- Email: [email protected]
Major depression with anger attacks: The case of mary
271
COGNITIVE BEHAVIORAL CASE CONFERENCE Major Depression With Anger Attacks: The Case of Mary David A. E Haaga, A m e r i c a n University Mary, a 44-year-old, never-married African American woman, presented for treatment of panic disorder but was diagnosed instead as having major depression with recurrent anger attacks. Angry oulbursts had caused numerous problems in her career and in her interpersonal relationships. In the first paper in this CBT case conference, the therapist presents initial information about the case, derived from a diagrzostic interview and the first two treatment sessions. The next four papers each provide details of the case conceptualization and associated assessment and treatment strategies advocated by an expert clinician. Finally, the therapist comments on similarities and differences among the experts'recommendations and summarizes what actually transpired in the remainder of the therapy.
ARY is a 44-year-old, unmarried African American woman. She responded to an advertisement recruiting participants for a panic disorder group treatment study, but a diagnostic interview (Structured Clinical Interview for DSM-IV [SCID] ; First, Gibbon, Spitzer, & Williams, 1995) for that project indicated that she did not meet the inclusion criteria. In particular, she was not diagnosed with panic disorder. Her episodes of high physiological arousal were in the context of extreme anger and seemed to match the description of "anger attacks" ("spells of anger that are inappropriate to the situation and have physical features resembling panic attacks"; Fava et al., 1991, p. 275), which are positively correlated with current (Fava et al.) and past (Brody, Haaga, Kirk, & Solomon, 1999) major depressive disorder. Mary was diagnosed with major depressive disorder and referred for individual therapy in our departmental clinic. The information presented in this paper is based on the SCID and the first two individual therapy sessions.
M
Education and Employment Mary has a master's degree in theology and had worked in community economic development for 15 years. She reported having lost four different good jobs over the years in this field as a result of anger outbursts at work. She is now employed part-time in a retail sales position. She aspires to remain in the economic development field as a solo consultant but is between contracts and has no immediate prospects in that regard.
Family and Social Functioning Mary currently spends most of her free time in church activities or watching TV and reports feeling lonely and socially isolated. Her parents live about 2 hours away, and
Cognitive and Behavioral Practice 6, 271-273, 1999 1077-7229/99/271-27351.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
she speaks to them by telephone at least daily. She had lived in the same city as them until age 40, and feels guilty for having moved away. Her relations with her father are strained and distant, with her mother enmeshed ("codependent" in Mary's view). This pattern is of long standing; Mary reported, for instance, that when she was in her early 20s she would drive her mother around on her errands each day even though her mother was capable of driving herself. Mary's mother now has a medical condition requiring adherence to a fairly restrictive diet, but compliance with the diet is erratic. Mary perceives these episodes of noncompliance as a means of manipulation, as medical setbacks evoke attention from the rest of the family. Mary's guilt about moving away from the family is exacerbated by her mother's reminders about having helped Mary financially when she was unemployed and complaints when Mary is unable to drop everything and take time offwork to visit when her mother becomes ill. Mary's younger sister has a 9-year-old son and lives in the same city as their parents, and Mary sees herself as getting trapped in the middle of disagreements between her sister and her mother about child-rearing and other issues, as both confer with Mary by phone regularly. In general, Mary depicted herself as having been a lifelong caretaker: for her sister, her mother, two younger brothers who died in childhood, and now her few women friends. She wants to develop more balanced friendships, with give-and-take instead of nurturing and serving only as a sounding board. Mary has never married. Although she stated that she had been sad and lonely at least since high school, she dated the onset of serious depression and the increase in her anger control problems to a broken engagement 12 years ago.
Current Problems Mary entered treatment wanting to decrease her depression, increase self-esteem, improve her relationships with others, decrease anger outbursts, and decrease stress. She feels on the outside of groups in the workplace
Haaga
272
and at church and perceived this as a result of her own abrasive means of expressing anger at others and her tendency to be quick to interpret others' statements or actions as personal affronts. Mary was excluded from group projects at work, for instance, due to her reputation as a troublemaker. Likewise, committee work at church would lead to intense conflicts, such that ultimately she elected to take on only projects that could be completed solo or in consultation with the minister alone. As an example of her anger control difficulty, Mary described a recent conflict with her employer at the sales position. Her boss, on short notice, deviated from Mary's regular schedule and assigned her to work a late shift that conflicted with the time of a relative's funeral Mary had planned to attend. She took this personally and shouted at him about it in front of other employees. He then dug in his heels, refused to change the schedule, and demanded that she apologize. With 20-20 hindsight Mary saw that it might have been preferable to assume good intentions on the part of the boss (e.g., that he may not have known it was especially important to her not to get that late shift) and to request a schedule change in such a way (e.g., calmly and privately) that he could have complied with her request without losing face in front of the entire staff. At the time the new schedule was posted, though, she was not thinking strategically about longterm consequences. Instead, she felt slighted and mistreated and wanted to stand up for herself.
