The Depressive Patient - A Case Study

Notes of first therapy session with Edward J., male, 51, diagnosed with Depressive Personality Disorder
Edward has a lumbering, numbed presence. He walks as if in a dream, his gait robotic, his eyes downcast. Within minutes, it is abundantly clear to me that he is gloomy, dejected, pessimistic, overly serious, lacks a sense of humor, cheerless, joyless, and constantly unhappy.

How does he react to good news? - I ask him - What if I had just informed him that he has won a million bucks in a game of chance? He contemplates this improbable good fortune and then shrugs: "It wouldn't make much of a difference, Doc." A million bucks wouldn't make a difference in your life? - I am astounded. This time, he doesn't even bother to respond.

Let's try another tack: What would you have done with the money? "Probably fritter it away." - He laughs mirthlessly. I am no good with finances either, I confide in him. "I am not good at anything." - He counters. That's not what I hear from his wife and close friends whom I have interviewed, I try to reassure him. It seems that you are outstanding at your work, a loving husband, and a chess champion. "What do they know!" - He sneers - "I am a loser. The only thing I am really good at is disguising it."

Failing from time to time does not make you a failure, I try to reintroduce perspective into the fast-deteriorating conversation. He suddenly snaps: "I am worthless, OK? Inadequate, you get it? I consume scarce resources and give very little in return. I am too cowardly to put an end to it, is all. But don't give me these fake, sugary pep talks, Doc."
I am merely trying to understand, I reassure him. Can he provide examples of failure and defeat that prove conclusively his self-assessment and substantiate it? He slips into a bout of brooding and then reawakens: "I am afraid to lose my job." Why is that? His boss praises him to high heaven! He dismisses this contrary information: "When he finds out ..." Finds out what? "The REAL me!" - he blurts and averts his gaze.

Can he describe this stealthy, penumbral entity, the REAL he?

He feels - no, he knows - that he lacks perseverance, is hypocritical, obsequious, obstructive, and full of suppressed rage and violence. It worries him. He is very judgemental of others and, given authority or power over them, is sadistically punitive. He enjoys their writhing pain and suffering when he criticizes or chastises them but at the same time he hates and despises himself for being such a lowlife. He often apologizes to the victims of his abusive conduct, even crying as he does. He really feels bad about his behavior and because he is sincere, they forgive him and grant him another chance. He also claims knowledge, skills, and talents that he does not possess, so, in effect, he is a scammer, a con-artist.

That's along list, I observe. "Now you understand." - He concurs - "That's why I will likely end up unemployed." Can he try to imagine the day after he is sacked? He visibly shudders: "No way. Don't even go there, Doc." I point out that he has been leading the conversation inexorably to this topic. At which point he sulks and then rises from his chair and walks towards the door without a word.

"Where are you going?" - I am genuinely surprised.

"To get myself a real psychiatrist." - He triumphantly calls out - "You are as much of a sham as I am, Doc. It's no use one fraudster trying to cure another." And he is gone.