Читать книгу How To Be Depressed - George Scialabba - Страница 8
ОглавлениеII. Documentia
My mental health file whirs to life in 1969 in Cambridge, Massachusetts. I’d recently left Opus Dei, the Catholic religious order to which I’d committed my young soul, and a major depression had followed. The records printed below are out of the mouths of my many caretakers; they chronicle my treatment at various medical offices and psychiatric clinics in the Boston area from then until 2016.
How did I come by them? As I headed into a depression a few years ago, a friend who was helping out thought it would be useful to see my records, so I asked for them. Why publish them now? Certainly not because I think these extracts from my treatment notes reveal an exceptionally interesting psyche, nor because I intend the slightest scandal to be visited on my therapists, employers, or insurance company. All proper names have been altered.
Then why foist on you these sad memorials of my four decades of depression? These medical records and treatment notes do not display any special literary facility. In fact, they’re hardly written or composed at all—they’re a very distinct form of writing, almost a form of anti-writing. Over the last thirty or forty years, the process of documenting such encounters has changed drastically. It used to be much more free-form, wide open, reflective, and candid. You can still see some of that here, but for the most part, as medical liability has become more of a concern and the whole society has become more litigious, providers have become very much more self-protective. Now, instead of employing an individual voice to portray an individual subject, they limit themselves to handing you expeditiously on to the next provider, the notes a sort of bill of lading.
Our distractible human intelligence needs as many ways of talking about depression as can be provided—that’s all my motivation in publishing them. Given the longevity and tenacity of this particular demon in this particular life—mine—it seemed important to me to try to squeeze some insight from the mass of words and array of prescription drugs applied against its havoc. Even the most comprehensively bureaucratized medical knowledge can be made to speak, if only we are willing to listen closely to the blank spaces, the paraphrases, and even the acronyms.
The Crack-Up (1969–1970)
August 16, 1969
Trigg Clifton, MD/MB*
Harvard University Health Services, Psychiatric Clinic
Patient is seen as a courtesy visit because he is no longer actually eligible for consultation here, as he graduated here from the college [Harvard] in June of this year. He has plans to attend Columbia Graduate School.
He comes with very intense questions regarding Catholicism. In the last several months he has begun to question increasingly whether he can support a body of thought which stresses orthodoxy and lack of investigation. He approaches the problem with me and with himself quite intellectually, but he is indeed, in spite of intellect, feeling in much emotional turmoil over this. Support was given to him to move towards a middle ground, which, in his style, is very hard for him. He has felt frightened of the loss of the Church, and, therefore, it was clarified that he need not give up the Church, or the organization to which he belongs in the Church, to pursue his questioning, and that he would not be able to be content in any position he took until he opened up the questions with himself and others. He was also concerned that some of his actions have been inappropriate, and I did not feel that they were inappropriate save that they were indicative of a young man in considerable turmoil over some very important questions in life, and this was stated to the patient.
He will be talking with several priests and may indeed, when he gets to Columbia, seek psychiatric help for his semi-crippling obsessive-compulsive personality, i.e., he is often paralyzed by self-doubts and unable to be decisive.
At the end of the interview he questioned whether his difficulties would make him draft-deferrable. I stated that I did not think so.
Diagnoses: Adjustment Reaction of Adolescence in an obsessive-compulsive personality.
September 9, 1969
Trigg Clifton, MD/MB
Patient asked to be seen again because he now has to decide whether to go to Harvard Law School or to Columbia Graduate School. He spent the first fifty minutes of the session obsessing intellectually on both sides of the question, and I asked him very directly what his emotions told him, i.e. what he felt. He says that he now felt very uneasy about even the Church and Opus Dei. He felt that to pay attention to his emotions was a sign of weakness and lack of intellectual integrity. I clarified that man is both emotions and intellect, and it is lack of integrity not to be aware of the fact in making decisions. One must pay attention to one’s intellect, although one does not necessarily obey what it says.
We worked further on the thought that Harvard Law School would be a somewhat more predictable school to be in, and that the more stable day-to-day life it would provide might allow him a base from which to (1) obtain psychotherapy with a lessening of day-to-day anxiety and (2) to allow him to think over his religious questions. Patient will consider these ideas, and if he does go to Harvard Law School will contact me regarding psychotherapy.