Initial Treatment S e s s i o n s In the first session, we conducted a role play of the schedule-change incident, with the therapist (DAFH) in the role of the employer and Mary attempting to handle the situation more constructively. In this and later role plays she appeared tense during the interaction and somewhat terse or testy in her statements, but she maintained her composure and, in general, expressed clearly and unapologetically what she wanted and why. It seemed, therefore, as though she would be capable of assertive verbal behavior if she could learn to manage her arousal and reframe a situation in a way that would support a constructive response. Mary's inability to sustain full-time career-related employment cost her not only in terms of personal satisfaction but also with regard to financial solvency. She was carrying a burdensome credit card debt, and she had difficulty paying the phone bills resulting from her frequent calls to her parents. Her check for the first therapy session fee of $10 (one of the purposes of our clinic is to provide affordable service for people without health insurance or the means to pay an independent practitioner) bounced, though she was able to pay the fee by the next session.
The second session was not held until 4 weeks after the first, mainly because of difficulty scheduling around MalT'S job during a busy retail season and her medical clinic visits. Mary reported having had one anger attack since the first session. A new employee, whom she already resented (temporary employees were paid more than permanent employees, such as Mary, as part of a recruitment incentive), embroiled Mary in a dispute with a customer, and Mary ended up "going off' (her description) on the other employee in front of customers for not taking Mary's advice on how to manage the situation. Mary's supervisor failed to back her up in this dispute, leading her to believe "I've been made a complete fool of." In our debriefing of this incident, it was clear that Mary could think, after the fact, of ways to handle the situation more calmly, but, at the time, she felt more strongly about being right and saying so than about keeping her job. We discussed the differences among passive, assertive, and aggressive behavior and identified as one obstacle to assertion that she had difficulty accepting that you might not get what you want (i.e., one can give reasonable advice to a junior colleague and not have it followed, and you just have to leave it at that). Another contributory cause of Mary's stress level and relationship problems emerging in our second session was that she appeared to take personally many things of seemingly no direct relevance to her. For example, she indicated having trouble engaging in routine conversations after church because when people would talk about having gone to a movie or restaurant the night before Mary would think ill of them for having wasted money on frivolous activities and would therefore have to either bite her tongue or make confrontational, disapproving remarks.
Symptom Scores Patients in our training clinic routinely complete the Outcome Questionnaire (OQ; Wells, Burlingame, Lambert, Hoag, & Hope, 1996) at the start of each session. The O Q is a 45-item broad-band questionnaire intended to provide a brief, cost-effective, generically applicable and sensitive measure of psychotherapy outcome. Table 1 shouts Mary's total and subscale O Q scores from sessions 1 and 2 along with comparative data from the O Q manual (Lambert et al., 1996). Items on which she scored especially high (symptomatic) included: "I feel my love relationships are full and complete"
(never) "I have frequent arguments" (frequently) "I blame myself for things" (frequently) "I feel blue" (frequently) "I feel angry enough at work/school to do something I may regret" (frequently)
Response: Ethnicity and Cognitive Therapy Table 1 Initial Symptom Scores in Comparison to Normative Data InterSymptom personal Distress Relations
Social Role
Total
273
Response Paper Ethnic A w a r e n e s s in the Cognitive Behavioral Treatment of a D e p r e s s e d African American Female
Mary at Session 1 Mary at Session 2
43 46
21 23
23 22
87 91
Female nonclinical Female outpatient Outpatients after 7 sessions
27 45
11 18
9 15
48 82
American University
37
16
12
64
This case depicts an African American female who is currently depressed and experiences what appear to be anger attacks where she responds to perceived threat with verbal aggressiveness. As a result of these problems, the patient has experienced occupational and interpersonal difficulties. The following case formulation represents a blend of traditional cognitive behavioral therapy (CBT) with cultural sensitivity and cultural competence. Consistent with traditional CBT, the primary problems are first partitioned into their cognitive, behavioral, and affective components. Then, specific CBT techniques (e.g., behavioral activation, role-playing, and cognitive restructuring) are employed to manage the patient's depression and anger attacks. Along with these traditional techniques, several factors related to the patient being African American are discussed, specifically, the relationship between the patient's ethnicity, early termination, and the necessity of therapist flexibility. In addition, consideration is given to the role that culture may play in the expression of anger as well as to the relationship between culture and the utilization of techniques to decrease attrition and increase the patient's perceived empowerment. The combination of CBT and cultural sensitivity/competence are conceptualized as necessary for the successful treatment of African Americans in general, and this pat#nt in particular.
