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Have fear of rejection, chronic frustrations and unrealistic expectation. On prozac. Looking for proper diagnosis and cure

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XXXXXXX is a middle-aged, married, Caucasian male who has two grown children. XXXXXXX father passed away when XXXXXXX was in college, and this loss still pains him. He held his father in extremely high regard and at times referred to him as "brilliant XXXXXXX even though his father did not graduate from high school. His father worked at a skilled trade until he suffered a fatal illness in his late 40s or early 50s. XXXXXXX laments the loss of his father and, in particular, the guidance he thought his father could have provided during turbulent times in XXXXXXX life.

According to the pattern of alcohol use that XXXXXXX describes, it is likely that XXXXXXX father had a serious drinking problem, if he was not actually an alcoholic. XXXXXXX mother, who is also deceased, is described by XXXXXXX as a strong woman and the matriarch of the family. While XXXXXXX states that he had much respect for her, it seems that his respect was also tinged with fear of her disapproval. She never accepted or understood why XXXXXXX chose the college he did and why he had an interest in an Army career.

XXXXXXX states that his mother never used alcohol. He describes her as a very critical and judgmental person. His family of origin was devout in their religious beliefs, and this appears to play a significant role in XXXXXXX life. He is close to his siblings, but they do not talk often, and he feels guilt for not initiating calls to them. His hesitation to call them is due in part to a fear that they will reject him. It is for this reason that he also tries to keep conversations with them at a superficial level. His extended family includes people who have achieved at the highest levels of government and their professions.

XXXXXXX graduated from a prestigious college and embarked on a military career, which was his lifelong ambition. A "vindictive" superior officer who gave him poor performance evaluations cut XXXXXXX career short. It turns out that XXXXXXX may have had much more of a role in this than he is aware of or initially admits. He acknowledges a lengthy period of indecision and marginal adherence to military standards at the beginning of his career, but relates that he eventually got over that “down time.” Nonetheless, XXXXXXX developed the persona of hero in both military matters and civilian jobs, and to this day, he compares himself with heroic figures from antiquity and sees himself on the verge of doing something great, “if,” he says, “I can ever get over this serious case of the blues I’ve been experiencing for the past months.” He indicates that he has felt this way, “empty, really,” nearly all day every day for at least two to three months. As he says this he appears tearful. He relates that there was no particular incident or event that started him feeling this way. “It just came over me,” he says.

He reports that he has, in fact, lost interest in any kind of work or activities over the last months, and finds XXXXXXX in literally nothing. He has no energy and reports that others have been asking him why he’s so plodding and slow about everything lately. He has great difficulty getting out of bed in the morning and constantly thinks about suicide. While he feared death as a young man, he now says he would welcome it. He has been on Prozac “and things” for years and questions whether it is working.
XXXXXXX is awash in guilt. He feels guilt for things he has done and for things he has not done. He has a disarming smile that belies the pain he feels and keeps people from prying into his life. He has one or two drinks of XXXXXXX Daniels, neat, each night. Psychotherapy is difficult with him because of the chronic nature of his problems and his fear of alienating people who are close to him. He seems to genuinely believe that his expectations of other people are fair and reasonable, but he is so disappointed in “everything” that he doesn’t know what there is to live for.
XXXXXXX places unrealistic importance on the support available from his nuclear family. Yet, he says he is cautious around them because if he says or does the wrong thing, they might leave him or tell him to leave. He is, he adds, feeling pretty worthless and guilty about ridiculous little things he’s done and said to his family. He knows he has been emotionally “fragile” the last few months; in particular, he has found himself increasingly irritable. He expresses anger at his adult children because they do not appear as devoted to him as he was and still is to his late father. However, XXXXXXX keeps this anger to himself for fear of rejection. He has also recently experienced conflict with his wife of many years. It is not possible for her to XXXXXXX his expectations for support, so he becomes angry with her, but withholds the expression of his anger for fear of alienating her.

Here is my AXIS diagnosis….

Axis I: V62.82 Bereavement, 309.00 Adjustment Disorder with depressed mood, 305.00 Alcohol abuse

Axis II: 309.81 Post Traumatic Stress Disorder.

