Examples of Case Formulations

Patient names and details have been changed for confidentiality.

Case formulation #1: Catherine is a 35 year old woman who experienced her first depression in university after a break-up. She tells me her depression resolved on its own. She had a relapse in 2020 when she found out her husband was cheating on her and she suffered a miscarriage. At that time she was stabilized with medications and therapy.
She was off work for much of 2020 but has since returned and though she initially did well enough that she stopped her medication and therapy, there has been a change in management and she finds her new boss micro-manages and second-guesses her. She does not feel supported by any other members of her team. She has noticed since these work changes, her mood has deteriorated significantly and she has experienced a relapse of her depression and anxiety including intermittent suicidal ideation.
This is in the context of a difficult upbringing with a volatile father and being a parentified child to her mother who she still feels she needs to look after. Further exacerbating things is her ambivalence to take measures to look after herself and to protect her mental health. I can't help but wonder if she experiences her current work situation like the household where she grew up. Her father was demanding and belittling and she could not count on her mother to defend or help her. The helplessness and self-blame she described feeling in much of her childhood is similar to how she describes her boss making her feel now.
She has not responded yet to medication, because she has only restarted it 2 weeks ago. I believe however that her ongoing stressors make it difficult for any improvements to be sustainable, especially if she does not take steps to look after herself, like detaching from her workplace in her personal time and seeking out therapy to help her work through this difficult situation.

Case formulation #2: Maria is a 47 year old woman who presents with low mood, irritability, impulsivity and poor coping in the context of significant alcohol and cocaine use and a difficult last 2-3 years with several significant losses. As a result, Debra stopped work and entered into the mood and anxiety program at Homewood where she has successfully abstained from substances and built a routine for herself with self-care and social support such that she feels her mood is quite improved and she feels balanced and forward thinking for most of her days. She also is very committed to her sobriety and mental health. Unfortunately, ongoing hostilities between her and her husband can change her mood significantly and she continues to struggle with setting boundaries with him that protect her from his anger and frustration. Her behaviors over the past several years have taken a toll on him and their relationship.
It appears that Maria has a pattern of forming relationships that are volatile and where her substance use further exacerbates things. She also has been estranged from her daughter, likely due to her reaching out to her ex-boyfriend when she asked her not to. She describes a history of difficult relationships with siblings, ex-husbands, and children and today, gives me the impression that her impulsivity, mood lability and anger outbursts are in the context of an underlying personality disorder rather than ADHD.
Fortunately, Maria has some insight and psychological mindedness to understand what she must do to protect and nurture her own mental health. I sense limitations however, in her taking full ownership of the impact of her behaviors on others and her abilities to tolerate these negative emotions towards her. This will likely lead to ongoing vulnerabilities in her resilience and she has established limited coping (mainly through substances) that may become overwhelmed as these relationships play out.

Case formulation #3: Mark is a 63 year old male who presents with chronic low self-esteem and regret in his life, energy and concentration levels that fluctuate and a poor appetite with sleep disruption for the past 20 years. Today, he does not describe a persistent low mood and anhedonia that is consistent with a major depressive disorder, though I wonder if he met criteria for a major depressive disorder at some point. Today, greater concerns were raised by Mark's partner, Bill, about John's marijuana and alcohol use as well as Bill's concerns that Mark is not safe with himself when he is caught red-handed doing something he knows he should not do and an argument with Bill ensues.
This is in the backdrop of an emotionally neglectful childhood and Mark feeling he has repeatedly underperformed in his life and has nothing to show for his life at his age. His acute suicidal thinking was in the context of these chronic concerns as well as losing a significant amount of money earlier in the day at the casino.
Mark is quite forthcoming today and seems at least superficially, wanting to engage in treatment to improve his mental health and life circumstances. What I do not know, because his partner is such a strong presence, is whether Mark is as motivated as he says he is. From a chart review, he repeatedly voices frustration of needing to repeat his story to many different providers, only to admit to me that he was never honest, and very rarely followed up. He seemed to respond well to some of my therapeutic interventions today, but I observed incongruence at times when his emotional reactions were disproportionate to the content he was talking about. For example, he was most tearful talking about issues that did not happen, like the time he could have run over his partner with his bicycle, but was very calm when talking about his significant debt that increased his suicidal thoughts and his drug use.
There is likely a personality disorder or at least traits at play. He alludes to difficulties interpersonally at work and he is quite dependent in the relationship with his partner. We did not have the time to explore this in great detail but I will continue to assess this in my future appointments with Mark.
Fortunately Mark has responded well to his medication treatment. His mood is more stable and his anxiety has improved.
The core of the difficulties Mark describes today: not liking himself, disappointment in the choices he has made in his life, and his addictions are unfortunately less amenable to medications and so I will also be attempting to help connect him with the appropriate community resources to have these addressed.