chapter 1 case study answers alicia

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18.1 Case Study: Making Babies

Created by CK-12 Foundation/Adapted by Christine Miller

Case Study: Trying to Conceive

Alicia, 28, and Victor, 30, have been married for three years. A year ago, they decided they wanted to have a baby, and they stopped using birth control. At first, they did not pay attention to the timing of their sexual activity in relation to Alicia’s menstrual cycle, but after six months passed without Alicia becoming pregnant, they decided to try to maximize their efforts.

They knew that in order for a woman to become pregnant, the man’s sperm must encounter the woman’s egg, which is typically released once a month through a process called ovulation. They also had heard that for the average woman, ovulation occurs around day 14 of the menstrual cycle. To maximize their chances of conception, they tried to have sexual intercourse on day 14 of Alicia’s menstrual cycle each month.

After several months of trying this method, Alicia is still not pregnant. She is concerned that she may not be ovulating on a regular basis, because her menstrual cycles are irregular and often longer than the average 28 days. Victor is also concerned about his own fertility. He had some injuries to his testicles (testes) when he was younger, and wonders if that may have caused a problem with his sperm.

Alicia calls her doctor for advice. Dr. Bashir recommends that she try taking her temperature each morning before she gets out of bed. This temperature is called basal body temperature (BBT), and recording BBT throughout a woman’s menstrual cycle can sometimes help identify if and when she is ovulating. Additionally, Dr. Bashir recommends she try using a home ovulation predictor kit, which predicts ovulation by measuring the level of luteinizing hormone (LH) in urine. In the meantime, Dr. Bashir sets up an appointment for Victor to give a semen sample, so that his sperm may be examined with a microscope.

As you read this chapter, you will learn about the male and female reproductive systems, how sperm and eggs are produced, and how they meet each other to ultimately produce a baby. You will learn how these complex processes are regulated, and how they can be susceptible to problems along the way. Problems in either the male or female reproductive systems can result in infertility, or difficulty in achieving a successful pregnancy. As you read the chapter, you will understand exactly how BBT and LH relate to ovulation, why Dr. Bashir recommended that Alicia monitor these variables, and the types of problems she will look for in Victor’s semen. At the end of the chapter, you will find out the results of Alicia and Victor’s fertility assessments, steps they can take to increase their chances of conception, and whether they are ultimately able to get pregnant.

Chapter Overview: Reproductive System

In this chapter you will learn about the male and female reproductive systems. Specifically, you will learn about:

• The functions of the reproductive system, which includes the production and fertilization of gametes (eggs and sperm), the production of sex hormones by the gonads (testes and ovaries), and, in females, the carrying of a fetus.
• How the male and female reproductive systems differentiate in the embryo and fetus, and how they mature during puberty.
• The structures of the male reproductive system, including the testes, epididymis, vas deferens , ejaculatory ducts, seminal vesicles, prostate gland, bulbourethral glands, and the penis.
• How sperm are produced, how they mature, how they are stored, and how they are deposited into the female.
• The fluids in semen that protect and nourish sperm, and where those fluids are produced.
• Disorders of the male reproductive system, including erectile dysfunction, epididymitis, prostate cancer, and testicular cancer — some of which predominantly affect younger men.
• The structures of the female reproductive system, including the ovaries, fallopian tubes, uterus, cervix, vagina, and external structures of the vulva.
• How eggs are produced in the female fetus, and how they then mature after puberty through the process of ovulation.
• The menstrual cycle, its purpose, and the hormones that control it.
• How fertilization and implantation occur, the stages of pregnancy and childbirth, and how the mother’s body produces milk to feed the baby.
• Disorders of the female reproductive system, including cervical cancer, endometriosis, and vaginitis (which includes yeast infections).
• Some causes and treatments of male and female infertility.
• Forms of contraception (birth control), including barrier methods (such as condoms), hormonal methods (such as the birth control pill), behavioural methods, intrauterine devices, and sterilization.

