Belinda's puzzle: assembling the pieces of an illness. [clinical conference]

Abstract

he collection of signs and symptoms of illness is basic to the formulation of a differential diagnosis, but it is often the case that the significance of what we observe in the present cannot be fully ascertained without reference to the patient's personal and social history. The case presented here is a seemingly straightforward case of recurrent depression in a young mother. Despite the clear diagnosis and full remission with appropriate medication-factors that might have led us to believe we understood the nature of the problem-this case has another, less obvious, dimension that has important implications for diagnosis and treatment. This other dimension has to do with Belinda's struggle to balance home and work in her adult life, a nearly universal issue for women and men living in the United States in the late twentieth century. That issues such as this bring people to treatment is signaled by the use of the so-called V codes-conditions not attributable to a mental disorder that warrant therapeutic attention-in as much as 60% of the patients seeking mental health services (1).We are interested in examining several facets of Belinda's illness: the social construction of the problem, the foreshadowing of the crisis in the patient's early life, and the interaction between a life problem and serious psychiatric illness. CASE HISTORY History of Present IllnessBelinda is a 37-year-old, married, white, Protestant woman and the mother of two children, ages 1 and 4. She has a history of recurrent nonpsychotic unipolar depression. She came for treatment at the onset of her fourth episode of depression, 5 months after the birth of her child, with a request for pharmacotherapy and psychotherapy because "I want to find out why I get depressed and why I don't want to stop working."Belinda experienced her first episode of depression-although it was labeled as such only much later-at age 20, during the fall semester of her junior year at college. Although outgoing, cheerful, and hardworking, she began to shy away from social activities. Instead, she was tearful, irritable, and unreasonably worried about her school performance and financial future. She had difficulty falling asleep, woke early in the morning, and had no appetite; she felt as if she were struggling to get through each day. Although she had no thoughts of taking her own life, she wished to "sleep forever." Through a distressing 4-month period, Belinda struggled to manage her symptoms, aided only by the school chaplain in whom she confided her distress. Her symptoms slowly resolved, and she was able to complete her junior year with grades just slightly lower than her usual excellent performance. Feeling herself again by senior year, she resumed all social and athletic activities and graduated with high honors.The second episode of depression occurred at age 24, during the midst of her first serious romance. Belinda was employed at that time as a copy editor for a weekly magazine. The original panoply of symptoms returned, but she also experienced a complete lo...