Note. Normative data are mean scores and are taken from Lambert et al. (1996). "Total" does not always equal the sum of subscale scores due to rounding error. Age and ethnicity breakdowns were not available in Lambert et al. for nonclinical groups; within outpatient samples these variables were not correlated with OQ scores. Diagnosis Axis I: Axis II:
M a j o r depressive disorder, r e c u r r e n t , m o d e r a t e N o diagnosis ( i n a p p r o p r i a t e i n t e n s e a n g e r a n d difficulty c o n t r o l l i n g a n g e r as in b o r d e r l i n e personality d i s o r d e r [BPD] c r i t e r i o n 8, b u t does not m e e t o t h e r criteria for BPD o r a n y Axis II disorder) Axis III: H y p e r t e n s i o n , p r e m e n s t r u a l s y n d r o m e , fibroid t u m o r s , obesity Axis IV: Inability to r e t a i n j o b in d e s i r e d field, poverty, social isolation Axis V: GAF = 55
References Brody, C. L., Haaga, D. A. E, Kirk, L., & Solomon, A. (1999). Experiences of anger among recovered and nevex~depressed people. Journal of Nervous and Mental Disease, 187, 400-405. Fava, M., Rosenbaum, J. F., McCarthy, M., Pava, J., Steingard, R., & Bless, E. (1991). Anger attacks in depressed outpatients and their response to fluoxetine. PsychopharmacologyBulletin, 27, 275-279. First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1995).
User'sguidefor the Structured ClinicalInterviewfor DSM-IV Axis I disorders (SCID-1,Version 2.0, October 1995 Final Version). Lambert, M. J., Hansen, N. B., Umpress, V., Lunnen, K., Okiishi, J., Burlingame, G. M., & Reisinger, C. W. (1996). Administration and scoring manual for the 0Q-45.2: Outcome Questionnaire. Stevenson, MD: American Professional Credentialing Services LLC. Wells, M. G., Burlingame, G. M., Lambert, M.J., Hoag, M. J., & Hope, C. A. (1996). Conceptualization and measurement of patient change during psychotherapy: Development of the Outcome Questionnaire and Youth Outcome Questionnaire. Psychotherapy, 33, 275-283. A number of pieces of identifying information were changed to protect the patient's anonymity. Address correspondence to David A. E Haaga, Department of Psychology, Asbury Building, American University, Washington, DC 20016-8062; e-mail: [email protected].
Received: March 2, 1999 Accepted: March 30, 1999
M i c h e l e M. C a r t e r
Presenting Problem ARY IS a 44-year-old, single African A m e r i c a n fem a l e who initially r e s p o n d e d to a n a d d for treatm e n t of p a n i c disorder. U p o n p r e s e n t a t i o n , however, h e r p r i n c i p a l p r o b l e m s a p p e a r to b e a n g e r m a n a g e m e n t , depression, a n d low self-esteem, r a t h e r t h a n panic. Mary reports classic a n g e r attacks w h e r e she e x p e r i e n c e s difficulty c o n t r o l l i n g h e r t h o u g h t s , affect, a n d behavior. She does, however, r e c o g n i z e the connection b e t w e e n difficulty controlling her a n g e r a n d specific social a n d occup a t i o n a l p r o b l e m s she has e x p e r i e n c e d over h e r lifetime. Mary has h a d several c o n f r o n t a t i o n s at work a n d church that have r e s u l t e d in h e r b e i n g e x c l u d e d f r o m g r o u p
M
Cognitive and Behavioral Practice 6, 2 7 3 - 2 7 8 , 1999 1077-7229/99/273-27851.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
COGNITIVE BEHAVIORAL CASE CONFERENCE Major Depression With Anger Attacks: The Case of Mary David A. E Haaga, A m e r i c a n University Mary, a 44-year-old, never-married African American woman, presented for treatment of panic disorder but was diagnosed instead as having major depression with recurrent anger attacks. Angry oulbursts had caused numerous problems in her career and in her interpersonal relationships. In the first paper in this CBT case conference, the therapist presents initial information about the case, derived from a diagrzostic interview and the first two treatment sessions. The next four papers each provide details of the case conceptualization and associated assessment and treatment strategies advocated by an expert clinician. Finally, the therapist comments on similarities and differences among the experts'recommendations and summarizes what actually transpired in the remainder of the therapy.