As you read the chapter, think about the following questions:

• Why might sexual intercourse on day 14 of Alicia’s menstrual cycle not necessarily be optimal timing to achieve a pregnancy?
• Why is Alicia concerned about her irregular and long menstrual cycles? How could tracking her BBT and LH level help identify if she is ovulating and when?
• Why do you think Victor is concerned about past injuries to his testes? How might analysis of his semen help assess whether he has a fertility issue and, if so, the type of issue?

Attributions

Figure 18.1.1

Couple by Md saad andalib on Flickr is used under a CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/) license.

Figure 18.1.2

Basal_Body_Temperature by BruceBlaus on Wikimedia Commons is used under a   CC BY SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0) license.

Human Biology Copyright © 2020 by Christine Miller is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Chapter 9 . Alicia’s Case: Email Tirades and Four Stepfathers

9.1 screen 1.

Author: Taryn A. Myers, PhD, Virginia Wesleyan University

9.2 Screen 2

Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.

9.3 Screen 3

The receptionist hands you the intake paperwork prior to your interview with your new client, Alicia, who self-referred for therapy after losing her job. Select the button below to review the paperwork before you begin the interview.

New Client Alicia: Case #10116

Psychological Clinic

Intake Paperwork

Client Name: Alicia

Age: 28 years old

Gender: Female

Ethnicity: Latina

Occupation: Unemployed

Current living situation: I live by myself

Why are you seeking services at our clinic?

I got fired for no reason! Every job, someone I work with has it out for me. It’s like I don’t have any control and everyone in my life turns on me. No one wants to stay my friend, and I can’t find a good man. I really need someone who understands me and wants to help me. I need to take control of my life.

9.4 Screen 4

You will now ask Alicia a number of questions you would typically ask during the intake interview. As you conduct the interview with Alicia, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Select the “play” button to hear Alicia’s responses to your questions. To read the transcript for these answers, select the “transcript” button.

9.5 Screen 5

“Hi, Alicia. It’s good to meet you. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean having you continue to come to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today.”

Alicia: [agitated and oversharing] I just got fired! I keep getting fired. I just don’t get it. It’s not like it was my fault. My coworkers … always causing problems... Every time someone has it out for me. Like this most recent job – a girl I worked with complained about me, and BOOM … “You’re fired” [in “The Apprentice” style]! Or the job before that the nasty witch in the next cubicle asked me – get this! – to keep my voice down when speaking on the phone. [raising her voice] “How am I supposed to do my job if I can’t talk on the phone?” I say to her but she’s not sorry at all – the disrespect. She had no right. In school she would’ve got jumped for doing this to me. But HA! No apology, no nothing. So I go home and I think about it a little and it comes to me: let everybody know what she did. I emailed the supervisor and cc’d everyone! And then that supervisor took HER side and fired me from that job, too! He said it was “inappropriate” [you can almost hear her doing air quotes] – I think it was very “appropriate” – maybe even too nice. It’s hard to get a job when you have to work with idiots like that and you’ve only got short-term jobs on your record. And don’t get me started on my so-called friends and family!

Question 9.1

Which of the following symptoms of personality disorders does Alicia seem to be exhibiting based on her initial description of her problems at work? Select all that apply.

Self-criticism

Blaming others

Grandiosity/egocentricity

Impulsivity/recklessness

Emotional instability

Depression/helplessness

Attention deficiencies

Listen to Alicia again to review her symptoms.

9.6 Screen 6

“Wow! That sounds like a lot to deal with. Are there any other concerns you are having at this time?”

Alicia: My mood. It goes up and down all the time – it’s like all out of control. Any small thing can set me off. One moment I’m really happy, like everything is great. Like, I feel really, really good … On top of the world. And then … someone calls to change plans on me, and I feel like it’s all over.... Sometimes I just feel numb, like I can’t feel anything at all. That’s maybe the scariest time, because I mean, I have a big heart … I can’t feel just a little bit – but the ups and downs kind of wear me down after a while.

