Case formulation
In terms of his diagnoses, I was initially impressed by the presence of
chronic depressive disorder and generalized anxiety disorder. However,
as I listened deeply to his struggles, I realized that his central
issues could be better explained through the lenses of pathological
narcissism. From how he described his experiences, I learned that what
was at stake was his fragile self-esteem. He was preoccupied with
fantasies of perfect and ideal love while trying to maintain a superior,
though fragile and easily injured, sense of self. Shame, humiliation,
and embarrassment were unwelcome companions of his schoolwork and he
feared that every mistake would catastrophically and permanently taint
his reputation. I also thought that Alec’s self-esteem was contingent on
external indices of worth: the positive evaluation of professors, and
academic success. His perfectionism was shame-based, rather guilt-based
(Sorozkin, 1985), differentiating his personality functioning from an
obsessive compulsive personality disorder. At a deeper level, I thought
that Alec was torn between the wish to pursue his own academic career
versus succumbing to tacit expectations to stay in the family business.
The latter decision must have felt difficult given his father’s history.
It was as if the gravity of the family history was pulling him back to
the familiar – and familial – orbit. This formulation helped me see
his mood and anxiety symptoms as stemming from difficulty regulating
self-esteem. Formulating his treatment around his difficulty regulating
self-esteem, I imagined that a helpful treatment approach for Alec would
likely include helping him examine his strategies of self-esteem
regulation (e.g., self-esteem being contingent on evaluation of
professors or fulfillment of ideal love), develop adaptive alternatives
(including a capacity for a less black-and-white self-evaluation), and
develop his own sense of self independent of his family narrative. I
imagined that such a process would require an emphasis on stability in
my relationship with him and responsivity to his bids for attachment in
efforts to connect in a new way. Overall, the positive prognostic signs
were younger age, intelligence, interest in self-understanding,
engagement with school, absence of antisocial traits, and lack of
substance use.