How To Be Depressed. George Scialabba

boys and “tough” boys.

      December 30, 1987

      Melinda R. Maron

       Treatment Plan

      Problem No. 1:

      Depression as shown by social isolation, inability to make career decisions, and overwhelming feelings of guilt.

      Goal (long term):

      Reduce feelings of guilt, paralysis about decision, and social isolation.

      Objectives (short term):

      Patient will understand more about the connection between his behavior and his depression, and will feel less despair and guilt about his choices.

      Expected Achievement Dates:

      Long term—6/90

      Short term—9/88

      Specific Plans:

      Individual psychotherapy, once per week.

      Psychopharmacology with behavior therapy, once per month.

      Problem No. 2:

      Personality disorder with obsessive-compulsive style and depression that contribute to his paralysis and lack of intimate relationships.

      Goal (long term):

      Modification of obsessive-compulsive defenses.

      Objectives (short term):

      Patient will become more flexible and tolerant of himself and his affects.

      Expected Achievement Dates:

      Long-term—6/90

      Short-term—9/88

      Termination Criteria:

      Reduce depression. Modification of rigidity of obsessive-compulsive personality disorder.

      Chief Complaint:

      Mr. Scialabba described himself as “emotionally fragile, high-strung, and unable to make life decisions. I am ridiculously over-qualified for what I do; I feel stalled in my life and want to know if there is a medication that could help me.”

      History of Presenting Problem:

      Mr. Scialabba dates his psychiatric symptoms back to age 14, when he developed incapacitating anxiety in response to any sexual impulse, along with guilty ruminations that disrupted his usual activities. He went to a priest who told him he would take responsibility before God for the patient’s sexual impulses, and the anxiety episodes stopped.

      Some years later, he joined a very devout all-male Catholic organization called Opus Dei and was very involved with that organization during his undergraduate years at Harvard. He felt a missionary zeal about attracting others to Opus Dei. He describes his commitment as “intense, demanding, and lifelong.” But after four years of college he “lost all belief in Catholicism.”

      Mr. Scialabba describes his leaving the Catholic Church and Opus Dei as extremely difficult. He went into a meeting of Opus Dei and tried to speak publicly about his loss of faith. Instead he became so agitated that had to be led from the room. He feels he has never recovered from this emotional upset. He describes the time leading up to his departure from Opus Dei as the most intensely meaningful, exciting time in his life, when he felt that all of life and intellectual and philosophical pursuits were open to him. Instead when he left, he was overwhelmed by agitation.

      He attempted graduate school at Columbia in European intellectual history as well as Harvard Law School, but he dropped out of both because whenever he attempted to do any serious work, he would become unbearably agitated and have to stop. He returned to Cambridge after one year at Columbia and has remained here ever since.

      Mr. Scialabba has had a series of “undemanding and rewarding jobs” such as substitute teaching, welfare social worker, and currently is a receptionist/staff assistant at Harvard’s Center for International Studies. During the last 5 years he has done a fair amount of freelance book reviewing for the Village Voice, the Boston Phoenix, and a journal called Grand Street.

      January 7, 1988

      Melinda R. Maron

      Talked about commitment. He described himself as “butterfly-like,” floating from one thing to another without ever really choosing. Feels this has been his pattern in life—he doesn’t want to give up anything. When you choose, you are left with paralyzing doubts, as he was after leaving Opus Dei.

      January 7, 1988

      Juan Durendal

      S: “I am feeling discouraged again. This time of year always gets me down because it reminds me how little I’ve accomplished in the last year.”

      O: Mental status exam essentially unchanged. No side effects from Parnate.

      A: We have started doing behavior therapy focusing on vocational and interpersonal issues. No change in meds appears warranted, although tolerance to Parnate is possible. Will continue to observe.

      January 12, 1988

      Melinda R. Maron

      About 5 years ago Mr. Scialabba experienced an episode of major depression with low mood, decreased concentration, initial insomnia, decreased appetite, decreased energy, moderate anhedonia, social isolation, guilty ruminations and wishes of being dead, but with no sui cidal ideation. The stressor was the need to either to buy the apartment in which he lived or to vacate it. Mr. Scialabba improved spontaneously in September. He ended up buying the apartment with the help of his family.

      Recently Mr. Scialabba again became depressed during the summer months with no obvious stressor. He began to feel very stuck in his life and wanted to do something about it, and that prompted his seeking treatment.

      Personal History:

      Mr. Scialabba grew up in East Boston in an Italian Catholic working-class family. He has one brother, with whom he has a somewhat distant relationship. He describes his mother as a strict powerful figure in his childhood, who was angry and bitter about her working-class status and disappointed in her husband for not being ambitious enough. Mr. Scialabba recalls his father as being passive and dominated by his mother. He also felt afraid of his mother’s anger, although he does not remember her as being abusive. He was a quiet, sensitive, “good” child who always wanted to please the nuns at school, where he always did very well. He felt somewhat isolated and yearned to escape his East Boston neighborhood. He reports nothing remarkable during his childhood or adolescence until age 14 when he briefly developed anxiety around his sexual impulses. He visits his parents in East Boston several times a month.