9.7 Screen 7

“How has your life been affected by everything that is going on?”

Alicia: Um, let me think. I’m having trouble with my “friends,” too. That’s really hard for me, to keep people as friends long-term…find someone who doesn’t let me down. I want a “best friend” in my life, someone I can go to with anything and share everything with. So when I meet someone I have something in common with or who wants to hang out with me, I get really excited that this person will be that “best friend” I’ve been looking for. So I hang out with her all the time and try to get close, learn her story right away. But it never works out, and then I’m all alone again. Like, one time in high school, there was this girl that I knew was going to be my best friend. We had really been bonding for like a whole week, so I gave her a “best friends” necklace. She just walks away. She started ignoring me, acting like she didn’t see me after that. [pauses, then with more intensity] It really, really sucks. It hurts so bad when people turn on you, reject you like that … but it keeps happening to me. [brief pause; suddenly brightening] I’m glad I came to see you. Talking to you is totally going to help – I can tell.

Question 9.2

Think about which of the clusters Alicia’s symptoms best fit. Remember that her symptoms include hostility, blaming others, impulsivity and recklessness, and emotional instability.

9.8 Screen 8

“It sounds like you have been struggling for a while, at least since you were a teenager. How long have these issues been going on?”

Alicia: Even as a kid, I feel like my reactions were bigger than the other kids. My family – a lot of the time it was just Mamí and me – we were poorer than everyone else, so I got teased a lot because I didn’t have “THE” clothes or the rich-kid toys. They had so much nice stuff, but I didn’t fit in because we didn’t have money. When they teased me I would feel awful, just awful. I had a few friends, I guess. They were like me – none of us fit in. We sort of stuck together because we had that in common, but then we’d get into fights. It got ugly. Whenever I’d try to get close to people, they would be friends with other people, not me, and I’d feel jealous. So yeah, I guess this has been going on my entire life.

9.9 Screen 9

“Tell me about your childhood. What was it like growing up in your family?”

Alicia: [conversational tone like she’s talking to her best friend] Well, my parents got divorced when I was only 2. I lived with Mamí most of the time growing up, but sometimes I would live with my Abuela – my grandma – for a few months. My dad would contact us, but only when he felt like it. [Suddenly agitated and angry] He would call and promise he would pick me up for the weekend and take me someplace fun, like to the zoo, or go get ice cream. One time I was sitting on the front porch waiting for him for hours and I got so upset when he didn’t come. I would tell myself I wasn’t going to trust him again, he was garbage – not a man, but then he would apologize, be all sweet on the phone… [small, sad voice] and then not show up again. [suddenly resentful] He didn’t give us any child support, and Mamí never had a job for very long, so I wasn’t able to have nice things. Mamí remarried 4 times from the time I was 3 until I left home at 17. These guys were all losers – also garbage. I was never close to any of them.

Question 9.3

How could Alicia’s childhood have influenced what is happening to Alicia now? More than one answer could be correct. Select all that apply.

Alicia’s father’s neglect could have led her to have difficulties trusting others.

Alicia’s mother’s work history could have modeled Alicia’s current behavior at work.

Alicia’s time staying with her grandmother was likely a negative experience.

Alicia’s father would never do anything fun with her when they saw each other.

Alicia’s mother spoiled her with lavish gifts and favors.

The fact that Alicia had four stepfathers meant she likely had a bad relationship with all of them.

Think about how the behavior of the most significant people in Alicia’s life may have influenced her.

9.10 Screen 10

“Sometimes when people have childhood experiences like you are telling me you have had, people in their lives treated them poorly. Has anyone ever done anything to you to hurt you physically, or touched you in a way that was inappropriate or made you feel uncomfortable?”

