Sorry it’s long..

Case Study 3 – Paula Evans
Paula Evans is a 25 year old woman brought to the emergency room by her boyfriend, who has become progressively more alarmed at her complaints, demands, and errant behavior. Her chief complaint to the staff is “I keep thinking about wanting to kill myself.” Paula is a competent secretary, has her own apartment, and is self supporting. She is also attending university classes in the evening because she wants to advance her education and does not “want to stay a secretary all my life.”
The current crisis began when her boyfriend, Mark, refused to consider her demands for marriage after a 2 year exclusive relationship. Paula began to call him at work demanding more and more time, finally threatening to kill herself if he didn’t spend every evening with her. Mark reported that her demands, phone calls, and escalating threats were becoming intolerable and were making him want to break off the relationship entirely. On the evening Mark brought Paula to the emergency room, he had told her that he had to go on a business trip and would be away for several days. Paula insisted that he was doing this just to get away from her. She became severely agitated and began to talk wildly about killing herself. In the emergency room, Paula angrily belittles her boyfriend in front of the staff and accuses him of using and then rejecting her. After physically separating the arguing couple, the staff is able to obtain a history of the progressive development of Paula’s symptoms.
In response to the stress of the past several months, Paula has developed fluctuating depressive moods, a tendency to over sleep (especially sleeping in the evenings and on weekends), and a tendency to binge eat that has resulted in a 20 pound weight gain. Paula says she is constantly anxious and has been having increasing difficulty concentrating on her studies. She has continued to work throughout this stressful period, seeking support from those in her office. Attention from Mark or her co-workers produces a brightening of her mood that she is able to sustain while they are with her.
Paula experiences her most severe symptoms when she is alone. These include prolonged fantasies about hilling her boyfriend and a desire to hurt herself. She says that on several occasions she has cut her thighs with razor blades and describes watching herself do this as if from a distance, numb and dead inside and feeling little pain. Paula says that at these times she feels fat and unattractive as well as completely unlovable and worthless. At such moments, she calls Mark on the phone and threatens to commit suicide unless he comes and keeps her company. Mark reports that she has also begun to lose control of her temper. For example, shortly before he brought her to the emergency room, she attacked him with her fists in the midst of an argument.
Paula was the youngest of four children and one of two girls. Her parents separated and divorced when she was 3 years old because of her father’s alcoholism and physical abuse of his wife and children. A family secret was that Paula was sexually abused when she was 10 years old by a brother 5 years her senior.
In adolescence, Paula associated with a rebellious group and became involved in drug abuse and early sexuality to fit in. Paula said that her mother attributed Paula’s teenage rebellion to a need to “find a father” and that she thought that Paula had gotten “her sexual urges confused with wanting to be loved and cared for.” By age 16, Paula had already embarked on the pattern of chaotic unstable involvements with men that continues to characterize her adult life.
Her first drug overdose occurred at age 17 in response to a perceived rejection by her boyfriend. A series of intense relationships followed this incident, each of which followed a similar pattern: Paula would become progressively more clinging until she gradually alienated her partners. Each rejection was marked by a period of anger and self abuse, followed quickly by a new and identical relationship. Paula’s current boyfriend is only the latest in a long series of disappointing partners.