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1 Appendix B CASE WRITEUP EXAMPLE December 2, 1998 I. CASE HISTORY [actual word count 774] suggested of words 750 A. Identifying Ination Ann is a 44-year-old, twice-divorced, Caucasian woman who has no children, lives alone, and has been working full-time as a Spanish teacher for the past 22 years. B. Chief Complaint Ann sought treatment due to an escalation in her depression which started in October, 1996. She reported that she was also binge eating and overusing and abusing laxatives at least once a week, though she was much more concerned by the depression than the eating/laxative problem. C. History of Present Illness In October, 1996, Ann divorced her second husband and began to develop depressive symptoms sadness, crying, social withdrawal, severe self- criticism. The depression worsened until it reached the severe level in March, 1997. At intake May, 1997, her symptoms included the following emotional symptoms sadness, anxiety, lack of interest in almost all activities cognitive symptoms difficulty concentrating, believing she was worthless 2 and unloveable behavioral symptoms crying, social isolation physiological symptoms difficulty falling asleep, tiredness She developed subclinical symptoms of bulimia nervosa in April, 1997. At intake, she reported that she binged, felt out of control of this behavior, and overused laxatives about once a week; she was and is intermittently preoccupied with a misperception that she is fat and is highly self-critical. The major stressors in Ann’s life are social ones. Since her divorce she has withdrawn from friends, family, and co-workers. She has dated several times since her divorce but each date has been a “one-night stand,” which leaves her feeling rejected and defective. She used to derive significant satisfaction from relationships but has isolated herself and now feels sad, lonely, and rejected by others. While she finds it more difficult to do her job, work does not appear to be a significant stressor. Ann restarted Prozac about 2 weeks ago prescribed by her family physician but thus far sees no change in her depressive symptoms. D. Psychiatric History Ann’s first episode of major depression occurred in 1977 when her first husband divorced her. She was hospitalized for three weeks and was given Elavil. She discontinued the medication against medical advice at discharge but initiated psychological treatment cognitive therapy for the first time. Her depression remitted after four months of this outpatient psychotherapy, though she remained in therapy on a biweekly basis for another year, working on Axis II issues.3 In 1989, Ann and her second husband received about six sessions of predominantly psychodynamic marital counseling which she found “mildly helpful.” In October, 1996, Ann’s family physician prescribed Prozac which initially helped reduce her depressive symptoms. The depression worsened in December, 1997, and