Case Presentation and Verbatim Essay

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Susan Marx is a 31-year-old, right-handed, Caucasian woman who has completed 12 years of education. She was referred for complaints of depressed mood for the past month. When asked why she referred herself she responded, "I am very depressed and cannot motivate myself to do anything." She also reports experiencing feelings of extreme sadness, hopelessness, lack of appetite, difficulty sleeping at night, decreased energy, some suicidal thoughts, and feeling as if everything she does is of no consequence.

Presenting Problem

Marx reported that her depression began following being terminated from her position as a secretary for an attorney. She reported that she had a "romantic" affair with her employer, who decided to end the relationship and then terminated her. Since then she is quite depressed and does not have the energy to clean her apartment which is becoming quite messy. She sits on the couch and watches television all day long. She only gets up to use the bath room or leaves to go to the store and has not bathed, although the morning before the intake was the first time she had showered in two weeks. She lies on the couch most of the day and cries frequently. She reported sleeping on and off a few minutes at a time during the evening and does not have the energy to look for another job or talk to anyone. At the time she had made "a few" calls to her former employer, but her will not return her calls.

History of Presenting Problem

Ms. Marx stated that she has always been "taken advantage of by men" but is a "loving and giving person." Eventually men discard her "like yesterday's dirty laundry." She added that men are all "pigs." The most recent episode of depression began when she was fired from her job as secretary. She had been working there for about six months when she began dating her employer, a married man. At first the dates were casual lunches and her employer flirted with her. This eventually led to them having dinner together and then getting a hotel room and having sex. Their dates became more frequent, two to three times a week, and she fell in love with her employer. The affair lasted for eight months. Ms. Marx reported that her employer told her that he was in love with her and was going to divorce his wife; however, he kept putting this off and she became increasingly impatient with him. She began to ask him why he was putting off telling his wife and all he would say was that it was "complicated." Eventually her employer's wife received an anonymous letter that alerted her to the affair and he stopped seeing Ms. Marx who became quite upset and felt "betrayed." She insisted that she did not know who sent the letter to his wife but he accused her of sending it. When she tried to get an explanation from him at work he would not talk to her and she became "distraught." She became verbally abusive; yelling and screaming at her ex-employer and threw a chair through the office door. She had to be escorted out of the building by security and was terminated the next day.

Furthermore, after she was fired her employer's car was vandalized while in the parking lot and he blamed her for it; however, she denies vandalizing his car. There is a police investigation of the incident. The police questioning regarding the car has been "traumatic" for her.

This is not the first time that Ms. Marx has been romantically involved with an employer. She reports a similar incident that occurred two years ago when she became involved with a previous employer. She states that this employer "led me on and later dumped me." When she approached him to get an explanation the employer filed a personal protection order against her as he claimed she was leaving numerous messages on his phone and waiting for him when he came home. Even though she now refers to him as a "pig" at the time she became very distraught and took a bottle of over-the-counter sleeping pills as she did not want to live without him. Ms. Marx was hospitalized and reported that she was required to attend counseling by the physicians that treated her. She stated that the counselor (a female) was "verbally abusive" to her, was not interested in how she felt, and she terminated counseling. She stated that she was not currently suicidal but sometimes at night she thinks about killing herself to get back at her ex-employer.

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She denied having a plan as to how she would accomplish this or any current intent of hurting herself.

Childhood and Family History

Ms. Marx is an only child. She never knew her father and she was raised by her mother and two of her mother's brothers, Tom and Ken. When Tom married he moved out and Ms. Marx was raised by her Uncle Ken, who never married but died of alcohol-related cirrhosis of the liver several years ago. Her mother worked as a waitress and worked long hours in the afternoon and evening. Her mother also had "many boyfriends" but Ms. Marx recalls that most of them were not around for a very long time. Her mother died of breast cancer three years ago at the age of 50. Ms. Marx left the home when she was nearly 18 years-old after graduating from high school and getting a job as a teller in a local bank. She rented an apartment with several high school friends who were attending a local college, but this did not work out as she usually had a boyfriend over after work and her friends wanted to study. Sometimes her boyfriends and she would fight and this would cause tension with her roommates. She got her own apartment when she was 19 years-old and has lived alone since.

Ms. Marx' developmental history is normal the obtainment of age-related developmental milestones. Her history is also remarkable for self-reported sexual and physical abuse at the hands on an uncle (Ken) when she was 12 years-old. She stated he physically abused her and sexually molested her when he babysat for her. These incidents occurred multiple times over a period of three years; however, she stated that no charges were ever filed and that her mother "looked the other way." She reported that she also began to have sex with other boys and men when she was 14 years-old engaging in "too many sexual relations to count." She began cutting herself on the arm when she was 15 years old to deal with the emotional pain of being rejected by men. She stated that most of her relationships with men are sexual and do not last over two weeks. She has not cut herself in several years; however, she began drinking at age 16 three to five nights a week when she is alone. She has never been married.

Educational and Vocational History

Ms. Marx is a high school graduate. She has never been held back any grades and was a "B student" in school. She did not participate in extra-curricular activities.

Ms. Marx' first job was at the age of 18 as a teller in a local bank. She reported that she had a sexual affair while she was a high school student with the branch manager who hired her. She would occasionally have sex with him but the affair "never went anywhere." She worked for the bank until two and a half years ago when she was let go after a new branch manager took over. Ms. Marx then became a secretary at a law firm but was released after a year and after having an affair with her employer. She was then hired as a secretary at the position that she was recently terminated from.

Medical/Psychiatric: SA History

Ms. Marx had a physical examination at the hospital she was admitted following a suicide attempt. She was in the hospital for three days and released. She has had no follow-up appointments but her medical history is unremarkable. She reports that she smokes a pack of cigarettes a day, takes no medications currently, and has no family physician.

Her psychiatric history is remarkable for depression, a previous suicide attempt requiring hospitalization, current but occasional suicidal ideations, reported physical and sexual abuse, unstable personal relationships, sexual promiscuity, and anger management issues. The patient has completed five previous sessions of psychotherapy for depression. She has taken an antidepressant (Zoloft) in the past for three weeks but stopped that as she felt she did not need it.

Ms. Marx began drinking alcohol regularly at age 16. She usually has three to six mixed drinks at local taverns. She occasionally meets men at these taverns and brings them home to have sex with them. She reported that she usually only sees them once or twice because when she starts having feelings for men they reject her….....

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