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438 Depression Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 438
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox and Case Management Toolbox

– Review a case study using the transdiagnostic, transtheoretical PACER approach
– As they say on Law and Order…
– The following story is fictional and does not depict any actual person or event.”
– Tom is a 36 year old male and has been struggling with depression on and off for years, but the past 2 months it has gotten intolerable. He recently lost 85 pounds to try to help get his diabetes under control and improve his sleep apnea and blood pressure. He was thrilled with his weight loss progress, but he hit a plateau and feels like he is going backwards.
– Sleep
– On an average night how much sleep do you get- REM _1__ Deep _.5__ Light _6___
– On an average night how many times do you wake up- __3-4 but has sleep apnea___ Has not been waking up as much since he lost weight and started on the CPAP
– After an average night’s sleep how do you feel- Tired _x__ Okay ___ Energetic ____
– When you wake up feeling refreshed, how much sleep do you get- REM __3_ Deep __2+_ Light __3+__
– Sleep hygiene self assessment.

– Nutrition
– Using a free app like SparkPeople, track your nutrition for a week.
– Which nutrients do you get less than 75% the full RDA- Zinc
– Which nutrients do you get less than 25% of the RDA- None
– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- 6 months
– Describe your eating habits: I have been eating healthier on my diet and try not to get too crazy because of diabetes
– Do you eat due to stress or for comfort when you are upset- yes
– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- yes
– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) ~600mg

– Nutrition
– How much nicotine do you have on an average day- (1mg/1 cigarette; 6-24mg/vaping cartridges) __0___
– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _no____
– Have you recently had any problems with excessive thirst or hunger- __no
– Do you have problems with hypoglycemia (your blood sugar dropping)- _yes (diabetic)
– Have you recently gained or lost a lot of weight- Yes
– Has your doctor tested your blood sugar lately (fasting blood test)- __yes
– Do you mainly gain weight around your belly- __yes__
– Referral to PCP

– Pain
– Do you have any chronic pain- __Yes__
– If so what causes it-__bad knees___ How long have you had it- _since college___
– What makes it worse- __standing, walking_________
– What makes it better- _heat, ice, elevation
– How has it impacted your mood/relationships/energy/sleep/self-esteem- Knee pain is annoying and keeps me from playing tennis with my daughter

– Exercise/sedentariness
– Do you exercise- ____not anymore ______ If yes, how often and for how long- ____daily 45 minutes_____
– How is your energy, mood and appetite after you exercise- ___I’m exhausted________________
– Do you sleep better on days you exercise- __-___ Does muscle soreness make it harder to sleep- __No___

– Energy
– Which best describes your average energy level Low__x_ I can get through the day___ Great! ___
– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__
– Using a pulse ox monitor: What is your resting heart rate- __85_ What is your O2 saturation- __98___
– Do you have high blood pressure- _Y__ (managed with medication) Heart conditions- _N____ if so, what

– Libido/Sex hormones
– How is your sex drive- Low __x___ Good _____ Incredible______
– Has there been any change in your sex drive- __N___ If so when and what caused it- ____-__ Been low for a couple years
– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___
– How often do you masturbate or have sex- ___<1_____/ week Physical - Do you tend to feel on edge and startle easily- ___N___ - Do you have a history of trauma- ____N___ - Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_ - Have you ever had a concussion or other traumatic brain injury- ___N_____ - How often do you have headaches- ____N__ What triggers them- __ - What helps them go away- _________ - Do you ever see spots or floaties when you get a headache- __ - Do you get migraines- ___N_____ - How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_ - How many drinks do you have in an average week- __2-3/day - Do you gamble or play the lottery- __N___ How much money do you spend on it each week- _______ Affective - For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better. - I feel happy 0-3 days a week __x__ 4 or 5 days a week __ More than 5 days a week __ - What 5 things help you feel happy- ___ - * What things used to make you happy or did you enjoy - I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week __x__ - What triggers it- Breathing - What helps you feel better- Nothing - I feel stressed or overwhelmed 0-3 days a week __x__ 4 or 5 days a week ____ More than 5 days a week _____ - What triggers it- ___ - What helps you feel better- __ Affective - I feel anxious or worried 0-3 days a week _0_ 4-5 days a week _ >5 days a week ____
– What triggers it- __
– What helps you feel better- ______-____
– I feel angry, resentful 0-3 days a week ___ 4 or 5 days a week _X_ >5 days a week
– What triggers it- The news, my depression, messages about “toxic masculinity” and white male privilege.
– What helps you feel better- Nothing
– I feel guilty 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
– What triggers it- ___
– What helps you feel better- _______

– In the past year, I have experienced the following losses which caused me to feel grief: None
– What stressors are currently present- __Lost a promotion to someone who was less qualified and had less seniority but was not a white male. I am still [bitter] about that, my diabetes, kids getting ready for college which will be expensive. So many people get paid a crap ton of money for “jobs” that don’t contribute to society (anchors, actors, athletes).
– What is different when you are happy- I am not tired all the time. I am able to workout. People don’t [annoy] me as much
– How long does it take for you to calm down after you get upset- _+/- 1hr
– What helps you calm down- __I vent about it to my wife___
Educate about HPA-Axis activation, biofeedback and relaxation techniques.
Discuss affective issues in counseling

– How is your attention/concentration- ___awful___
– Have you ever been diagnosed with ADHD- _N____
– Has there been a change in your ability to concentrate lately- _Y__ How long- ___6 months___
– If so, what is causing it- __lack of sleep- Depression- I don’t know.
– Does it seem to be taking longer to process information- _Y_
– How is your memory- __awful______ Have you been more forgetful than usual- ___y_____
– If so, when did your forgetfulness start- A few months ago What is causing it- I don’t know
– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___
– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__

