Case Study: Mallory
Client information & presenting concern:
At age 65, Mallory, a retired professor of social work, was living a full and active life. Although retired, she had never been one to sit back and let life pass her by. She had always been an energetic and outgoing woman, something of a social butterfly who enjoyed good friends and good food. She was a regular subway rider, traveling all over the city to go to her favorite shops, restaurants, museums, and lectures and to visit her numerous friends from the university community.
Mallory was a picture of emotional and physical strength—a woman of incredible poise, self- confidence, and direction. Then, in one brief moment, everything seemed to change. She was struck by a catastrophe that took her life and state of mind in a direction that she could never have anticipated or imagined. Mallory was taking the subway home from a shopping trip when it struck a stationary train on the track ahead. Although her train was not traveling at high speed— perhaps 20 miles an hour at most—the impact was forceful enough to hurl the passengers from their seats and partially crush the metal cars. Mallory herself had been standing at the moment of impact. As she was thrown forward, her left leg struck a seat jutting out in front of her, wrenching her knee, and her head struck a metal pole, knocking her out.
When Mallory regained consciousness, she was lying in a pile of other passengers who had been thrown together in the same corner of the car. As far as she could make out in the dim light, most were unconscious and bleeding. Mallory put her hand to her own forehead and it came back wet with blood. She was horrified. What if she was bleeding to death and no one could reach her to stop the flow? She tried to get up but could not overcome the weight of the other passengers. She spent the next half hour lying there, paralyzed with fear, wondering if she would be able to survive until help arrived.
When the rescue squad finally did arrive on the scene, the injured passengers were taken out of the train on stretchers. The initial examination in the emergency room determined that Mallory did not have a critical loss of blood. Mallory spent 3 hours in this highly anxious state, restrained by the straps on the gurney, until she was finally taken to the radiology department for tests. At first, she was relieved to be removed from the throng, but then, as she was wheeled down a dark corridor, she began to wonder if her relief was premature. Overcome by her fears, she even wondered whether she was being taken away to be hurt or killed by the hospital orderly, of all people.
Once her X rays and a computed tomography (CT) scan were done, Mallory was returned to the waiting area, where her fears further intensified. Now she began to focus on the risk of contagion. Numerous patients were coughing persistently, and Mallory became afraid that she was being exposed to tuberculosis, which had been making a well-publicized comeback in city hospitals. She glanced at the disreputable-looking man hacking away next to her. He seemed extremely haggard and sickly, practically spitting on the floor, and she became convinced she was about to contract a drug-resistant strain of tuberculosis.
After another 2 hours, the doctor finally arrived and informed Mallory that the X rays and CT scan had revealed no fracture or brain hemorrhage. He then helped her up from the gurney and tested her gait, physical mobility, and neurological signs. Everything seemed normal. The doctor told Mallory she was free to go home as soon as the nurse dressed her head wound. To play things safe, however, he also advised Mallory to see a doctor for follow-up.
Mallory was relieved to be released finally. However, she glanced at the clock and saw that it was now 1:00 a.m., 6 hours from when she had originally been brought to the hospital. The idea of venturing out into the night at this hour, in this condition, in this neighborhood, was, like everything else, terrifying. She was in a tremendous conflict. This horrifying emergency room was the last place on earth that she wanted to be in. But the alternative, leaving the emergency room to be discharged into the unknown, seemed even worse right now. She soon positioned herself in the same waiting area that moments before she had so fervently been hoping to flee. The frightened woman sat there amid the other patients’ coughing, shaking, vomiting, and bleeding. In fact, she waited there until the first glimmer of dawn, and then hobbled out to a taxi waiting at curbside.
The taxi carried her through the awakening city. It was a strangely quiet, dreamy ride, completing the journey Mallory had begun on the subway some 12 hours before. She arrived at her apartment house in 20 minutes and dragged herself out of the cab and into her building, where she took the elevator up to her floor. Once inside her apartment, she collapsed on her bed, happy to be home at long last. What had begun as a simple trip home from a downtown shopping expedition had turned into a nightmare. Mallory slept for almost a full 24 hours.
The next day, Mallory called some close friends to tell them what had happened. In the light of day, she now realized that one of the most disturbing elements of the whole experience had been coming face-to-face with the prospect of physical disability. As someone who lived alone and had no close living relatives, she realized that even a temporary inability to care for herself could be disastrous. Fortunately, she had a close-knit network of friends and colleagues from the university where she had taught until a few years ago. With her calls this morning, she hoped to reassure herself that her friends would indeed step in if the need arose.
Her friends were sympathetic and asked her if she needed anything. But oddly, Mallory felt
disoriented and found it difficult to answer their questions. The previous day’s experience was
now jumbled in her mind, and explaining it required considerable effort. It was tiring just to talk
for a few minutes. By the time she had made the third call, her voice was so weak that her friend
felt great concern and suggested she see a doctor sooner rather than later.
