial
insight)

R has self-referred herself to the psychologist. She reports none of the

doctors she saw diagnosed her as having depression. R grew up in a
conservative family where girls do not really have a say or their
existence does not matter. Her brother, who had died at 38 of a sudden
cardiac arrest, was an addict and had some issues, however, according
to R, her family does not admit weakness and does not believe in
therapy. He did not get any intervention that may have worsened his
condition.

R was an average student in high school and college. She was in love
with a boy, but they could not get married, and she never accepted her
husband as a partner. They had a difficult marriage. She started staying
sad and negativity started clutching her from her early marriage days.
She gave birth to a daughter after 2 years of marriage. Married in a very
conservative family birth of a daughter widened the gap between the
couple and family.

R worked with an NGO and in as a schoolteacher on contractual terms

for a small stint. Though she did reasonably well at both places, but
cannot continue her career due to a lack of confidence and her
overprotective attitude towards her daughter.

R’s brother died of a sudden Cardiac Arrest. Her brother breathed his
last in her arms. This event could be a trigger for her Depressive
Disorder.

Now she mostly spends her day at home and does most of the
household chores herself. Her routine is fixed, her day starts with
orderly arranging the house and dusting. R is very particular about
dusting and keeping everything in its respective places. She is so
obsessed with cleaning that she cleans the fan blades every day. She
avoids travel and never goes to the market alone.

The family is financially stable because of her husband, who is a class I

officer in the government. They live in a government house and their
future is secured by the pension scheme of the government.

Diagnostic impression

(Depression/Anxiety Disorder/Psychosis/Substance use disorders/Nil

diagnosis)

Mild Persistent Depressive Disorder

Axis I DSM-5 300.4 (F34.1) Persistent Depressive Disorder, No

Manic or Hypomanic Episode, Attacks, No Psychotic
Features, Sleep Disturbance, OCD.

Axis II No Diagnosis

Axis III Postpartum Depression

Axis IV Sudden death of Brother in her arms

Axis V GAF = 70

DSM-5 states that the symptoms of persistent depressive disorder are

very similar to major depressive disorder. However, these symptoms
are chronic, meaning that people have these depressive symptoms
most days for a period of at least two years for adults and one year for
children and teens.

Of those symptoms on the list, the followings are reported by R.

 1. She and her husband claim that she experiences a depressing
mood most of the day, almost every day. She is experiencing this
certainly for over two years now.
2. Her interest in all or almost all activities have diminished. They
include activities she was interested in before the onset of the
disease, like sex, cooking, shopping, socializing, and travel.
3. Her sleep is disturbed. Some days, she would experience
hypersomnia, which results in her sleeping 12 to 14 hours a day.
On some other days, she experiences insomnia when she cannot
sleep for even 4 hours.
4. In addition, she experiences excessive fatigue and loss of energy.
She is not being able to concentrate and performing even the
household chores has become a task for her.
5. Because of her malfunctioning and loss of interest, she blames
herself and fears that she will lose her only possession, her
daughter.
6. She is fearful of many things; she avoids going to the malls and
markets, avoids journeys, does not use escalators, etc.
7. She lacks confidence and self-esteem. She seeks validation from
others for her every action and decision.
8. She feels trapped and has planned and unsuccessfully executed
running away from home.

Though she has been depressed for several years, she has never been
through any therapy or medication. In addition, she has never been on
any drug or severe substance use. Thus, it seems depression is not
caused by medications. In addition, she did not report any Manic
Episodes, Mixed Episodes, or Hypomanic Episodes.

For Axis II, it seems there are no Personality Disorders that fit her
perfectly. She does not seem to have a tendency to avoid nor depend on
others excessively. Moreover, she reports having a good friend circle
her personality seems stable, and nowhere near antisocial.

However, it is also worth noting that this diagnosis is made based

majorly on reports from R and her husband only, meaning there is
room to consider other possible disorders if more information from
other sources and perspectives is made available.
Differential Diagnosis

Instead of diagnosing her as experiencing Persistent Depressive

Disorder, Major Depressive Disorder could have been applied. However,
both R and her husband claimed her mood is like this forever, and that
they could not even point out when it started.