Alicia: Um … [silent for a moment, then in a flat, matter-of-fact tone] … Yeah, actually. When I was 8, my second stepfather molested me. It started off as just touching me. It got worse and worse over time. Then when I was 9, he started raping me… I was so scared. I told no one—no best friend to talk to, like I told you. He said he would hurt me if I told anyone. I was so embarrassed. All I could think was why is this happening to me? What am I doing wrong? But finally I worked up the courage to tell my mom. I was sure she would throw him out of the house because she would be so mad. [pause] But Mamí didn’t believe me. She said I was making it up. So Mamí stayed with this molester, this garbage, … and I just tried to hide from him as much as I could. I would say I was doing some clubs and stuff after school, and sometimes I could make excuses to stay late after school, but mostly I hung out in the park near our building just so I didn’t have to be home alone with him. [Suddenly earnest, intimate] I haven’t told that to anyone since I tried to tell Mamí about it. I feel like you really GET me.

Question 9.4

Think about how this experience may be linked with other issues Alicia has told you about.

9.11 Screen 11

“I really want to acknowledge how difficult it was for you to share that with me. Thank you for trusting me with this information so early in our relationship. What your stepfather did was wrong, and it must have been very difficult when your mother did not react the way you had hoped and remove your stepfather from your home. I want to let you know I believe you, and I will support you as you deal with this and your other issues. Many times when individuals have been sexually abused, they have difficulties with romantic relationships later in life. Have you found that to be the case?”

Alicia: Yes, totally. I’ve had boyfriends since I was 14. When you like a guy and you can tell he’s into you it’s so great! I know he’s “the one” – every time, it feels that way – and I’m thinking about marriage and children and having a real family, you know? But then I start thinking… maybe he’s getting tired of me… maybe this won’t last. I worry that this guy is going to dump me like all the other guys before. Or I see him looking at a girl and I think he’s cheating on me and I can’t get it out of my head. I mean, all men are cheaters, but I think maybe this one will stay. So I’ll set up “tests” to make sure he really cares about me. Like, I’ll send him a text saying, “how could anyone love someone like me?” I wonder that all the time so why not ask? Then I’ll time how long it takes him to text back. If he doesn’t respond right away, I figure he’s already moving on … falling out of love with me and even if he gets back to me it’s like “you’re so hot, I’m into you” and then I know it’s all about sex and it’s not about me, loving ME. If he tries to give me some BS story like he was in a meeting, I know he’s lying and ignoring me. Nothing lasts. Every single time they start to drop hints they are going to break up with me. Then I get really scared. I’ll do anything to keep them with me. I’ll tell them my grandmother is about to die or that I got a test back saying I have cancer, whatever I think will work. The last guy I dated – Justin – he was so perfect, really smart and hot. I told him I’d hurt myself if he left – I showed him a razor I had. It worked for a little while, but then he still left me. I felt frantic – like I wanted to kill myself for real. I tried to tell him – I sent emails, I left notes on his car. I thought anything would be better than hurting so much and I kept trying to reach him, to tell him, but he blocked me and … I was alone again.

9.12 Screen 12

“You mentioned feeling like you want to kill yourself and sending your ex-boyfriends messages about that. Have you ever done anything to hurt yourself?”

Alicia: Yes. When I was probably 13 or 14, I figured out that when I was feeling really bad, I could feel a little better if I dug my fingernails into my arm as hard as I could and counted to ten. It started out sort of like a ritual and I would wear long sleeve shirts to cover up the marks my nails would make. Then I started using a paperclip to scratch my arms, my legs, sometimes till they started bleeding. But then that felt like it wasn’t enough, so I started cutting myself with a razor. I would do it in places my clothes would cover so that no one else would know. I was – I am – embarrassed of the scars. I have to be careful what I wear out, but it was really hard NOT to cut myself after a while. It just made me feel better – like I could handle things and be okay.

Question 9.5

You want to find out more information related to what Alicia just told you.

9.13 Screen 13

“You said that cutting yourself helped you to deal with your emotions when you were younger. Sometimes when people engage in patterns like this, they also use other ways to cope with their emotions, some of which might be harmful to them in different ways. They also sometimes think about killing themselves. What else have you tried to help you block out these overwhelming emotions? Do you currently feel like harming or killing yourself?”

