Debbie is a 34-year-old married homemaker. Her husband, Mark, is a 37-year-old corporate lawyer who specializes in international law. Debbie and Mark met each other 11 years ago, shortly after he was hired by her father's firm. They have been married for seven years and have no children. They divide their time among three residences: a lavishly decorated townhouse in Boston, a 14-room summer home in New Hampshire, and a large condominium in Zurich, where Mark stays during his frequent business trips to Europe. The therapist made first contact with Debbie one afternoon in February when she called in a panic about a "marital crisis."

She was clearly agitated and sounded as if she had been sob-bing. After briefly introducing herself, she described her crisis.

She and Mark had gotten into an argument just as he finished packing for a business trip. She accused him of abandoning her and began to insult and berate him. In the heat of the fight she threw several porcelain figurines at him, each one costing several hundred dollars. None had struck him or even come close. As she continued to fight with him, he slapped her with enough force to knock her off balance. She then started sobbing.

When he saw that she was not injured, he began to leave. Debbie threatened to kill herself if he left her alone, but he walked out the door. After a little while Debbie called a friend. The friend was a former patient of the therapist and suggested that Debbie call him.

The therapist was extremely concerned over the mention of suicide and asked Debbie if she really wanted to die. She seemed a little surprised by the urgency in his voice. No, she said, she didn't really want to die. But she often got so angry with Mark that she said things like that. The therapist con-tinued. Did she have a concrete plan? Had she made any previous attempts? When her answers were again negative, the therapist felt assured that she was in no immediate danger and did not require hospitalization. He then arranged an initial consultation during lunch the next day.

Debbie arrived right on time. She began by thanking the therapist for his concern the day before. His concerns were not over, though, and he began by asking her once again about her ideas of suicide and her feelings of depression. She repeated that suicide was a frequent threat, but that she had no real intention of dying. He then asked her about her mood. Had she been depressed? Irritable? Bored? She reacted to the latter, saying that for the last several years she has felt apathetic and lethargic.

This was especially noticeable when Mark was away, but it persisted to some extent most of the time when he was home, too.

He then asked her whether she had spoken to Mark since their argument. She had called him in Switzerland to apologize and to say how important he was to her. Mostly she didn't want him to worry. According to Debbie, this switch from anger to concern was common.

I have these "lightning-fast" changes in my feelings for Mark. It's like there's a little switch inside me that moves from NICE to MEAN. I remember one time when we took an elevator to a business party. I was feeling fond of him and proud of his success. But then, the moment he walked out of the elevator and into the hall, I suddenly hated him. I started saying that he only had his job because he married me, that he was living off my father's money. It's not true, you know.

Anyway, I said that he was manipulative and controlling and arrogant. There we were in the hallway. I was yelling at him, and he was yelling back. We had to just turn around and leave. This happens all the time; I suddenly get mean and vindictive. I really worry that one day I'll just drive him away.

The therapist asked Debbie about violence. Mark struck her yesterday; had he hit her before? She replied that he had slapped her once before. It was a slap like yesterday's. She had also slapped him on occasion, but usually she throws things at him. She claims that she doesn't really want to hit him. In fact, she never really aims. The violence has never escalated beyond this level. The therapist then asked her about other aspects of their relationship.

Therapist: How is your sexual relationship with

Mark?

Debbie: Do you mean how much or how good?

Therapist: Both.

Debbie: Well, it's pretty dismal. I guess we

make love twice a month, on average.

But remember, he's not home a lot.

Therapist: Do you enjoy it?

Debbie: He seems to, but I don't, really. I don't

think I was meant to enjoy it. I used to get excited by sex, but I haven't for a long time now. I feel like I'm sexually dead.

Therapist: Do you have any plans for a family?

Debbie: God, no. We used to talk about it, but

we usually ended up fighting. I'd get so angry at Mark that I'd swear I'd never have his children. I didn't think he deserved any. You know, I've had two abortions. I scheduled them for when he was away, and I don't think he knows. I mean really, why should I go through all that just for him? First of all, I don't know if I could take the pain of having children. But that's just the be-ginning. I don't think I could stand them always being around, needing me, depending on me. I suppose I would get a nanny, like my mother did for my brothers. But I'd still be their mother.

They would always be needing things and wanting things. I don't want that.

And then think of the money they'll

cost.

Therapist: Would the money be a problem?

Debbie: Well, you can't just throw it away. Now

Mark does that. His younger brother is always asking for a handout of one kind or another, and there's Mark, Mr. Gen-erous, always shelling out.