Mallory set up an appointment with a neurologist for 3 days later. In leaving her apartment—for the first time since the accident—she was alarmed at how noisy and confusing it was just to be outside. The city traffic seemed unbearably loud, and Mallory wondered if she would even be able to cross the street. Her body still ached from the accident, but more important, she became concerned that history might repeat itself. She had never been in an accident before and had never been concerned about crossing the street. Now, however, she found herself jumping back and running from cars as they zoomed past, even though she was still on the sidewalk.
Eventually, Mallory reached the doctor’s office exhausted and out of breath. She was panting noticeably, as much from running as from her anxiety about the traffic. She didn’t even speak to the receptionist when she first arrived. Instead, she collapsed on the nearest seat, closed her eyes and gulped for air, as though having just escaped some grave danger. After a few minutes, the receptionist noticed her sitting there and walked up to greet her. At the sound of the receptionist’s voice, Mallory practically jumped out of her seat, she was so startled to find someone suddenly upon her.
The neurologist gave her a thorough examination and reviewed the X rays and CT scan taken in the hospital emergency room. He said that all results seemed normal, but that judging from the cuts and bruises on her head and her complaints about fatigue, noise sensitivity, and disorientation, she might well have sustained a concussion. He told her it was mild, but the symptoms could take several days or even weeks to go away. In the meantime, she should take it easy and get all the rest she needed.
Noticing that Mallory’s knee seemed quite swollen, the neurologist also referred her to an orthopedist. Two days later, the latter physician determined that Mallory must have torn the cartilage in her knee as a result of the accident, and now it was becoming inflamed. He said that for the time being, he would treat the knee with an anti-inflammatory drug; but if the inflammation did not improve or if it worsened, arthroscopic surgery to remove the inflamed tissue would be necessary.
Mallory returned home from her appointment with the orthopedist with a vague sense of unease
that gradually built to a feeling of impending doom. She had not expected to hear surgery mentioned, and the idea was unusually threatening to her. She shuddered at the thought of going back to a hospital. She recalled her emergency room experience and practically shook with fear as she considered the terrifying scene.
As time passed. Mallory’s post-concussion symptoms—her fatigue, noise sensitivity, and disorientation—subsided. Physically, she started to feel more her old self, but she couldn’t seem to shake her fearfulness. Each trip outdoors was extraordinarily stressful. Crossing the street was consistently anxiety provoking, as she couldn’t get over her preoccupation with being in another accident, this time as a pedestrian. Taking the bus or subway was simply out of the question. The very thought of getting on a train made her shudder. Accordingly, her travels were confined to small local trips in her neighborhood, just to do the necessities: buy food and go to doctor appointments.
It seemed that Mallory’s accident and emergency room experience had transformed her entire
outlook on life. Somehow, having spent several hours in a highly charged emotional state,
focusing almost exclusively on the prospect of dying or being raped or murdered, her mind had
started to see everything through this lens. And there was no escaping the memories. When
home, in what she considered a safe environment, her memories of the subway car or the
emergency room would constantly intrude. As she watched television, her eyes would glaze over
as some particularly harrowing element of her experience forced itself into her consciousness:
the pile of bodies in the subway car, the grim ride down the hall to the X ray room, or one of the
bleeding or coughing “thugs” sitting just a few seats away. Then she would try to shake the
memory loose, forcing it out of her mind and trying to focus on something more pleasant, only to
find it returning in bits and pieces throughout the evening.
Previously a sound sleeper; she now found herself waking frequently from dreams that contained
images of her subway or emergency room experience. They were not exactly nightmares; rather,
they were mostly accurate renditions of her all-too-real experience. She couldn’t escape the
images, even in sleep.
Instructions
1. Choose a vignette.Choose one of the case vignettes posted on Canvas. There are four possible options that you can choose from, but make sure that you only complete one and not all 4.
2. Provide a diagnosis. After you choose a case vignette, you will assign a diagnosis to the client in the vignette. Make sure to reference the vignette and tie the DSM-5 criteria to those references. You may write this in essay format or in bullet points. You may also write the diagnostic criteria as it is written in the DSM-5. No citations are needed. You should only need the lecture notes and the provided resources to complete this assignment.
3. Differential diagnosis. You will also add at least one other diagnosis that you are ruling out. This means that another diagnosis could potentially explain some of the symptoms the client is experiencing, but ultimately the diagnosis you are assigning explains the symptoms better. For the differential diagnosis section, you will do the same as the diagnosis section, adding proof as to why
this diagnosis does and does not explain what the client is experiencing. You may also write this either in essay form or in bullet points.
4. Biopsychosocial conceptualization. In this section, explain what biological (e.g., temperament), psychological (e.g., stressors), and social (e.g., environment) factors could have contributed to the client developing the specific disorder through predisposing, precipitating, perpetuating, and protective factors. The biopsychosocial section will be in essay format and should be no more than four paragraphs. Please visit the linked biopsychosocial formulation resource below for more information.
5. Treatment recommendations. Lastly, provide 2 to 3 treatment recommendations, such as therapeutic interventions (e.g., CBT) or medications (e.g., SSRIs). The treatment recommendations section requires you to provide a 2-4 sentence rationale as to why this treatment is appropriate for each recommendation. This may also be in essay or bullet point form.
