Psychiatric, Family, and Medical History

The patient had had no prior severe depressive episodes and no history of mania or substance use. He did meet criteria for early-onset dysthymic disorder, which remained untreated in the past. Currently, he also fulfilled criteria for benzodiazepine dependency.

Mike’s mother had a history of recurrent depressive episodes. There was no other family history of psychiatric illness or treatment. Mike had been physically healthy, with no history of thyroid disease.

Case Formulation

Several life events clearly contributed to the onset of the patient’s depressive episode, which was superimposed on dysthymic disorder. Most important was the death of his older brother and the consequent restructuring of the family hierarchy within the business (even though all brothers kept the same number of company shares). Mike anticipated Jack’s death for a long time and, supported by his wife, grieved normally, but he could not adapt to the new structure of the company. Due to his anxious- avoidant personality style and probably as a reflection of dysthymic symptoms, Mike was too insecure to follow in Jack’s footsteps and abruptly left the business following an argument with his brothers. He had to endure an unintended role transition from business manager to inactivity to being ill. The conflict with his half-brothers remained unresolved, “on hold,” and Mike waited passively for a solution. He felt stuck between returning to the family business to deal with his brothers and leaving the business to start a new career. He found neither alternative attractive.

Individual therapist: Mike, we looked at what was going on in your life when you had your first depressive symptoms. Let me summarize what I heard you saying

so far. Your oldest brother’s death and its consequences for your position in the family business began a series of disputes with others and led to more life changes. You went through the normal grieving process following your brother’s loss, but it was hard to stand up for your needs in the company. Your unintended move to the East, the separation from your family, the closing of the company branch in the East, and the arguments with your brothers presented challenges that seemed to overwhelm you. You told me that you are still hoping your brothers will turn to you and make up, but you are losing this hope with each day that you are hospitalized. The marked severity of your depression is reflected by a score of 29 on the Ham-D and 37 in the self-rated BDI questionnaire.

What do you think about us starting to work on the problem area of a “role transition”—that is, your coming to terms with letting go of your old position of being protected by Jack and finding out what your actual choices are and how your new role should look?

Mike: Yes, that makes sense. I still can’t believe what has happened. It seems as if my whole life got out of control and I feel overwhelmed with mixed emotions. I’ll be relieved if you help me to sort out the chaos and come to a decision on how to proceed.

Individual therapist: You said it feels as if you lost everything you’ve worked hard for all your life, you lost Jack and your illusion of a family clan that sticks together in good times and bad. It’s very understandable that you got depressed. Once you are able to deal with your complex emotions, it will be easier to figure out what you want for your future and how to deal with your brothers. I also heard you saying that you feel too confused to approach the conflicts with your brothers. However, at a later stage of therapy when things have cleared up, we may want to add the focus of “interpersonal disputes” to our treatment contract.

Mike: Okay, maybe later; I am not ready for that yet.

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