I feel

robbed. You know, sometimes I think his brother is out to take us. I really do.

But I try not to think about it. I have Mark's accountant look after all the money. I was never good with numbers myself.

The therapist scheduled Debbie for two sessions a week.

Debbie is the oldest of four children.

She has three

brothers who are 12, 15, and 17 years younger. Debbie had persistent problems with mathematics and writing throughout school. She graduated from high school without distinction and did not attend college. Debbie had a moderately successful career as a fashion model until her marriage to Mark.

Debbie's parents are from a poor manufacturing town in Connecticut. They were married in their teens when her mother became pregnant with Debbie. For the first few years of her life, Debbie lived in Cambridge, Massachusetts, where her father went to engineering school. Soon after graduating he founded a small company that designed and manufactured medical equip-ment. This business has grown into a large corporation with three plants in the United States and two in Europe. Debbie's mother has never been employed outside the home. Debbie describes her as a "professional hostess" who is very involved in entertaining clients and socializing at company events.

Debbie describes her father as a strict, demanding tyrant who gets his way through intimidation and reproach. She also describes him as opinionated and bigoted. He was very proud of his rags-to-riches rise in business, and he expected his children to show similar successes. Debbie recalls that he would stand over her while she did her homework and criticize her whenever she had any trouble. Countless times he asked, "Why can't you get it?" or "What's the matter with you?" Debbie describes her mother as a "non-entity" who passively submits to her husband's overpowering will. She rarely offered Debbie any encouragement or compassion; she seemed consumed with trying to perform to her husband's stringent expectations and by her growing dependence on alcohol and barbiturates. Over the years Debbie's parents spent less and less time with her, and by the time her brothers were born, they had little interest in child care. They hired professional sitters to care for the boys and saw them very little.

None of the four children is close to either parent. The oldest boy was always the nonconformist of the family. He is now a graduate student working toward his Ph.D. in history. At first his father was proud of his eldest son's academic ac-complishments, but his pride turned to dismay when the son opted for a career as a history professor. His father would ask him, "Why don't you get a real job?" Two years ago this son married a Jewish woman. Not only did her parents refuse to attend the wedding, they disowned the son outright. The middle son has always had considerable difficulty in school. Like Deb-bie, he seems to have particular trouble with mathematics. Unlike his older brother, he felt intimidated by his father and constantly tried to please him. He is now attending a local junior college and plans to work in the company after he graduates.

The youngest brother is a senior in high school. Debbie believes that he is the smartest of the three boys, but he has always gotten mediocre grades. She describes him as spoiled and apathetic. Debbie feels close to the eldest brother but not the younger two.

After reading the case study please answer the following:

1. In a narrative paragraph, you should state what your diagnosis for Debbie is, then list the symptoms that most concern you. These should come from the text of the case study.For example, if the case study states that a child "continually interrupts others when it is not his turn," you report that one symptom is this interrupting behavior. In short, the diagnosis that you are reporting should be supported by the appropriate number of symptoms that you outline based on the text of the case study. Each relevant criteria that you discuss in your diagnosis should be supported by an example from the case study that the person in the case study does, in fact, seem to demonstrate aspects of the diagnosis.
2. Following this narrative paragraph, you are to provide a deeper level of analysis in which you explore the psychosocial impact that the diagnosis has for Debbie as well as the person's overall ability to continue functioning in his or her normal life-roles.
3. Finally, you should provide a brief summary of your beliefs for how the disorder developed. You can include anything that we've discussed in class, but again, make sure there is documented evidence in the case study, and that you include this evidence as part of your hypothesis. For example, if you think that the child is exercising poor self control, be able to report evidence from the case study that the child's parents show a negative parenting style or that the child has not internalized appropriate behaviors.

A sample outline would appear like this:

I. Overview

1. Clinical Diagnosis

2. DSM-5 symptoms that are shown in the case study

3. Examples from the case study for each DSM symptom

II. Clinical Formulation (follow a list-type format in the paper)

1. What types of psychosocial stressors might the client be experiencing?

2. Describe these and how they might impact their clinical diagnosis

3. What is the client's overall level of functioning, currently? How are they able to continue functioning in their regular routine? Describe this and note how their diagnosis might be impacting his/her ability to function.

III. Hypotheses for the Development of the Disorder

1. Why might this person have developed this disorder?
2. Evidence from the case study to support your hypotheses.