Grand Rounds

Hi, and thanks for attending this case presentation. My name is Dr. Stephen Brewer and I am a licensed

clinical psychologist in San Diego, California and Assistant Professor of Psychology and Applied

Behavioral Sciences at Ashford University. Today, I will be sharing with you the story of Bob.

Presenting problem

Bob Smith is a 36-year-old man who came to me approximately six months ago with concerns about his

career choice and life direction. He did not have any significant psychiatric symptoms, besides some

understandable existential anxiety regarding his future. Bob was cooperative, friendly, open, and

knowledgeable about psychology during our first few sessions together. I noticed that he seemed

guarded only when talking about his family and childhood experiences. To confirm his identity, I checked

his driver’s license to ensure his name was indeed Bob Smith and that he lived close by in a mobile home

in Spring Valley. Given his relatively mild symptoms, we decided to meet once a week for supportive

psychotherapy so he could work through his anxieties. I gave him a diagnosis of adjustment disorder

with anxiety.

History

Here’s some background on Bob to give you a sense of who he is.

Family

Bob grew up as an only child in Edmonton, Canada, in a low-income, conservative, and very religious

household.

He shared that his father was largely absent during his childhood, as he spent most of the week residing

north of Edmonton, where he worked as a mechanic in the oil fields near Fort McMurray. On weekends,

Bob’s father would return home and spend as much time as possible with his family. Bob described his

father as warm, caring, and a hard worker. His father reportedly died one year ago.

Bob’s mother was described as a strict, rule-based woman who had a short temper and was prone to

furious outbursts over trivial matters. She worked in Bob’s junior high as a janitor, which meant that Bob

often crossed paths with his mother at school, where she would often check up on him. During Bob’s

high school years, Bob’s mother got a new job as a high school librarian.

At 18, Bob moved to San Diego to study psychology at San Diego State University. He lived in the dorms

for his first few years, where he easily made friends and joined a fraternity. Bob maintained contact with

his parents, but ceased all contact when his mother suggested she would move to San Diego to be closer

to him. He graduated with a 3.2 GPA and began working for the county as a psychiatric technician. He

worked as a psych tech for 14 years and described it as “fun at first, but it got boring and predictable

after a while.”

Treatment

Bob shared that he has a medical doctor that he visits once every few years for his routine physical. He

denied having any significant medical problems. Additionally, he denied using any illicit substances and

reported drinking only on occasion with friends from his fraternity.

Collateral

About a month ago, I was curious to learn more about Bob from his friends and mother. He was happy

to sign a release of information for me to speak with his friends, but he refused to sign one so I could

talk with his mother. Still, since his mother’s point of view seemed very important to me, I hired a

private detective to find Bob’s mother’s contact information so I could speak with her about Bob’s life

and treatment.

Bob’s fraternity friends shared some startling information that I wasn’t expecting to hear. They shared

they were relieved that Bob was seeing a psychologist and that they have been trying to convince Bob to

see a psychologist for years. They added that Bob’s personality changed significantly approximately

three years ago. Where Bob was originally a friendly, gregarious, outgoing individual, he suddenly

turned into a suspicious and reclusive man who disappeared for months at a time. They observed Bob

losing a significant amount of weight over the course of only a few months, and they suspected drug use

of some kind. According to them, Bob hasn’t been showing up to work regularly and doesn’t return their

calls.

Current symptoms

Here is my problem.

Bob’s current presentation in therapy seems to be incongruent with what I’ve only recently learned

from his friends. It’s almost as if I’m learning about two completely different people. Although Bob

seems to be friendly and open with me, his friends describe him as suspicious and closed off. This is

puzzling.

Question

Given this new information, how should I make sense of Bob?