Psychoanalytic Formulation — 03/27/2025 → Present

Name: Yehoshua Osborne · DOB: 1968-01-13 · Date of Eval: 2025-08-30 · Descriptive self-report (not a billing/diagnostic note)

Presenting Problem

Acute health threat (stroke scare) followed by glioblastoma diagnosis and treatment. Results: fluctuating anxiety/depressed mood, steroid-linked irritability/insomnia, cognitive strain, and a strong drive to create an honest legacy.

Medical Anchors (context)

• 03/27/2025: Stroke scare.
• 05/01/2025: Craniotomy.
• 05/05/2025: Pathology: Glioblastoma, IDH-wildtype (CNS WHO grade 4).
• 05/30–07/14/2025: Chemoradiation (60 Gy/30 fx with concurrent temozolomide ~75 mg/m²).
• Since May: Lacosamide/Vimpat (antiseizure).
• 07/26/2025: Dexamethasone started; tapering toward 2 mg.

Phenomenology by Phase

• Mar–Apr: Alarm → control-seeking, planning surge, poor sleep.
• May: Shock → grief → operational mode; anxiety spikes around pathology/chemo.
• Jun–Jul: Fatigue; steroids add irritability/insomnia; routines become essential.
• Aug (now): Determined, sometimes brittle; progress reduces anxiety; delays/sloppiness trigger anger.

Intrapsychic Dynamics

• Theme: Control vs helplessness; structure/action to contain dread.
• Meaning-making: Legacy site as sublimation and continuity of self.
• Ego functions: Reality testing/judgment intact; attention/word-finding dip under stress/sleep loss.
• Superego: Strict; demands honesty and precision.

Defenses (mostly adaptive)

• Sublimation (build/document) · Anticipation (plans/versioning) · Dark humor · Suppression (park distress) · Intellectualization and control (can turn rigid when others are sloppy).

Affects & Conflicts

• Fear, anger, grief, pride.
• Autonomy vs dependence; truth vs comfort (prefers truth).

Relational Patterns

• Tests for competence; straight talk → fast trust; vagueness → anger/cutoff.
• Fierce loyalty with intimates; unreliability → distance.
• Self as demanding coach; redirects shame/anger into tasks.

Self-Representation

• Identity: builder, truth-teller, protector; documentation counters threat to executive control.
• Mortality stance: not avoidant; order and story reduce annihilation anxiety.

Somatic–Psychic Link

• Seizure risk → stronger control rituals.
• Steroids ↑ activation/irritability; fragment sleep.
• Yogurt/smoothie routine stabilizes energy and signals control/care.

Strengths

• Clarity, courage, rapid execution, technical skill, purpose focus, chosen-family bonds.

Risks

• Exhaustion → brittle interactions; all-or-nothing judgments.
• No SI stated here; continue explicit checks during steroid shifts/medical turns.
• Risk of cutting off imperfect but useful supports.

Working Hypotheses

• CCRT: Wish = “Be straight/competent and help me execute.” Precise/reliable others → engaged collaboration; vague/slow → anger/dismissal.
• Anxiety driver: Loss of executive control (seizure, bureaucracy) → fight (anger) or tighter control (procedures/versioning).

Concrete Interventions

1. Daily 15-min “order pass”: version bump, backups, 3-item list — then stop.
2. 3-line complaint rule: what broke, impact, exact fix by when.
3. Grief reps: 5 min, 3×/week — one loss + one thing you’re keeping alive via the site.
4. Sleep guards: fixed window; cool/dark; no screens last 60 min; park tasks for morning.
5. Bandwidth budget: label days A/B/C; match tasks; no A-tasks on C-days.
6. Scripts for pharmacies/clinics: precise ask, deadline, consequence.

Escalate If

• New/persistent anhedonia, SI, or panic.
• Steroid mood changes that don’t settle with taper.
• New cognitive drop beyond baseline — contact neuro-onc.