Assignment 2 Vignette: Megan

Megan is an 18 year old female living at home with her parents and older brother. She is in her first year of a Bachelor of Biomedical Science degree. Megan is part of an accelerated student program. Her academic mentor has been worried because Megan was at risk of
failing her semester and has made a referral for counselling.

Megan reports having had low mood since the end of last year which has progressively worsened. The onset of depressive symptoms began soon after Megan found out she did not receive entry to her first choice preference of Medicine. She developed symptoms characterised by sadness, crying, social withdrawal and severe self-criticism. In the last 6 months it has become increasingly difficult for Megan to engage in her studies. Megan had always been a bright student throughout her school years but is now at risk of failing her current semester.

Megan had been close with a group of good school friends who also attend the same university. However, recently Megan has been declining social invitations by her friends and now no longer receives many invitations to social gatherings. “I didn’t want to go out, putting on a fake smile when I felt so rotten inside. After a while my friends stopped asking me to come out so I don’t think they really care anyway.” Megan reports recent comfort-eating and has gained a few kilos and is now slightly overweight.

Megan describes her parents as busy. “They both work in high-powered jobs as doctors, so they have never been around much. They work so hard to provide for us, and I wouldn’t want to burden them with my struggles anyway. I’d be too ashamed. At least when I was little I could talk to my Nanny if I was sad.” Megan acknowledged that her parents set very high standards that she finds unrelenting and difficult to live up to. “Once I got a 90% on a test. I remember showing Dad, and he just said ‘Why didn’t you get 100%?’” She reports that her older brother was Dux of his school and is in his final year of medicine. Megan tells you “I remember at his school graduation ceremony when he got the Dux award, Mum saying to me ‘You see? People with talent like your brother are winners! He is really someone worth
knowing. The cream always rises to the top. When you have talent you will always succeed.’”

Recently, Megan has developed a pattern of staying up until 1-2am either playing games on her phone or watching YouTube videos and sleeping in until almost midday. She feels tired and unmotivated most of the time. She has been missing most of her University lectures.
‘What’s the point anyway, I have already missed so many it won’t make a difference. And when I go, I can’t focus or understand a lot of the material’. She has been procrastinating on completing her assessments and this has led to recent late submissions with penalties.

Megan gets caught up in thoughts ‘I’ll never be as smart as my brother and parents, I am already a failure anyway‘, ‘If I don’t eventually get into medicine, I’ll be a loser. I might as well quit Uni”

EDF5531 Cognitive behaviour therapies
Assignment 2 Case Formulation: Megan

Megan is an 18 year old female first year Biomedical Science student at University who presents with a six-month history of depressed mood and associated features including social withdrawal, dysregulated sleep patterns (delayed cycle), poor concentration, comfort-
eating with weight-gain, a sense of hopelessness, and low energy as well as a motivation. These symptoms have been impacting on her engagement in her studies, and she is at risk of failing the semester.

Megan’s depressive episode appears to have been triggered by her failure to gain entry into Medicine after completion of her VCE – notably the profession that her parents both work in and her brother is studying.

One suspects that the initial shock of missing out on her preferred course was likely to have resulted in an acute adjustment difficulty with sadness. She did not want friends to see her sad, believing that she must pretend to be happy, which she found difficult, and so this led to
social withdrawal. Megan’s belief that her friends don’t care about her further contributes to her withdrawal. The loss of her protective social networks, with associated loss of enjoyable activities/events, played a role in Megan’s sadness deepening into depression. Her pattern of using phone games/YouTube to delay sleep onset and also her procrastination with university assignments might reflect avoidant coping strategies. The sleep pattern indicates a disrupted circadian (sleep/wake) cycle which is likely to contribute to fatigue and poor concentration. This also contributed to her missing university lectures, which in turn (as a vicious cycle) led to further difficulties concentrating or understanding material, presumably due to having missed previous lectures.

Megan’s difficulty understanding lectures and her assignment penalties appears to have caused an expectation she will fail, which may contribute to poor self-concept, especially in the context of a family that highly values academic performance. Megan’s expectation that she will fail to gain entry to Medicine and is therefore a failure is an example of black-and-white thinking that also contributes to her poor self-worth and low mood.

Megan’s comfort-eating may provide short-term pleasure, or relief of low mood. However, it also contributes to weight gain that potentially has an impact on poor self-concept and may make socialising slightly more difficult due to increased self-consciousness regarding her body image. It may also contribute to reduced energy.

There are several aspects of Megan’s background that may explain her vulnerability to depression from this particular trigger. The long hours her parents have always worked, with her only reliable source of emotional support coming from a Nanny in her early years, was
likely to have contributed to a belief that she is not intrinsically important, but rather must “earn” positive responses from her parents. The role modelling and overt messaging she experienced from her parents and brother led to the belief that this positive regard and self-
worth could be earned through academic performance and, ultimately, a prestigious career such as Medicine. She also incorporated an apparent view of her parents, that ability is a fixed trait, which people either have or not, rather than something that can be developed through persistent effort. Therefore, Megan interpreted her failure to gain entry to Medicine from school as proof that she lacks sufficient talent, and therefore has no hope of gaining entry to that course via the Biomedical Science pathway.

Megan has some notable strengths and access to supports, which may help her to recover from this depressive episode. She has successfully developed close friendships in the past, so presumably has reasonable social skills. She potentially can still re-engage with her
social group. Megan has demonstrated academic aptitude including selection into an accelerated program which also provides access to an academic mentor. This has led to earlier intervention via referral for counselling than might have happened otherwise. This may also mean that Megan can access support services to assist her in catching up on missed work. Megan has also shown a willingness to engage in counselling, as well as an ability to articulate her thoughts and feelings with reasonable insight.