Alicia: No, not today [laughs ironically] I have you to thank for that – I can tell you’re going to make me feel better. But, okay, I’ve tried pretty much everything. I get so down and depressed and just…like you said… overwhelmed, you know? I’ll have these moments when I feel like I’m back in that room with my stepfather doing stuff to me – [pause, like she is back in that moment, zoned out] I’ll see him when he isn’t there, or I’ll feel him touching me when he’s not there, especially when I’m really stressed out. Eating a lot of food all at once seems to help a little. I’ll eat a lot in the middle of the night, standing over the kitchen counter. I tell myself I need to stop doing that because I’m going to gain weight, so I’ll stop for a few weeks but then when I stop eating, it’s like I still need something to help me feel okay. So I’ll drink – beer, whiskey, you name it – a lot in one sitting. I know that’s not good, either, so every morning I wake up and I think “I’ll never do that again.” But then something happens and I get all out of control again, so I eat, or drink or [quickly, a little embarrassed] … I cut myself. Not for almost a month, though.

Question 9.6

Think about how Alicia describes her feelings about these behaviors.

9.14 Screen 14

“You’ve talked about hurting yourself. Have you ever lashed out and hurt someone else?”

Alicia: Hmmm… I don’t know if this is what you are asking, but when I was 17, my 4th stepfather and I got into a huge fight. It started real small, but then I got really angry really fast. I got so mad I ended up throwing a chair through the sliding door onto the balcony. Then that jerk threw me out of the house, and Mamí did nothing to stop him! [pause] Ever since then, I’ve had to move a lot. I’ve lived with some boyfriends, but that never lasts. I even had to live in a homeless shelter for a couple of weeks. And that brings me back to my main problem, which is that I can’t hold down a job for very long, which makes it hard to pay rent. [brightly, intimately] Can I just say, I feel like I can really TALK to you. I know you’re going to help me. I am so glad I’ll be coming to see you.

Question 9.7

Which of the following symptoms is Alicia currently experiencing? Select all that apply.

Relationship problems

Suspicious/distrustful

Deceitfulness

Controlling/manipulative

Aloof/isolated

Self-absorbed

Self-critical

Grandiosity/egocentrism

Overly emotional

Depressed/helpless

Anxious/tense

Cognitive/perceptual eccentricities

Psychotic-like episodes

Think about all of the symptoms Alicia is showing.

9.15 Screen 15

From the File. You remember a former patient who experienced symptoms similar to Alicia’s. You review this case to help you diagnose Alicia.

WOMAN 1: A lot of it revolved around relationships, just really intense relationships, trust issues, lots of fears around abandonment and being left and not being able to tolerate and handle those fears even when they weren't always realistic. They felt really real to me. WOMAN 2: Yeah. WOMAN 1: You know? And I had no way of knowing, at the time, how to decipher that. It felt real, so it was real. And I reacted as if it was real. Threatening that I would hurt myself in some way because I felt so desperate for whoever it was not to leave me. And I didn't know any other way. And I found that that worked to really grab someone's attention and make them care. I don't know who I am, and I'm freaking out. And can you help me? Is there something that I can do to figure out who I am and to heal this part me? It was scary because I noticed that I was very chameleon-like. And whoever I was around, back at that time, if I was in that place, I would be looking at you right now and your mannerisms and mimicking that back and trying to be like you. You know? So I never really had a sense of who I was apart from anyone. And the thought that occurred to me before I really have the breakdown, where I ended up in the intensive outpatient and got my diagnosis, was-- I was really distressed about something that happened at work. And I was thinking about how I had behaved that day versus how I behaved with other people in a different setting. And I thought, what would happen if I were in a room with all of these different people from my life at the same time-- like my boyfriend, my sister, my therapist, people from school, people from work. I just froze and freaked out because I realized I was so different with each of them in each of those settings, that I had no idea how I would live or how I would be. I had no sense of self.

Question 9.8

9.16 screen 16, question 9.9.