ARY is a 44-year-old, unmarried African American woman. She responded to an advertisement recruiting participants for a panic disorder group treatment study, but a diagnostic interview (Structured Clinical Interview for DSM-IV [SCID] ; First, Gibbon, Spitzer, & Williams, 1995) for that project indicated that she did not meet the inclusion criteria. In particular, she was not diagnosed with panic disorder. Her episodes of high physiological arousal were in the context of extreme anger and seemed to match the description of "anger attacks" ("spells of anger that are inappropriate to the situation and have physical features resembling panic attacks"; Fava et al., 1991, p. 275), which are positively correlated with current (Fava et al.) and past (Brody, Haaga, Kirk, & Solomon, 1999) major depressive disorder. Mary was diagnosed with major depressive disorder and referred for individual therapy in our departmental clinic. The information presented in this paper is based on the SCID and the first two individual therapy sessions.
M
Education and Employment Mary has a master's degree in theology and had worked in community economic development for 15 years. She reported having lost four different good jobs over the years in this field as a result of anger outbursts at work. She is now employed part-time in a retail sales position. She aspires to remain in the economic development field as a solo consultant but is between contracts and has no immediate prospects in that regard.
Family and Social Functioning Mary currently spends most of her free time in church activities or watching TV and reports feeling lonely and socially isolated. Her parents live about 2 hours away, and
Cognitive and Behavioral Practice 6, 271-273, 1999 1077-7229/99/271-27351.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
she speaks to them by telephone at least daily. She had lived in the same city as them until age 40, and feels guilty for having moved away. Her relations with her father are strained and distant, with her mother enmeshed ("codependent" in Mary's view). This pattern is of long standing; Mary reported, for instance, that when she was in her early 20s she would drive her mother around on her errands each day even though her mother was capable of driving herself. Mary's mother now has a medical condition requiring adherence to a fairly restrictive diet, but compliance with the diet is erratic. Mary perceives these episodes of noncompliance as a means of manipulation, as medical setbacks evoke attention from the rest of the family. Mary's guilt about moving away from the family is exacerbated by her mother's reminders about having helped Mary financially when she was unemployed and complaints when Mary is unable to drop everything and take time offwork to visit when her mother becomes ill. Mary's younger sister has a 9-year-old son and lives in the same city as their parents, and Mary sees herself as getting trapped in the middle of disagreements between her sister and her mother about child-rearing and other issues, as both confer with Mary by phone regularly. In general, Mary depicted herself as having been a lifelong caretaker: for her sister, her mother, two younger brothers who died in childhood, and now her few women friends. She wants to develop more balanced friendships, with give-and-take instead of nurturing and serving only as a sounding board. Mary has never married. Although she stated that she had been sad and lonely at least since high school, she dated the onset of serious depression and the increase in her anger control problems to a broken engagement 12 years ago.
Current Problems Mary entered treatment wanting to decrease her depression, increase self-esteem, improve her relationships with others, decrease anger outbursts, and decrease stress. She feels on the outside of groups in the workplace
Haaga
272
and at church and perceived this as a result of her own abrasive means of expressing anger at others and her tendency to be quick to interpret others' statements or actions as personal affronts. Mary was excluded from group projects at work, for instance, due to her reputation as a troublemaker. Likewise, committee work at church would lead to intense conflicts, such that ultimately she elected to take on only projects that could be completed solo or in consultation with the minister alone. As an example of her anger control difficulty, Mary described a recent conflict with her employer at the sales position. Her boss, on short notice, deviated from Mary's regular schedule and assigned her to work a late shift that conflicted with the time of a relative's funeral Mary had planned to attend. She took this personally and shouted at him about it in front of other employees. He then dug in his heels, refused to change the schedule, and demanded that she apologize. With 20-20 hindsight Mary saw that it might have been preferable to assume good intentions on the part of the boss (e.g., that he may not have known it was especially important to her not to get that late shift) and to request a schedule change in such a way (e.g., calmly and privately) that he could have complied with her request without losing face in front of the entire staff. At the time the new schedule was posted, though, she was not thinking strategically about longterm consequences. Instead, she felt slighted and mistreated and wanted to stand up for herself.