September 30, 1970
Trigg Clifton, MD/MB
The patient has been in New York City in graduate school at Columbia but had a severe obsessive breakdown in functioning, necessitating his dropping out of school. He was in treatment for about eight months in New York City but left two months ago, for reasons that are not clear. He is now back here, hoping to pull himself together, and plans to take courses through the Extension School.
He came to see me to reestablish contact, and to question if he could get into treatment. I am aware that his treatment has been difficult for him but see him as a very troubled man, and probably sicker than an adjustment reaction of adolescence—more likely borderline personality with obsessive-compulsive features. Obviously, he could not be treated at this clinic, and he is uncertain whether he wants to get into treatment at all. I told him that if he did, he should feel free to get in touch with me and I would find him a clinic in the area.
He is not suicidal, and there are no signs of acute decompensation.
A Season in Hell (1981)
August 17, 1981
Jennifer R. Hornstein, MD/MB
Harvard University Health Services, Psychiatric Clinic
This was the first Mental Health Service visit for this 33-year-old man, currently working as a receptionist for the Center for International Studies. He is a neatly groomed, articulate young man who has been suffering extreme anxiety for the past four months. Since April, he has had difficulty falling asleep, with midnight awakening and early morning awakening. Over the past few weeks he has only been able to sleep around five hours per night. He describes compulsive eating and heavy intake of “junk foods.” He reports a loss of energy, anhedonia, and a decrease in sexual interest as well as a difficulty in obtaining erections. He denies suicidal or homicidal ideation. No history of hallucinations or delusions. No drug or alcohol use.
He says his current agitation reminds him of a period when he was 21, when he decided to leave a Catholic religious order which he had committed himself to, an order for laymen who dedicated themselves to chastity and poverty. Since then he has not been able to commit himself to any pursuits. Over the past several months, he has gone from one therapist to another, even including primal therapy. A therapist at the Harvard Community Health Plan prescribed some Valium, which helps him sleep but has not relieved his anxiety. Another therapist prescribed Sinequan, but it did not help.
Patient reports severe anxiety and obsessionality. He is unable to decide about anything, even whether to continue therapy. He is worried that there might be something medically wrong with him and has made an appointment to see his PCP [primary care physician]. He is not sure what he would like from me at this time, other than some instant relief or reassurance that his symptoms will not get much worse. He is afraid he will become so tired that he will not be able to walk across the campus to see me for our next appointment. I will see him Friday and then refer him for the two weeks that I am on vacation. He says he has friends who visit him occasionally, so he is not entirely isolated.
My initial impression is of a young man with agitated depression or anxiety attacks. No hyperventilation or palpitations but does describe some phobic symptoms (afraid he will stay in his house and not be able to leave). I do not think hospitalization is necessary. We discussed antidepressants, but I advised him that we would need further work-up before beginning medication.
August 21, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba returned for his second appointment. He appears slightly calmer than last time. His speech was slower and his affect more depressed. He describes a continuation of the symptoms noted on 8/17: difficulty falling asleep, early morning awakening, an urge to eat “junk food,” difficulty making decisions, loss of energy, decrease in libido. He has frequent thoughts of dying and going to hell, which he connects with his experience in the Catholic Church.
He also appeared rather guarded when talking about a referral several years ago to the Homophile Community Health Service. He was referred to an individual who was a “good therapist.” He denied that he had any thoughts about homosexuality or experience with homosexual liaisons.
He continued to demonstrate obsessive thought processes, though there were some loose associations, for instance when he began to quote from the gospel. Although the quotation was relevant to our discussion, his thinking did appear slightly tangential.