– Negative self-talk
– Do you frequently judge or criticize yourself- ___Not really_______
– Do you hold yourself to a higher standard than you hold other people- ____N______
– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______
– Where did you learn your negative self talk- __

– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
X All or none thinking Find Exceptions
X Assuming/Jumping to conclusions without all the facts Get the facts
X Focusing on a small aspect instead of the bigger picture Consider alternate explanations
X Expecting life to be fair Explore living in the AND
X Taking things too personally Consider alternate explanations
X Focusing on the negative and ignoring the positive Learn about radical acceptance
– Taking something bad and blowing it out of proportion (catastrophizing)
– Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
– Assuming you know what others are thinking. Evaluate your evidence. Get the facts.
Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
– Time management
– How effective are you at managing your time- Good when I am not depressed
– Do you often take on too much and feel overwhelmed or rushed- No
– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-
– Do you procrastinate- __Y__ I just don’t have the energy to do anything so I put it off until it is a crisis.
– If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

– Do you feel safe most of the time- _____Y___ If no, where do you not feel safe and why-
– What helps you feel safe- __My dogs. My neighborhood. My guns (Former Reserves. No deployments)
– Are you able to have peace and quiet when you want it and when you sleep- ___Yes___I wear earplugs to block out the sound of the CPAP__ If no, what can you do to reduce unwanted noise-
– During the day are you able to access natural light, or at least a really bright working area- ___Yes_but I don’t
– When you sleep, are you able to make your room totally dark or block out the light- _Y_
– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- __N I watch television until I drift off__
– What smells are you regularly exposed to-
– Noxious/unpleasant/irritating __nothing. My allergies keep me from smelling much__
– Triggering (reminds you of something unpleasant) __
– Happy/relaxing/energizing __
– Are you able to keep your environments at a temperature you find comfortable- __No. My wife keeps it hot in the summer and cold in the winter.
– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___
– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______
– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____
– Do you have a social support system that can provide practical assistance and emotional support- __Practical assistance, yes…Emotional support from my parents, not so much my wife.

Initial Tx Plan goals
– Referral to PCP for hormone evaluation and to check blood pressure medication levels due to rapid weight loss. Discuss antihistamines and allergies Get feedback from physician visit.(Week 0)
– Sleep duration and quality–Sleep hygiene assessment handout (Week 0)
– Make a sleep hygiene enhancement plan based on handout data. (Review progress and impact weekly through week 8)

Initial Tx Plan goals
– Emotional Dysregulation and Psychological Flexibility Matrix
– Week 0: Define a rich and meaningful life—People, activities, thoughts, behaviors to achieve it
– Week 1: Identify autopilot thoughts and behaviors in response to distress and discuss radical acceptance
– Week 2: Develop a list of distress tolerance skills and empowerment oriented self-talk to add to the matrix. Provide matrix handout (complete at least one each day)
– Weeks 3-8: Practice applying the matrix at home and in session

Initial Tx Plan goals
– Cognitive distortions worksheet/log. Focus on one distortion each week. (due weeks 3-8)
– Hardiness Enhancement to increase positive chemicals (Week 3-8). Create a schedule to help better use time to focus on the important things.
– Specific Stressors for Discussion (Beginning Week 1)
– Unfairness in the world
– Discrimination due to being a white male and feelings of rejection due to society’s stance on “toxic masculinity”
– Financial stress of kids getting ready to leave for college

– Tom went to his PCP and had a physical. The doctor was pleased with his weight loss and reduced his blood pressure medications. Tom’s thyroid hormones were on the low end of normal range and testosterone levels were low so he was put on a low dose testosterone replacement gel. He discussed his allergies with his doctor who switched him to an antihistamine nasal spray. Tom is still not being totally open with his doctor about alcohol and caffeine use.
– Sleep hygiene assessment identified issues with allergies, blue light exposure, caffeine intake, daytime napping, and staying in the dark. Tom ordered a blue light filter for his TV and now sets a sleep timer. He also ordered noise cancelling ear buds and wears those at night when he watches television and they help block out CPAP noise the rest of the night. He stopped drinking alcohol after 7pm and has cut out caffeine after 3pm.
– Tom’s energy seems to be improving. He rated his energy “good” or “okay” 6 out of 7 days for the last 3 weeks.
– Tom’s persistent frustration with “life” seems to be contributing to learned helplessness and hypocortisolism which is also impacting his blood pressure, diabetes and mood.
– Tom is becoming more aware that a sense of disempowerment is contributing to his depression and is practicing using the matrix each day.
– Tom has been consistent with sticking to his hardiness enhancement plan which has left him less time to perseverate on the news and is getting him out of the house more
– He has removed all news apps from his phone and only allows himself to watch the news when he is on the stationary bike at the gym. He says he can work out his frustrations easier that way.

– Tom is still struggling with some cognitive distortions because he feels like if he doesn’t focus on the injustices in the world, “they” are winning. We are continuing to work on identifying what parts are within his control, which irritants are worth his energy and refocusing attention on what is going right in his life instead of what he perceives as wrong with the world.
– Tom has stopped looking for a new job as he likes his current job and believes he will experience the same injustices elsewhere.

– Depression can be the result of low serotonin, dopamine, norepinephrine or glutamate; excessive anxiety or trauma causing hypocortisolism; buildup of adenosine as a result of poor quality sleep.
– Sleep can be disrupted by alcohol, caffeine, sleep apnea, blue light exposure, circadian rhythm disruption,
– Fatigue can be caused by poor sleep, some antihistamines, blood pressure medication, diabetes, excessive stimulant use, poor nutrition, low testosterone.
– Social and behavioral withdrawal can be caused by anhedonia, fatigue and irritability.