Initial Treatment S e s s i o n s In the first session, we conducted a role play of the schedule-change incident, with the therapist (DAFH) in the role of the employer and Mary attempting to handle the situation more constructively. In this and later role plays she appeared tense during the interaction and somewhat terse or testy in her statements, but she maintained her composure and, in general, expressed clearly and unapologetically what she wanted and why. It seemed, therefore, as though she would be capable of assertive verbal behavior if she could learn to manage her arousal and reframe a situation in a way that would support a constructive response. Mary's inability to sustain full-time career-related employment cost her not only in terms of personal satisfaction but also with regard to financial solvency. She was carrying a burdensome credit card debt, and she had difficulty paying the phone bills resulting from her frequent calls to her parents. Her check for the first therapy session fee of $10 (one of the purposes of our clinic is to provide affordable service for people without health insurance or the means to pay an independent practitioner) bounced, though she was able to pay the fee by the next session.
The second session was not held until 4 weeks after the first, mainly because of difficulty scheduling around MalT'S job during a busy retail season and her medical clinic visits. Mary reported having had one anger attack since the first session. A new employee, whom she already resented (temporary employees were paid more than permanent employees, such as Mary, as part of a recruitment incentive), embroiled Mary in a dispute with a customer, and Mary ended up "going off' (her description) on the other employee in front of customers for not taking Mary's advice on how to manage the situation. Mary's supervisor failed to back her up in this dispute, leading her to believe "I've been made a complete fool of." In our debriefing of this incident, it was clear that Mary could think, after the fact, of ways to handle the situation more calmly, but, at the time, she felt more strongly about being right and saying so than about keeping her job. We discussed the differences among passive, assertive, and aggressive behavior and identified as one obstacle to assertion that she had difficulty accepting that you might not get what you want (i.e., one can give reasonable advice to a junior colleague and not have it followed, and you just have to leave it at that). Another contributory cause of Mary's stress level and relationship problems emerging in our second session was that she appeared to take personally many things of seemingly no direct relevance to her. For example, she indicated having trouble engaging in routine conversations after church because when people would talk about having gone to a movie or restaurant the night before Mary would think ill of them for having wasted money on frivolous activities and would therefore have to either bite her tongue or make confrontational, disapproving remarks.
Symptom Scores Patients in our training clinic routinely complete the Outcome Questionnaire (OQ; Wells, Burlingame, Lambert, Hoag, & Hope, 1996) at the start of each session. The O Q is a 45-item broad-band questionnaire intended to provide a brief, cost-effective, generically applicable and sensitive measure of psychotherapy outcome. Table 1 shouts Mary's total and subscale O Q scores from sessions 1 and 2 along with comparative data from the O Q manual (Lambert et al., 1996). Items on which she scored especially high (symptomatic) included: "I feel my love relationships are full and complete"
(never) "I have frequent arguments" (frequently) "I blame myself for things" (frequently) "I feel blue" (frequently) "I feel angry enough at work/school to do something I may regret" (frequently)
Response: Ethnicity and Cognitive Therapy Table 1 Initial Symptom Scores in Comparison to Normative Data InterSymptom personal Distress Relations
Social Role
Total
273
Response Paper Ethnic A w a r e n e s s in the Cognitive Behavioral Treatment of a D e p r e s s e d African American Female
Mary at Session 1 Mary at Session 2
43 46
21 23
23 22
87 91
Female nonclinical Female outpatient Outpatients after 7 sessions
27 45
11 18
9 15
48 82
American University
37
16
12
64
This case depicts an African American female who is currently depressed and experiences what appear to be anger attacks where she responds to perceived threat with verbal aggressiveness. As a result of these problems, the patient has experienced occupational and interpersonal difficulties. The following case formulation represents a blend of traditional cognitive behavioral therapy (CBT) with cultural sensitivity and cultural competence. Consistent with traditional CBT, the primary problems are first partitioned into their cognitive, behavioral, and affective components. Then, specific CBT techniques (e.g., behavioral activation, role-playing, and cognitive restructuring) are employed to manage the patient's depression and anger attacks. Along with these traditional techniques, several factors related to the patient being African American are discussed, specifically, the relationship between the patient's ethnicity, early termination, and the necessity of therapist flexibility. In addition, consideration is given to the role that culture may play in the expression of anger as well as to the relationship between culture and the utilization of techniques to decrease attrition and increase the patient's perceived empowerment. The combination of CBT and cultural sensitivity/competence are conceptualized as necessary for the successful treatment of African Americans in general, and this pat#nt in particular.