We continued to discuss his therapeutic history. He has had many experiences with therapists in the past, mostly short-term. After college he began therapy with Dr. Wendell O’Grady, a New York psychoanalyst, for six months. Shortly thereafter, he began treatment with the counselor at the Homophile Community Health Service. In the ’70s he saw a therapist for one year, who was a member of SOMA [an alternative therapy collective]. In ’71 he was in treatment for eight months as part of a group therapy with Alfred Lau. From ’76 to ’77 he was in an eight-month therapy which he describes as “scream therapy” with Raven McCracken at “Pathways.” He saw Dr. Oliver Tipton in Cambridge for four sessions, the last appointment being four weeks ago. He saw Dr. Olliphant, a psychiatrist, on one occasion. She prescribed Sinequan of which he took 10 mgs. on one occasion.
My initial impression is that this is an agitated depression in a severely obsessional and schizoid young man. There is some question of whether he is decompensating to a psychotic state. There does seem to be some indication of intrusion of more primary process material. However, he appeared more organized (although more depressed) in this appointment than he had appeared on 8/17/81. This patient has had a physical examination with Dr. Cindy Shepard, his blood levels etc. are within normal limits.
My plan at this point is to order an EKG as well as a deximethasone suppression test. I gave the patient a prescription for 1 mg of Decadron to be taken at 11 p.m. on Sunday night and with instructions to have a 4 p.m. cortisol level drawn on Monday.
I discussed the possibility of psychological testing with Dr. Andrew Berl. In his estimation, it would be preferable to postpone psychological testing until after my vacation in early September. The reasons for this are twofold: first, if this is a decompensating process it would be helpful to observe the patient over the next two weeks; second, there is some possibility, although slight, that this psychological testing may make the patient more disorganized. This would be particularly difficult during my absence of the next two weeks. I would order psychological testing upon my return to consider the question of underlying psychotic process, to question issues of sexual identity, to evaluate depressive and suicidal ideation, to evaluate his reality testing, specifically around religious preoccupations, and to evaluate some of his ego strengths.
I have given the patient a prescription for Serax, with dosage instructions. He has taken Valium in the past without difficulty.
I would recommend that when he is seen next week the possibility of changing to an antipsychotic, such as Stelazine, be continued when he can be followed over the course of the week.
I have discussed this case with Dr. Jeffrey Parsnip, who will plan to see the patient on Wednesday at 3 p.m.
August 26, 1981
Jeffrey F. Parsnip, MD/MB
Harvard University Health Services, Psychiatric Clinic
As arranged by Dr. Jennifer R. Hornstein, I met with Mr. Scialabba today. My assessment, which is in agreement with Dr. Hornstein’s, is that this man suffers from a rather severe endogenous depression superimposed on a schizoid personality.
Symptoms of major depression, which have been present for two to four months, include frequent early awakening; constipation; absent interest in sex; diurnal variations, with early morning the worst; compulsive eating; and profoundly decreased energy. I do not think that he suffers from true panic attacks but rather from somatic symptoms of anxiety.
The only family history of emotional illness is a first cousin, mother’s brother’s son, who committed suicide at age 21. There is no family history of alcohol abuse.
Certainly the chronic decline in functioning from his levels of a decade ago is disturbing. After graduating Harvard in 1969 with a group 2 average, he flunked out of Columbia, where he was studying history. Since then, he has spent a number of years working as a social worker in a local welfare department, though he says that this job was largely paperwork. He has been working as a receptionist at Harvard for the last year. He has no close friends and although he has had sexual intercourse he has not had close or enduring relationships.
He describes his mother as having been dominating, although very nervous, and his father as a timid, weak man. Father held an office job and mother worked in a textile factory. There is one brother who is taking night school courses and works in the Massachusetts Public Works Department. Thus, the patient greatly exceeded the level of the success of his family simply by going to Harvard and doing well there.
I wonder whether part of his subsequent decline is attributable to oedipal fears which his success represented. He now has multiple fears of losing control, which he fantasizes would result in his becoming passive, being unable to hold a job, going on welfare or into a hospital, and not being able to take care of himself. This may be a regression prompted by his earlier successes.
He describes having wanted to be a priest from the second or third grade, a role that was highly respected within his community. He currently has fears that his turning away from religion may have been a mistake and that he could be damned to hell for this. He also fears punishment for compulsive masturbation, which he says he is engaged in daily for ten years prior to his loss of sexual urges these last few months.
