Case formulation
In terms of his diagnoses, I was initially impressed by the presence of chronic depressive disorder and generalized anxiety disorder. However, as I listened deeply to his struggles, I realized that his central issues could be better explained through the lenses of pathological narcissism. From how he described his experiences, I learned that what was at stake was his fragile self-esteem. He was preoccupied with fantasies of perfect and ideal love while trying to maintain a superior, though fragile and easily injured, sense of self. Shame, humiliation, and embarrassment were unwelcome companions of his schoolwork and he feared that every mistake would catastrophically and permanently taint his reputation. I also thought that Alec’s self-esteem was contingent on external indices of worth: the positive evaluation of professors, and academic success. His perfectionism was shame-based, rather guilt-based (Sorozkin, 1985), differentiating his personality functioning from an obsessive compulsive personality disorder. At a deeper level, I thought that Alec was torn between the wish to pursue his own academic career versus succumbing to tacit expectations to stay in the family business. The latter decision must have felt difficult given his father’s history. It was as if the gravity of the family history was pulling him back to the familiar – and familial – orbit. This formulation helped me see his mood and anxiety symptoms as stemming from difficulty regulating self-esteem. Formulating his treatment around his difficulty regulating self-esteem, I imagined that a helpful treatment approach for Alec would likely include helping him examine his strategies of self-esteem regulation (e.g., self-esteem being contingent on evaluation of professors or fulfillment of ideal love), develop adaptive alternatives (including a capacity for a less black-and-white self-evaluation), and develop his own sense of self independent of his family narrative. I imagined that such a process would require an emphasis on stability in my relationship with him and responsivity to his bids for attachment in efforts to connect in a new way. Overall, the positive prognostic signs were younger age, intelligence, interest in self-understanding, engagement with school, absence of antisocial traits, and lack of substance use.