Axis III: None to Report

AXIS IV: Social, employment, family, suicidal ideation

Axis V: 10

1.     Would there be a different in the diagnosis if we were to use the ICD-10 to arrive at these diagnoses?

2.     What would be the three primary issues that need to be addressed in the treatment for XXXXXXX?

His bereavement, substance abuse, and suicidal ideation issues. I'm on the correct track?

3.     Keeping the diathesis-stress model in mind, what etiological factors do you think are relevant in this case, and why?

XXXXXXX has several stressors that are present and may be the cause of these diagnosed disorders including the death of his father, fearing the rejection of his mother, his feelings of anxiety at losing his parental figure of his mother, he also feels stressed by his children in that they don’t look up to him as much as he continues to look up to his late father. I’m I on the correct track?
Posted Sat, 17 Nov 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 4 hours later
Hi XXXXXXX .. Thanks for your query.

Since there is a long history and lots of information, first let's sieve through the info and pick out the important symptom clusters. Now, we can broadly put XXXXXXX problems into two groups.

One group of symptoms is his chronic problems:
- fear of rejection, fear of failure or disapproval (indicative of low self-esteem)
- chronic frustrations
- disappointed in "everything"
- unrealistic expectations from others and tendency to blame others
- "feeling pretty worthless and guilty about ridiculous little things"
- been on Prozac "and things" for years and quetsions whether its working

So, XXXXXXX has a background of years of chronic low grade symptoms of low mood, poor self esteem, frustrations, unhappiness and discontent, and some neurotic traits. Agree with me?

The second broad group of symptoms seems to be of recent onset (in the last few months):

"the serious case of the blues I’ve been experiencing for the PAST MONTHS”...
“empty, really,” nearly all day every day for at least TWO TO THREE MONTHS...
no particular incident or event that started him feeling this way. “It just came over me,” he says...
lost interest in any kind of work or activities over the LAST MONTHS...
reports that others have been asking him why he’s so plodding and slow about everything LATELY...
He knows he has been emotionally “fragile” the LAST FEW MONTHS; in particular, he has found himself increasingly irritable...

So, it's clear that XXXXXXX is having many significant depressive symptoms in the last few months - feeling low, decreased energy, lack of interest, anhedonia ("finds XXXXXXX in literally nothing", slowness and lethargy, guilt, suicidal ideas, emotional fragility and irritability. This group of symptoms seem to be characteristically distinct and of a much greater severity than his chronic problems. Agree with me?

Other significant issues in history are the psychodynamic issues:
- Psychodynamics of his parental relationships and their impact on XXXXXXX later life:
* Matriarchial, over-critical, overjudgemental, disapproving mother
* Father playing a laid back role, not very responsible, alcoholic, but XXXXXXX obviously seems more emotionally attached to his father and idealizes him
(Remember, that though XXXXXXX idealizes his father and is saddened by his loss - the history only mentions that XXXXXXX laments and misses his guidance (which is quite understandable, given the fact that he was never close to his critical, disapproving mother and felt 'wanted' or 'approved' only by his father). Nowhere else in his depressive symproms - acute or chronic - the loss of his father is mentioned to be a cause or a playing a major part. In fact, the history clearly states "He relates that there was no particular incident or event that started him feeling this way. “It just came over me,” he says XXXXXXX

Other than this, there are brief mentions about XXXXXXX drinking and problems in relationship with his wife and children.

So, in summary - XXXXXXX who has a background of chronic low-grade depressive symptoms (more neurotic), recently develops a full syndromal, clinically significant depression (WITH NO APPARENT RECENT STRESSOR)

Now, with the history more "sorted" and salient features highlighted, now what are your views about the Axis I diagnosis?

(I'll answer the other questions subsequently)

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

Above answer was peer-reviewed by
Follow-up: Have fear of rejection, chronic frustrations and unrealistic expectation. On prozac. Looking for proper diagnosis and cure 5 hours later
I would say....296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features

Or did I still miss the boat?
Answered by Dr. Jonas Sundarakumar 5 hours later

You are in the correct track now - XXXXXXX recent symtoms will definitely qualify for a major depressive episode. But we should also consider his chronic, low-grade 'neurotic' deppressive sympoms as well - which I feel would also qualify for a Dysthymia.