Given the chronic schizoid adaptation, the apparent decline in function over a ten-year period, and his interest in religion and philosophy, I looked hard for a thought disorder but was unable to satisfy myself of the presence of one. His functioning within the last four months is clearly discontinuous with his chronic level of functioning over the last ten years. During these four months he has had classic signs of an endogenous depression of severe degree, with agitation. In this context, I am rather strongly inclined to see him as having major depression superimposed on a schizoid personality.
Physical examination has been performed and is normal; dexamethasone suppression test is negative.
I believe he will likely benefit from tricyclic antidepressant therapy. I began discussing this with him today and will meet with him for further discussion tomorrow. Will probably start him on desipramine at that time.
September 14, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba’s return appointment today. He has been on desipramine since August 27. States that he is lightheaded when he stands, also still lethargic and sedated. He saw Dr. Wolf before our appointment.
I spoke with Dr. Shepard, who informed me that he was postural. Blood pressure is indicated in the medical record.
Says he had a brief resurgence of energy at the end of August, but since then has had a resumption of his depressive symptoms. Broken sleep; appetite and sexual energy low. No signs of a thought disorder. Feels hopeless and helpless.
Summary of his medication is as follows: 8/27 desipramine 25 mg qhs. On 8/28—50 mg hs. From 8/29 until 8/30, 75 mg qhs. From 8/31 until 9/2, 100 mg qhs. From 9/4 until 9/7, he was on 150 mg desipramine. From 9/8 until 9/13, the dose was decreased 100 mg qhs for symptoms of faintness.
Given the patient’s symptoms of faintness, lightheadedness, and postural hypotension, I have decreased his dose to 75 mg of desipramine. I will keep him on this dose for one week and then consider increasing the dose in slow increments.
I have discussed psychological testing with Maggie Ewing, who will refer him to a psychologist. I have requested that the psychological testing consider these questions: an underlying psychotic process, sexual identity, depressive and suicidal ideation, reality testing (specifically around religious preoccupations), and ego strengths.
The patient has stated that he is considering a referral to the Boston Center for Modern Psychoanalytic Studies. I have informed him that I will give him a referral if he wishes.
September 21, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba in for a return appointment. The medication is relieving his anxiety somewhat, but he continues to feel extremely sedated and exhausted. He has no further complaints or faintness or weakness. Still has some difficulty falling asleep, though not so much, and occasional early morning awakening. I increased his medication to 100 mgs of desipramine.
We discussed his frustration with his slow progress. He talked about his anger, and wondered whether it would be useful to spend the session expressing his anger. It seems he is particularly angry at the psychological evaluators who administered the psychological testing. He talked at great length about feeling insulted by the psychological test and expressed his anger at being dependent on “clerks and stupid bureaucrats.” He associated this with more longstanding anger at feeling dependent upon his mother, whom he also saw as a kind bureaucrat, and as vindictive and unavailable. In contrast he said he felt close to his father, a civil engineer.
He continued, affirming his anger at having to depend upon incompetent people, and at the same time acknowledged his very strong wish to be taken care of. He felt this particularly strongly in our sessions and wished I could see him more often. He could not articulate what he had hoped to gain by meeting more often, other than a sense that he was being looked after.
His affect was alternately sad and angry. He started to cry at one point, talking about his own compassion for suffering people and his wish that his own suffering would be treated with similar compassion.
September 28, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba appeared slightly more energetic and less fatigued than previously. He continues angry and frustrated with the psychological evaluation, and with bureaucracy in general.
He went on to speak about a longstanding sense of frustration, dating back at least to the age of 21. Again he spoke now of a strong wish to be taken care of, as well as frustration that he was not getting immediate relief from the medication. Despite that frustration, he appeared notably more animated today.
October 5, 1981
Jennifer R. Hornstein, MD/MB
He appears much improved today: more alert and articulate, less angry and agitated. His sleep has improved and he feels less anxious. He attributed this in part to the medication and in part to his article being accepted for publication by the Village Voice. During today’s session the change in his presentation was noticeable. He was less argumentative and more thoughtful. He was more obsessional than usual but less tearful and distracted. He spoke of the significance of his becoming 33. He felt that this age marked the end of early adulthood and meant he could no longer fall back on the fact that he was young, but had to begin to consider why he had not achieved more to date.