Moreover, full criteria for a major depressive episode have NOT been
met in at least the preceding 2 years.

One of the most important but often overlooked differences between

these two conditions is how others perceive them. In the case of R she
is perceived by her husband and daughter as normal. As she takes care
of all her household chores and is functioning well, so family assumes
she is fine. For them, it's just her attention-seeking behavior, while she
is struggling every day.

Biopsychosocial model to understand the client’s

illness/problems (Risk, precipitating, maintaining, and protective
factors)

R appears to be suffering from depression. Her lack of energy, libido

and interest in anything in her life except her daughter is indicative of
this. Now we shall attempt to perceive what the underlying causes, or
the etiology, of her depressive symptoms, are.

The Canadian edition of the textbook Essentials of Abnormal

Psychology in a Changing World (Nevid, J., Greene, B., Johnson, P.,
Taylor, S., 2005) provides some theories that have been proposed by
psychodynamic theorists. According to Freudian psychodynamics,
depression is derived from a loss in one’s life. For example, if a
woman’s husband divorces her, Freud would suggest that the wife
would first feel angry at the husband. She would then “introject, or
bring inward, a mental representation of the [husband]” in order to
preserve some psychological connection to him. Therefore, she turns
the anger and rage meant for her husband on herself and this leads to
depression. Later psychodynamic theorists propose the self-focusing
model.

This model suggests that when one loses someone or something dear
to them, depression-prone individuals may spend all of their attention
and thoughts on themselves and how they may restore the lost
connection to the lost person or object.

Both these explanations partly apply to R’s case. Though she is not
divorced, she has had a strained marriage for the past 22 years. Though
her symptoms preceded her brother’s death, the sudden death of a
loved one and that too in her arms could be a trigger. This would have
definitely worsened her problem.

To further inspect, we must consider other psychoanalytical

approaches. One more recent psychoanalytical explanation of
depression suggests that individuals who utilize immature versions of
unconscious defense mechanisms are more prone to depression
(Kwon, P., Lemon, K., 2000). R shows signs of maladaptive defense
mechanisms as a child. She explains that at the age of five, when her
younger sister was born, she started feeling neglected and unwanted.
She explained that to cope with it, she started spending time with
friends to stay away from home. This suggests that she was attempting
to repress these hurtful thoughts from her consciousness. The manner
in which she represses is not typically suitable or healthy behavior,
which suggests that she has developed an immature defense
mechanism. She also practiced regression or the defense mechanism,
which explains when an individual returns to an earlier developmental
stage in life.

She use to make friends and spend time with them to stay away from
home. It is said that defense mechanisms mature with age; therefore,
she may have slowed the development of her psychic defenses near this
age. She says that she still has a lot of friends with whom she loves
spending time, which could be explained as a return of her regressive
behavior. This suggests that she still has underdeveloped defense
mechanisms, which could account for some of her depressive
symptoms.

Drinking and drug use has been said to increase the chance of having a
mental disorder, but this would not apply in this case. R is clean; she
does not do drugs or self-medication, so her depression could not be
derived from substance abuse.

But in the case of R, it seems that most of her symptoms could be

attributed to biological factors. She explained how her postpartum
depression was never noticed and remained untreated.

As stated in the textbook, genetics play a fair role in contributing to

depressive symptoms. Several studies, such as twin studies, have
provided evidence for this notion. Twins who grow up in different
environments are shown to more likely be similar in mood. If one is
depressed, it is likely that the other will also be depressed.

R’s brother who died of cardiac arrest was an addict and as per R’s
statement there are good chances that he was also experiencing
episodes of depression, but R’s depression cannot be attributed to
genetics. Her brother has never had a consultation or formal diagnosis,
so there are many probabilities. One, he had no depressive disorder.
Two, if at he had a depressive disorder, there are more chance that his
depression was due to substance use. Three, we do not have any
supportive evidence to attribute his depression to genes. Therefore,
there are thin chances that R has acquired some of her depressive
symptoms genetically.