Now, it is not uncommon for persons who have dysthymia of many years duration, to have an acute superimposed major depressive episode. This is what is called as "double depression". Although it is not specifically described in the DSM-IV, the literature defines double depression as an episode of major depression that occurs at least two years after an adult patient — or one year after a child or adolescent — develops dysthymic disorder. More than 75% of patients with dysthymic disorder will experience double depression at some point in their lives. And 25% of patients who seek treatment for major depression will recall having had dysthymic disorder in the past. Researchers do not yet know whether dysthymic disorder is an early manifestation of major depression, or if they are separate disorders with overlapping symptoms.

So, XXXXXXX Axis I diagnosis would be a dual diagnosis of Major Depressive Disorder and an underlying Dysthymic Disorder

(XXXXXXX may also be having an alcohol problem, but the history doesn't give any evidence whether he is using it in a harmful use pattern or a dependence patter. So, this needs more exploration)

Axis II is for Personality disorder and Mental Retardation. So, PTSD cannot come there since it is separate disorder (to be classified an Axis I diagnosis)
In XXXXXXX case, there seem to be some hints of Cluster C personality traits, like feelings of social inhibition and social inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction. But since there are only hints of these traits, he may not qualify for a full-fledged personality disorder. So, under Axis II, I would put "Avoidant personality traits"

Axis III - none specified

Axis IV - correct (except suicidal ideation, which is part of his psychiatric disorder)

Axis V - my estimate would be about 20-30

1) ICD generally uses more specific criteria for diagnosis. However, since the depressive symptoms are severe and prominent, the diagnoses of depression and dysthymia would still hold true. ICD does not use the term 'major depression'; the applicable would be "Severe depression without psychotic features"

2) Primary issues to be addressed are:
-his depression (including suicidal ideas)
- neurotic traits / personality issues - poor frustration tolerance, high interpersonal rejection sensitivity, poor coping skills, etc.
-alcohol abuse.

3) Diathesis - Genetic factors: family history of alcohol abuse
Stress: Childhood difficulties, loss of his father, unemployment, marital conflicts, problems in relationship with his children, etc.

So, in XXXXXXX case, the multiple stressors when superimposed on his pre-disposition (diathesis) could have resulted in his psychiatric illness.

Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
Follow-up: Have fear of rejection, chronic frustrations and unrealistic expectation. On prozac. Looking for proper diagnosis and cure 6 hours later
Thank you so much...I'm slowly getting a better understanding of everything. One last question, What kind of questions would you ask to help you diagnose this person?
Is there any other additional information you would need? Thanks
Answered by Dr. Jonas Sundarakumar 15 hours later

I would like to explore the following areas more in detail...

First priority would be his suicidal ideas. This is not only additional information, but (risk assessment) is also be an essential part of any assessment. Any suicidal plans, definitive motive, last notes, previous failed attempts, past suicidal or parasuicidal behaviour.

Second would be XXXXXXX personality traits - he definitely seems to have hints of Cluster C personality traits. It would be worthwhile to see how much these are contributing to his symptoms and his dysfunctional behaviour.

Third would be his alcohol use. XXXXXXX has a strong family history of alcohol abuse. So, we need to find out his pattern of use, ask about craving, tolerance, withdrawal, etc. to see whether his pattern would amount to an abuse or dependence pattern... Or whether he is simply self-medicating himself with alcohol for his depression.

Another important issue to be explored would be the psychodynamics of XXXXXXX relationships. It appears that XXXXXXX past relationships with his parents seem to be having a big impact on his current relationships. For example, avoiding his siblings and not getting close to anyone maybe stemming from XXXXXXX rooted fears of rejection incorporated from his childhood relationship with his mother. Or his conflicts with his children could be due to mirroring of his relationship with his father and unrealistically expecting his children to idealize him.

More information can be obtained about his past treatment / therapy to explore why they were not successful.

Finally, if there is any significant medical history.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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