He wonders whether he should return to primal scream therapy and whether his current episode may have been related to early childhood experiences. In particular, he described a sense of frustration of not being taken care of as he would have liked by his mother. He fears that such concerns would not be taken seriously in other forms of therapy.
Mr. Scialabba appears to be coping with his anxiety with more obsessional defenses at this point. He appears more available for therapy at this time.
October 19, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba appeared calm and in good spirits today. He has felt quite confident since his article appeared. He also attributes some of the improvement to the medication. We discussed some of the results of the psychological testing.
In answer to his question about primal therapy, I suggested that he embark on a weekly course of psychotherapy, probably long term. I told him that his difficulty was not in experiencing affect, but rather in integrating his feelings with his intellectual perceptions. When he begins to experience feelings, he feels overwhelmed, panicked, and becomes frightened. When writing, on the other hand, uses his intellectual capacity exclusively. It appears that the task will be to help integrate both the intellectual and the affective experiences. I referred him to Dr. James Garcia, for possible therapy.
November 17, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba has decided not to continue with Dr. James Garcia. There is apparently some financial difficulty. He has decided instead to meet in once-a-week therapy with Dr. Buenavista through the Boston Center for Modern Psychoanalysis. I have suggested that he ask whether he could receive the medication through the Boston Center for Modern Psychoanalysis or through a physician associated with the Center. I have advised him quite strongly that I see difficulties in splitting up the therapy from the medication in his case. He will get back to me next week about this.
He seems in good spirits today. He is calm, less anxious, and reports that he is sleeping six to seven hours a day. His appetite is good. He has more energy and is attending work without difficulty. No crying episodes. He has occasional headaches—every two or three weeks. Other than this, no medication-related side effects. I renewed his prescription for desipramine and advised him to increase his fluid intake since his last BUN was 20.
Reality Components (1986–1987)
December 29, 1986
Grace Franklin, MD/MTL
McLean Hospital
Of his background I learned that he is the younger of two children born to second-generation Italian parents. Although he speaks kindly and sensitively about his parents, he describes his home life as deprived in some ways, based on his parents’ educational and socio-economic status. Very difficult relationship with his mother, who was highly critical and demanding and who could not be pleased. He has a good relationship with his only sibling, a brother who lives in the area, is married with children, and works in the same city department for which his father worked for twenty or thirty years. He feels somewhat estranged from his family because he broke away intellectually and educationally, but nonetheless sees them on a regular basis every three or four weeks and the relationship is cordial.
As we talked about what he is seeking in therapy, it came out that he has a good deal of intellectual insight. Indeed his major defenses are intellectual and rather powerful. He defends against affect and he defends against intimacy; I suspect this is the reason his therapy has not gotten very far in the past. Indeed, his relationships with therapists haven’t gone much further than his relationship with anyone else in his life. When we began to talk about his wishes regarding a therapist, the resistances immediately surfaced. Money is a problem for him: his insurance coverage is not good, and while he does have some small savings, he is not sure at this point how much he wants to commit his savings to treatment. This clearly is not going to be an easy treatment situation, although I think he would be a very interesting person to work with. I think he should be in the hands of a very experienced therapist, someone well trained in developmental issues. There’s an additional factor: this man has had two major periods of upheaval in his life, and although the history is not clear-cut, I found myself thinking in terms of a possible recurrent depression. At one point in 1980, when he was seen at UHS [University Health Service], he was put on an antidepressant. He cannot tell me whether his depression responded to the antidepressant or just went away spontaneously. His mother seems to have a great deal of emotional difficulty, and there was a cousin on the mother’s side who committed suicide, so there is a possible biochemical or genetic vulnerability. For this reason, I feel that he also ought to be in the hands of a physician who will be sensitive to medical issues. In short, in this one session, the diagnosis is not clear. This is a man with a narcissistic character; a manic-depressive diagnosis must be ruled out. Because he could not make up his mind today about treatment and could not advise me how to refer him it was left that he will consider his assets, get more information about his insurance, and when he is ready to be referred he will be in touch with me so that I can be more helpful to him.