Note. Normative data are mean scores and are taken from Lambert et al. (1996). "Total" does not always equal the sum of subscale scores due to rounding error. Age and ethnicity breakdowns were not available in Lambert et al. for nonclinical groups; within outpatient samples these variables were not correlated with OQ scores. Diagnosis Axis I: Axis II:
M a j o r depressive disorder, r e c u r r e n t , m o d e r a t e N o diagnosis ( i n a p p r o p r i a t e i n t e n s e a n g e r a n d difficulty c o n t r o l l i n g a n g e r as in b o r d e r l i n e personality d i s o r d e r [BPD] c r i t e r i o n 8, b u t does not m e e t o t h e r criteria for BPD o r a n y Axis II disorder) Axis III: H y p e r t e n s i o n , p r e m e n s t r u a l s y n d r o m e , fibroid t u m o r s , obesity Axis IV: Inability to r e t a i n j o b in d e s i r e d field, poverty, social isolation Axis V: GAF = 55
References Brody, C. L., Haaga, D. A. E, Kirk, L., & Solomon, A. (1999). Experiences of anger among recovered and nevex~depressed people. Journal of Nervous and Mental Disease, 187, 400-405. Fava, M., Rosenbaum, J. F., McCarthy, M., Pava, J., Steingard, R., & Bless, E. (1991). Anger attacks in depressed outpatients and their response to fluoxetine. PsychopharmacologyBulletin, 27, 275-279. First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1995).
User'sguidefor the Structured ClinicalInterviewfor DSM-IV Axis I disorders (SCID-1,Version 2.0, October 1995 Final Version). Lambert, M. J., Hansen, N. B., Umpress, V., Lunnen, K., Okiishi, J., Burlingame, G. M., & Reisinger, C. W. (1996). Administration and scoring manual for the 0Q-45.2: Outcome Questionnaire. Stevenson, MD: American Professional Credentialing Services LLC. Wells, M. G., Burlingame, G. M., Lambert, M.J., Hoag, M. J., & Hope, C. A. (1996). Conceptualization and measurement of patient change during psychotherapy: Development of the Outcome Questionnaire and Youth Outcome Questionnaire. Psychotherapy, 33, 275-283. A number of pieces of identifying information were changed to protect the patient's anonymity. Address correspondence to David A. E Haaga, Department of Psychology, Asbury Building, American University, Washington, DC 20016-8062; e-mail: [email protected].
Received: March 2, 1999 Accepted: March 30, 1999
M i c h e l e M. C a r t e r
Presenting Problem ARY IS a 44-year-old, single African A m e r i c a n fem a l e who initially r e s p o n d e d to a n a d d for treatm e n t of p a n i c disorder. U p o n p r e s e n t a t i o n , however, h e r p r i n c i p a l p r o b l e m s a p p e a r to b e a n g e r m a n a g e m e n t , depression, a n d low self-esteem, r a t h e r t h a n panic. Mary reports classic a n g e r attacks w h e r e she e x p e r i e n c e s difficulty c o n t r o l l i n g h e r t h o u g h t s , affect, a n d behavior. She does, however, r e c o g n i z e the connection b e t w e e n difficulty controlling her a n g e r a n d specific social a n d occup a t i o n a l p r o b l e m s she has e x p e r i e n c e d over h e r lifetime. Mary has h a d several c o n f r o n t a t i o n s at work a n d church that have r e s u l t e d in h e r b e i n g e x c l u d e d f r o m g r o u p
M
Cognitive and Behavioral Practice 6, 2 7 3 - 2 7 8 , 1999 1077-7229/99/273-27851.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.