In making your choice, think about the following symptoms Alicia exhibits:

• Difficulties in relationships
• Fear of abandonment, with dramatic measures taken if she thinks she will be abandoned
• Self-harm behaviors

Question 9.10

9.17 screen 17, question 9.11.

In making your choice, think about which type of therapy has been shown to be very helpful in treating individuals with self-harm behaviors.

9.18 Screen 18

Question 9.12.

Think about what you learned in your feedback so far.

Question 9.13

Think about how effective the research has shown DBT to be.

9.19 Screen 19

You are trained in DBT, so you begin treating Alicia individually and refer her to your practice’s skills training group. In the group, she meets other people who share her experience and she learns valuable coping skills in the areas of mindfulness, emotion regulation, distress tolerance, and interpersonal communication. When she is feeling overwhelmed and feels an urge to cut herself, she calls you as you have instructed her to do, and you coach her to try some of these skills she has learned instead of engaging in self-harm behaviors. The individual sessions are a longer road. Phase 1 of DBT, which entails focusing on getting her self-harm behaviors under control, takes you and Alicia two years to complete. During this time, Alicia repeats group skills training and works on identifying when and why she self-harms, to figure out how to stop self-harming in the future. Only then do you feel that Alicia has gained enough control of her self-harm behaviors to begin addressing the trauma of her stepfather’s sexual abuse. After the difficult process of addressing this trauma and its related symptoms, you work with Alicia on dealing with ordinary life problems such as setting long-term goals, something she never did previously. During the last stage of treatment, you work with Alicia on finding meaningfulness and connection in her life. Although it is a very long process with some slips along the way, including trips to the ER and hospitalizations when she harms herself, Alicia eventually is able to hold down a steady job as an office manager at a doctor’s office. She feels more open to relationships and less worried about what will happen if the man she is dating leaves her or if she and a friend have a disagreement.

9.20 Screen 20

Real World Application

Watch this video and answer the questions that follow.

Dr. Marsha Linehan: Do you want a therapist, though, who will help you see the things you are doing that you might not be aware of? MAN: Yes. Dr. Marsha Linehan: Do you realize that will be painful? I mean, do you realize that? I mean, surely you do because it seems to me like this has been somewhat of a painful interaction itself. Has this been painful? Yeah. So that's one thing about therapy I have to tell you. Therapy is usually very painful. One of the painful parts of therapy, among other parts, are that you often see things about yourself that you don't like. So you kind of have to be ready for that before you go into it. MAN: Well, I think it couldn't be worse than the last few months. Dr. Marsha Linehan: Yeah. OK. So one, you have to see things about yourself you don't like. And the other is often in therapy you have to work on changing things about yourself. Do you want to do that? MAN: Again, my first reaction is, why should I change? Dr. Marsha Linehan: Why? So are you willing to change anyway? So you notice that he said, why should I change? And so you may wonder why didn't I discuss that with him. The reason I didn't discuss it with him is in my own mind I'm thinking, this is irrelevant. The facts in that are, you are going to have to change, and there's no point in discussing why you have to change. For one, we've already discussed that you're the only one in therapy. And second, really, I'm thinking in my own mind, you're in tough shit. You'll have to change. So I want to make sure he's on board. So I say, so are you willing to change anyway? In other words, I didn't get in a discussion why should he change. I want to move him into agreeing that he will change.

Question 9.14

In 2011, Dr. Marsha Linehan, the therapist who is doing therapy in this video, revealed in an interview with The New York Times that she herself had suffered from borderline personality disorder as a teenager. In order to “treat” Dr. Linehan, doctors put her in a seclusion room, which had only a bed, a chair, and one window. They claimed that doing so would prevent her from attacking herself, as she had repeatedly cut and burned herself. Left alone in the seclusion room, she instead banged her head on the wall and floor to engage in self-harm. When she got out, she vowed to help others like herself. Many years later, she earned her PhD in psychology and created DBT.

Question 9.15

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