CASE EXAMPLE History of Present Illness

Tom, a 28-year-old male third-year university art student, was referred to me by his general practitioner for treatment of depression. Tom had visited the doctor saying that he was low in energy, tired all the time, and not functioning. He described increasing bouts of anxiety described as shaking, tightness in his chest, sweating, and an overwhelming feeling of being “crippled," as he had felt more and more despondent about his inability to produce artwork. Over the past two months he had increasingly worsening mood, loss of enjoyment, and poor concentration, and had found it more and more difficult to summon the energy to attend his university lectures and practical sessions. As a result he had spent more time in bed and had eventually stopped attending college altogether.

He described feeling lonely and isolated, feelings that worsened when his flatmates were socializing and bringing home friends and girlfriends. He said he felt different from everyone in his flat and unable to connect with other, younger students in his department. After he stopped attending lectures, he felt so low and tired that he went to his GP, thinking he might have a physical illness, “perhaps iron deficiency" The GP elicited the full range of depressive symptoms and referred him because Tom did not want antidepressant medication and the GP knew we were recruiting for a psychotherapy study. The referral letter indicated increasing isolation in an already isolative individual, withdrawal from his studies, no obvious life events, and a frustration with his symptoms.

Beginning Session: BDI = 28

In our first meeting I sought to clarify his depressive symptoms, confirm the diagnosis, address safety issues, and then discuss treatment options. In the waiting room I noted a tall, dark-haired male who appeared nervous. He had difficulty making eye contact as I greeted him. He was dressed casually in frayed jeans with holes in them, skate shoes, a long brown torn jersey with sleeves pushed up, and a T-shirt underneath. On his left arm was an intricate tribal-type tattoo commonly seen in New Zealand. He also had pierced ears, sported a goatee, and wore a necklace, some rings, and small dark-rimmed glasses. He entered the consultation room slowly in front of me, sat down on the chair I indicated, and leaned forward, elbows on knees. He gave a small sigh and looked awkward, apparently still finding it hard to make eye contact. This was my first observational clue about a possible problem area. Why did he find it hard to make eye contact: Was this part of his mood disorder? Was he shy? Ashamed? Overwhelmed? Intimidated?

When we settled into my room, I explained I would be taking a history to confirm his diagnosis and to help us work out how to proceed. We first talked of his current symptoms and how they had impaired his functioning dramatically. He had a full range of depressive symptoms that I could clearly confirm, and I noted on his symptom report form that his BDI score was 28, indicating moderately severe depression. Besides acknowledging his depressive symptoms, Tom outlined his recent past and his functioning. I learned that he had started his art course two and a half years previously, after a period of transient jobs. He quickly became aware he was the oldest in his course by about four years. Tom had supplemented his formal study earning money by selling his paintings every weekend in a local trade market where he had a regular stall. On these weekends he painted, watched the world go by, and conversed with customers. He stated that although he had always had “a bit of a confidence thing" this had worsened over the past year as he talked less and less with customers, found it increasingly difficult to relate to the younger college students, and became more isolated. I wondered to myself whether this shift was part of his current symptomatic picture and therefore depression-related isolation, or whether his difficulty relating constituted his role as an older student not fitting in.

Tom described generally feeling that his “time was running out” and that he isolated himself because he could not endure the scrutiny of others, felt different, and did not fit in. He said he had never been good at small talk but that this had become more of an issue. He had tried meditation, which had helped his sleep a bit, but he felt despairing and disconnected and that he was closing in on thirty with little to show for his life. Again, while he appeared to be describing himself as lonely and isolated, I also wondered about the relevance of lack of role transition to adulthood for him. As a twenty-eight-year-old, he had made no move away from the student role, and since he would have graduated from high school around eighteen or nineteen there was no clearly defined shift out of tertiary education—but within this role he had become increasingly socially awkward, something that had been an issue for him growing up even before the onset of his depressive symptoms.

Throughout our first meeting Tom appeared nondescript and very shy. He hesitated and struggled in answering some of my questions, often looking puzzled or frowning when I asked him to elaborate or explain. He seemed to find it difficult to provide clear explanations. He at times made complex, somewhat philosophical comments to elaborate on themes. I began to worry that he would be hard to work with and also acknowledged my dismal lack of philosophical background knowledge. Towards the end of the session he asked whether I had read Nietzsche. Help! I thought. What is this about? I haven’t read him. Is he testing me? Is he serious? Is he trying to find a common ground for our therapeutic relationship or trying to make me look stupid? I really wasn’t sure how to answer. I said I was curious why that would interest him. “Because I want to be able to relate to you.” Help! I thought again: What other personal things is he going to ask me, my marital status, my religion? I noted that this would be essential to take to supervision.

From an interpersonal perspective, I wondered if he came across this way outside the clinic room and decided I would try to explore this with him at a later stage: this might be a relevant factor in his isolation from others, but he might experience my raising it now as confrontational and critical since we had not yet developed a therapeutic relationship for me to confidently bring this up yet.

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