February 1987
Grace Franklin, MD/MTL
Mr. Scialabba remains ambivalent about therapy. He couches it in terms of his inability to afford any ongoing treatment, and I do think that is partly realistic. He asked whether Valium on a regular basis might be useful. As we discussed this, he mentioned an article by a prominent writer about using Valium for symptoms not unlike his. Unfortunately, she became a Valium addict, so Mr. Scialabba in effect answered his own question. I reaffirmed my views that many of the things he was coping with were characterological, and that was not an indication for Valium use. We did talk a bit about anti-depressants, whether they had a role in his treatment. Since I saw him last, he’s had two periods of depression, which were very short-lived, generally just a couple of days, and most of the time he’s been feeling fairly well. I don’t have enough of the indications myself to put him on anti-depressant, but I told him that I was fairly conservative about the use of drugs and encouraged him, if he wished, to have a consultation with a psycho-pharmacologist to see whether someone with this kind of experience might recommend the use of them. I gave him the names of Douglas Ore, Tom Elfwood and Robert Ellis as possible consultants to this end.
Mr. Scialabba is a 38-year-old Harvard employee, who comes to me for a referral for ongoing therapy. He’s a graduate of Harvard College, class of ’69, has had a fair amount of treatment with a variety of therapists in the past, including having been seen by a number of people in the UHS, although that record was not available to me today. He recognizes that he is stalemated in his life and his career and that it’s emotional problems that are blocking him from taking next developmental step. He wants to definitively go to work on these problems. Though he’s seen many therapists in the past and has made some progress with some and with others considered the experience worthless, he has never been able to grow in the way he clearly needs to do if he’s going to move beyond his current position. By that he means that he has considerable intellectual capability, was originally planning to go into a religious order but split off from that when he was in college, did begin graduate school at Columbia but was in so much emotional turmoil and was unable to concentrate that even that came to an end after a year. Since that time he has had a variety of low-level jobs and although he functions adequately in them, he is certainly not living up to his intellectual potential at all. This is also true in his personal life, he lives alone, he has some friends, but he only allows people to get so close to him. His best friend is an old one from the past but one who lives in New York, and I gather the friendship is expressed mostly by letter. There have been many women in his life but the relationships have always been short-lived, and when he begins to sense that the woman wants to go further with the relationship, he begins to find things that are wrong and creates such distance that the relationship breaks off.
April 13, 1987
Grace Franklin, MD/MTL
In case he changes his mind about ongoing therapy, I gave him Margaret Williams’s name. Her clinic might be able to offer him a reduced fee for therapy that would be manageable for him.
Intermittently Hopeless (1987–1988)
July 6, 1987
Melinda R. Maron
McLean Hospital, Ambulatory Care Services
Intake Report
Chief Complaint:
Patient saw Dr. Mason once. Referred him here because of financial concerns. Feels emotionally fragile, high-strung, unable to make life decisions. Feels he’s drifting professionally. “Ridiculously over-qualified for what he does.”
History of Present Problem:
Early traumatic break from religious tradition, Catholicism, at age 21 from which he’s never really recovered.
Family Information/Current Living Situation:
Lives alone. Parents and one brother live in the area.
Medical History/Current Medications:
Physically in good health, though not “bursting with energy.”
No meds, alcohol or drugs.
Previous Outpatient Treatment:
Yes—few times in the ’70s.
Previous Hospitalizations:
None.
Additional Psychiatric History:
One cousin had psych problems and suicide at age 22.
Insurance Coverage:
Harvard University Group Health Plan (HUGHP)
Impression at Intake:
Patient found it difficult to talk, seemed very constricted and upset.
August 25, 1987
Juan Durendal, MD
McLean Hospital, Ambulatory Care Services
S. I was feeling really down when I called you.
O. Anxious, mildly depressed, ruminative.
A. Given history of anxiety with prominent somatic components, depression, following relatively minor negative events, n/o phobias, an MAOI seems indicated. Patient aware of risks and benefits of trial, understands possibility of HTN [hypertensive response] if not following diet. Aware of the need for concomitant psychotherapy, agrees to see Melinda Maron weekly.