Many people suffer from depression and R is not much different from
anyone else. On the outside, she appears to have a good life. She has a
husband, a daughter, and a good social life. Yet she still feels depressed
on the inside. Her upbringing has a huge role to play in her depressive
symptoms. Her genetic makeup may be leading to chemical imbalances
in the brain, which leads to depression. The psychodynamic theory
would account for some of her regressive and repressive actions, such
as staying away from home for long periods of time. These could also
increase the amount and severity of her symptoms.

To begin with, her treatment should include lifestyle changes, some

interventions, and psychotherapy to help her deal with persistent
depressive disorder. Family counseling can play an important role, her
husband and daughter can aid and support her deal this better.
Treatment Plan

As R is suffering from both depression as well as strained marriage.

This Seven-phase treatment and management plan will start with
mild anti-depressant (prescribed by a physician) medication to uplift
the overall mood of the client. The anti-depressant medication will
also be an ongoing process, or until they are no longer required (as
per the advice of the physician). Phase one and phase two will have a
simultaneous effect. As it usually takes four to six weeks for anti-
depressants to take effect, the second phase of this client’s
treatment plan will not begin until the client has felt the effects of
the anti-depressant medication.

In the second phase, lifestyle changes for R will be introduced and

personal counseling sessions with a clinical psychologist will be held
to address her issues. This phase will start after the client starts
responding to the medication. These sessions will last at least two
months and will be continued further if need be.

In the third phase, which will start simultaneously with the second
phase, family counseling sessions will be held. Here we will address
the family issues and these sessions will bring the family on board.
The family counseling sessions will go on at least for four sessions.

Phase four, which addresses the client’s dietary and physical fitness
needs will also have a simultaneous effect. This phase will begin
after the third phase is completed and will go on simultaneously
with phase two.

Phase five, psychotherapy, will begin after the third week of phases
three and four. In this phase of the treatment, the client discusses her
problems with the psychotherapist.
Phase six will address this client’s sleeping habits.

In phase seven, the psychotherapist will begin the cognitive approach

to this client’s treatment plan. This phase is set to begin only after
week twelve of the client’s psychotherapy sessions.

According to Beck’s theory, the cognitive approach is used to assist the

client in changing their negative thoughts to positive thoughts. The
cognitive approach also includes behavior changes. Behavior changes
include, but are not limited to, relaxation skills, an increase of pleasant
activities, and building social skills (Nevid et al.; 2005, pp. 244, 246).

The purpose for breaking down the treatment plan in this manner is
because when a client is experiencing persistent depression, they are
emotionally shut down. The client loses motivation to take steps to
change their negative thoughts to positive ones. The client has also lost
interest in activities they once enjoyed. The purpose of this treatment
plan is to re-motivate the client, and this is a step-by-step process.

Management Plan

● Referrals
o R is referred to a physician for assessment and medication
for depression.
o A qualified psychotherapist will handle R’s sessions after
the phase V of the treatment.
● Psychosocial intervention
o Cognitive Behaviour Therapy
o Behaviour Therapy
o Personalised care with intervention in dietary and physical
fitness.
References

● American Psychiatric Association. (2000). Diagnostic and

statistical manual of mental disorders (Revised 5th ed.).
Washington, DC: American Psychiatric Association.
● Butcher; Hooley; Mineka; Kapoor (2019). Abnormal Psychology
(17th edition). India. Pearson India Education Service Pvt Ltd.
● Nevid, J. S.; Greene, B.; Johnson, P. A.; Taylor, S. (2005).
Essentials of Abnormal Psychology in a Changing World,
Canadian Edition. Toronto, ON. Pearson Prentice Hall.
● Kwon, P. & Lemon, K. (2000). Attributional Style and Defense
Mechanisms: A synthesis of Cognitive and Psychodynamic
Factors in Depression. J Clin Psychol 56: 723 – 735.
● Nevid, J. S.; Greene, B.; Johnson, P. A.; Taylor, S. (2005).
Essentials of Abnormal Psychology in a Changing World,
Canadian Edition. Toronto, ON. Pearson Prentice Hall.