This is the seventh post in this series. If you are just starting in this series, then it would help you to read at least the fifth post to get the background on today's discussion.
As a refresher, this is a "case study" of Robert. He is a single male in his early twenties. Robert was recently in a Major Depressive episode and now presents with anxiety. The precipitant to the depression was Robert's unrequited love for a woman. The anxiety came in the context of falling in love at first sight with a second woman. Robert is seeking treatment to help him plan an elopement with the second woman, Julia.
Robert's situation is a mess. For the past two days, Robert has acted impulsively. He was not using good judgement or insight. Julia has plans to return to São Miguel, a Portuguese island, and may marry a man there. Both Robert's and Julia's families intensely dislike each other. None of their parents would approve of the marriage. Further, Robert is at high risk for a relapse back into Major Depression. Ominously, Robert says that he would rather kill himself than live without Julia. However, today there is no inclination to suicide and he anxiously anticipates happy days in the near future.
We are still in Robert's initial evaluation. I am about to present him with treatment options. In the last post, I ruled out offering him help in problem solving his elopement.
There is possibly another way to meet Robert's request for a speedy resolution to his anxiety symptoms and improving his ability to plan the elopement. That would be a referral for a psychiatric medication evaluation.
I could suggest to Robert that he see a psychiatrist. He can ask about medication for the anxiety and the depression. An anxiolytic might provide relief from most of the anxiety symptoms within a half-hour of ingesting it. Freed of the anxiety, he could think more clearly. Robert could then probably figure out for himself how to marry Julia. The anti-depressant, on the other hand, would take 4 to 6 weeks before having an effect.
Perhaps, though, the anxiety serves more masters than we have seen so far. Symptoms can have a pig pile of underlying motivations. More formally stated, Robert's anxiety might be overdetermined. That is, the ego is trying to satisfy a number of demands on it through the one symptom of anxiety. We have already seen that Robert's anxiety is a defense against a return to depression and the possibility that time and events (e.g., Julia's return to São Miguel) would prevent him from marrying the woman he loves. Let's see if there might be other factors in his anxiety.
Robert says that he is anxious in large measure because he wants to be married as quickly as possible. He can then be with the woman he loves. He says that he wants it so badly that he cannot think straight. However, one potential subconscious purpose that the anxiety may serve is exactly the effect it is wreaking. Maybe one point of the anxiety is specifically to disrupt or prevent Robert's elopement.
There are many reasons why Robert might subconsciously use anxiety to derail his marriage plans.
In Freud's The Ego and the Id, he writes "...the ego seeks to bring the influence of the external world to bear upon the id and its tendencies, and endeavors to substitute the reality principle for the pleasure principle which reigns unrestrictedly in the id." The reality confronting Robert stands directly opposed to marrying Julia, which he thinks will be pleasurable. Robert is aware of that many people would reject the marriage to Julia. His desire to elude reality accounts for some large measure of his haste to wed. Robert's ego could use the anxiety as a means to bring reality to bear on his impulses.
Furthermore, the marriage would bring parental disapproval and rejection. The anticipation of this disapproval and rejection may cause some anxiety. He can also anticipate his own guilt feelings about breaking their rules. Expecting guilt in the future produces anxiety as well.
Freud puts it this way in The Ego and the Id:
"As a child grows up, the role of father is carried on by teachers and others in authority; their injunctions and prohibitions remain powerful in the ego ideal and continue, in the form of conscience, to exercise moral censorship. The tension between the demands of conscience [what Robert knows he ought to do in the eyes of his parents and society] and the actual performances of the ego [Robert's scheme to marry Julia without his parents' blessing or knowledge] is experienced as a sense of guilt."
After all, his parents do seem concerned about him and love him. His father has said: "If we could only find out why he's sad, we'd be as eager to help him as we were to learn the reason for his sadness." (Act 1, Scene 1, Page 8 ) His mother also expressed concern for him: "Oh, where's [Robert]? Have you seen him today? I'm glad he wasn't here for this fight."(Act 1, Scene 1, Page 7) We can reasonably assume that hurting his parents would cause guilt for Robert. Therefore, the anxiety would be protecting him against hurting his parents and the guilt that he would experience for bringing suffering to them.
We could hypothesize a number of other subconscious uses for the anxiety. However, we will leave it here for the time being.
There are many instances where it is desirable to remove or reduce severe anxiety as quickly as possible. In those cases, anxiolytic medications are very useful. I think, though, that Robert is better off without the immediate introduction of medications. Removing the anxiety removes some of the emotional barriers to carrying out his impulse-ridden plans. That is, in my judgement, it is in Robert's best interests not to elope in the next few days.
Getting some Klonopin or Xanax or another anxiolytic today would be roughly the same as helping him problem solve the marriage today. For the same reasons I ruled out helping him problem solve the elopement, and the reasons mentioned here, I would not want him to get the medicines now.
Some bad situations have unseen benefits. In Rhode Island, the state where I practice, it takes about six to eight weeks for a new patient to get in to see a psychiatrist. Usually that is thoroughly undesirable. But not this time. Such a lengthy wait means that I can refer Robert to a psychiatrist today. However, he won't get an appointment any time soon. That, in this case, is a good thing. It will buy some time to work through the complexities of his crisis.
Now I can tell Robert his diagnosis: Panic Disorder without Agoraphobia. I provide him with some information about this illness. In addition, I give him the names and phone numbers of several psychiatrists.
I then have to tell him to expect about a two-month delay before he can get an appointment.
Obviously, Robert does not like this recommendation. He sees time as an enemy. Two months is far too long to delay his elopement. For one thing, Julia will be out of the country by then. There will be no wedding if that happens. Depression lurks in any delay to the marriage.
Honestly, I agree with Robert. Two months is too long to wait for a remedy to his problems. He is in a lot of emotional pain and turmoil. I also agree that the situation is complex. It needs to be broken down into its component elements and sorted out. Moreover, there is another person involved, Julia. And in her, I find an option that might satisfy everyone.
I suggest to Robert that we schedule another appointment, as soon as can be arranged. If I get a cancellation, the appointment can be as soon as tomorrow.
I also propose that he bring Julia to the next appointment. We can get her point of view. After all, it is her elopement/wedding, too. At the least, a couple's session would give the two of them a chance to look rationally at their situation and to get to know one another better.
In the short-term, my goal is going to try to find an alternative to an abrupt elopement. Perhaps Julia can defer her trip to Portugal. Or maybe between the two of them, they can identify the parent or another authority figure that is most likely to be sympathetic to their situation. We could then try to enlist that person as an ally to the couple. Potentially, that third person could come in at the third session. At this point, I am not sure what assistance Julia can be. But starting couple's counseling is the best option I can think of at this point.
In the long-term, I want to provide Robert with treatment to address his vulnerability to both depression and anxiety. Providing successful short-term couples counseling around the elopement may be the best way to engage him in therapy.
In the next post, I will look at some facets of adult anaclitic depression. That type of depression may help us get a better understanding of Robert. It will also provide a differential diagnosis to instances where anxiety defends against a depression.