P. 1) Start Parnate 10 mg po. Follow-up in a week.
August 25, 1987
Juan Durendal
S. I’m intermittently hopeless.
O. Very tense, restless, sighing, unchanged from previous meetings.
Patient had to turn down a teaching job offered to him by a friend because of overwhelming anxiety, fear of failure or “crack-up.” Felt better after turning it down but became somewhat hopeless. No side effects from Parnate.
Increase Parnate to 20 mg. Follow-up in a week.
September 9, 1987
Juan Durendal
S. Feeling the same, sleeping more or less okay.
O. Tense, anxious still ruminating about giving up the opportunity to teach history because of his anxiety.
A/P. Tolerating increasing doses of Parnate, no side-effects prominent.
Increase Parnate to 30 mg po AM. Follow-up in a week.
September 23, 1987
Juan Durendal
S. I’ve been having some orthostatic hypotension, my mood is as usual.
Constricted, anxious affect. Sleeping well, waking up once during the night as is usual for him, well rested in the morning. Patient is interested in shifting his sleeping pattern from sleeping between 2:00 a.m.—10:00 a.m. to something like 12:00 midnight—7:00 a.m. to be able to have a more socially active life, prepare papers for courses, etc.
A. Tolerating Parnate 40 mg d, some orthostatic hypotension, some increased energy. Finds therapy to be beneficial “at least I have someone intelligent to talk to.” Will attempt shifting his s/a cycle over the next 2–3 wks. Patient given instructions regarding hygienic measures to improve sleep. Will discuss starting cognitive Rx.
P. Continue Parnate 40 mg Halcion 0.123 mg for insomnia.
December 3, 1987
Melinda R. Maron
Met with Mr. Scialabba for 50 minutes. Focus of session was his difficulties in relationships; feeling either intimidated and unequal or feeling superior and condescending. Pattern is to avoid all relationships. Lately, however, is making attempts to socialize.
December 10, 1987
Melinda R. Maron
Said that for him the pursuit of pleasure and self-expression seems to be confused with anger. Said a woman in a psychotherapy group once described him as a “ticking bomb.” He feels that in some way this is true. Is afraid of his angry impulses. Feels he has to “pay his dues” by paying attention to politics and taking moral stands. Worries he left Opus Dei for pursuit of pleasure rather than on principle. Very conflicted regarding both pleasure and regression.
December 17, 1987
Melinda R. Maron
Patient talked about his difficulty with intimate relationships. Feels he can only succeed with young, naïve women, who won’t perceive his failings. A “mature” relationship with a “mature” woman is something he avoids. Mr. S seems to worry about every aspect of relationships. Also ambivalent about gratifying his more “superficial” impulses.
December 24, 1987
Melinda R. Maron
Patient reports some old obsessions coming back now. He is again envious of friends and feeling inferior to them. Described his wish to be a reclusive mouse of an academic who would bury himself in serious academic work rather than being the “dabbler” he feels himself to be. Worries that he’s superficial because won’t allow himself to pursue literature and philosophy, which is what he wants to do. Near the end of the session, he described a scene from adolescence when he tried to resolve a conflict on the playground between “good” boys and “tough” boys.
December 30, 1987
Melinda R. Maron
Treatment Plan
Problem No. 1:
Depression as shown by social isolation, inability to make career decisions, and overwhelming feelings of guilt.
Goal (long term):
Reduce feelings of guilt, paralysis about decision, and social isolation.
Objectives (short term):
Patient will understand more about the connection between his behavior and his depression, and will feel less despair and guilt about his choices.
Expected Achievement Dates:
Long term—6/90
Short term—9/88
Specific Plans:
Individual psychotherapy, once per week.
Psychopharmacology with behavior therapy, once per month.
Problem No. 2:
Personality disorder with obsessive-compulsive style and depression that contribute to his paralysis and lack of intimate relationships.
Goal (long term):
Modification of obsessive-compulsive defenses.
Objectives (short term):
Patient will become more flexible and tolerant of himself and his affects.
Expected Achievement Dates:
Long-term—6/90
Short-term—9/88
Termination Criteria:
Reduce depression. Modification of rigidity of obsessive-compulsive personality disorder.
Chief Complaint:
Mr. Scialabba described himself as “emotionally fragile, high-strung, and unable to make life decisions. I am ridiculously over-qualified for what I do; I feel stalled in my life and want to know if there is a medication that could help me.”
History of Presenting Problem:
Mr. Scialabba dates his psychiatric symptoms back to age 14, when he developed incapacitating anxiety in response to any sexual impulse, along with guilty ruminations that disrupted his usual activities. He went to a priest who told him he would take responsibility before God for the patient’s sexual impulses, and the anxiety episodes stopped.
Some years later, he joined a very devout all-male Catholic organization called Opus Dei and was very involved with that organization during his undergraduate years at Harvard. He felt a missionary zeal about attracting others to Opus Dei. He describes his commitment as “intense, demanding, and lifelong.” But after four years of college he “lost all belief in Catholicism.”
Mr. Scialabba describes his leaving the Catholic Church and Opus Dei as extremely difficult. He went into a meeting of Opus Dei and tried to speak publicly about his loss of faith. Instead he became so agitated that had to be led from the room. He feels he has never recovered from this emotional upset. He describes the time leading up to his departure from Opus Dei as the most intensely meaningful, exciting time in his life, when he felt that all of life and intellectual and philosophical pursuits were open to him. Instead when he left, he was overwhelmed by agitation.
He attempted graduate school at Columbia in European intellectual history as well as Harvard Law School, but he dropped out of both because whenever he attempted to do any serious work, he would become unbearably agitated and have to stop. He returned to Cambridge after one year at Columbia and has remained here ever since.
Mr. Scialabba has had a series of “undemanding and rewarding jobs” such as substitute teaching, welfare social worker, and currently is a receptionist/staff assistant at Harvard’s Center for International Studies. During the last 5 years he has done a fair amount of freelance book reviewing for the Village Voice, the Boston Phoenix, and a journal called Grand Street.
January 7, 1988
Melinda R. Maron
Talked about commitment. He described himself as “butterfly-like,” floating from one thing to another without ever really choosing. Feels this has been his pattern in life—he doesn’t want to give up anything. When you choose, you are left with paralyzing doubts, as he was after leaving Opus Dei.
January 7, 1988
Juan Durendal
S: “I am feeling discouraged again. This time of year always gets me down because it reminds me how little I’ve accomplished in the last year.”
O: Mental status exam essentially unchanged. No side effects from Parnate.
A: We have started doing behavior therapy focusing on vocational and interpersonal issues. No change in meds appears warranted, although tolerance to Parnate is possible. Will continue to observe.
January 12, 1988
Melinda R. Maron
About 5 years ago Mr. Scialabba experienced an episode of major depression with low mood, decreased concentration, initial insomnia, decreased appetite, decreased energy, moderate anhedonia, social isolation, guilty ruminations and wishes of being dead, but with no sui cidal ideation. The stressor was the need to either to buy the apartment in which he lived or to vacate it. Mr. Scialabba improved spontaneously in September. He ended up buying the apartment with the help of his family.
Recently Mr. Scialabba again became depressed during the summer months with no obvious stressor. He began to feel very stuck in his life and wanted to do something about it, and that prompted his seeking treatment.
Personal History:
Mr. Scialabba grew up in East Boston in an Italian Catholic working-class family. He has one brother, with whom he has a somewhat distant relationship. He describes his mother as a strict powerful figure in his childhood, who was angry and bitter about her working-class status and disappointed in her husband for not being ambitious enough. Mr. Scialabba recalls his father as being passive and dominated by his mother. He also felt afraid of his mother’s anger, although he does not remember her as being abusive. He was a quiet, sensitive, “good” child who always wanted to please the nuns at school, where he always did very well. He felt somewhat isolated and yearned to escape his East Boston neighborhood. He reports nothing remarkable during his childhood or adolescence until age 14 when he briefly developed anxiety around his sexual impulses. He visits his parents in East Boston several times a month.
