Lecture 10: Differential diagnosis of major depressive disorder - workshop Flashcards
Briefly define the diagnosis “depressive episode with insufficient symptoms”
- It is classified under Other Specified Depressive Disorder
- The full criteria for a major depressive disorder are not met
- All these must be present:
• depressed affect
• one of the other 8 symptoms of MDD
• distress/impairment for at least 2 weels
• not due to active or residual psychotic disorder
• not due to mixed anxiety & depressive disorder symptoms
What diagnosis should be considered when depressive symptoms are current and associated with a psychosocial stressor?
Adjustment disorder
- with depressed mood
- with mixed anxiety and depression
Which diagnosis is characterised by avoidance of memories/feelings or external reminders linked to a psychosocial stressor?
PTSD
Do the alterations in arousal and reactivity in PTSD lower in intensity as time go by?
No, those symptoms begin or get increasingly worse after the traumatic event
Dx, diff. dx
Patient A is a 47-year-old man, reporting that for several months the stress in his life has been getting too much for him and that he has been feeling down. Even though he has experienced days that are not too bad (up to 4 consecutive days), he has been mostly feeling very low, the whole day, every day, consecutively for uninterrupted periods of more than two weeks. In these times of feeling low, he isolates himself, does not want to meet his family and friends and is not interested in going for a swim or a jog, activities he usually enjoys a lot. His appetite is very low, he does not want to eat, and has lost weight. In contrast to his usual 6-7 hours of sleep at night, in the weeks when his mood has been low, he has been sleeping 12 h on average. He does not feel restless and is able to sit still, but other people noticed that he is talking and moving more slowly than normal. He is less active, and his speech is slowed down. Patient A reported that he is very tired all the time and that he has no energy. He feels worthless and has trouble thinking and concentrating. When he reads something, it feels more like daydreaming to him which stops him from reading books which he normally does. Absolutely nothing can cheer him up, not even for a short time. His low mood stays the same throughout the day. He feels guilty about various things in his life; he particularly thinks he could have treated his girlfriend better. Patient A mentions that in the past month he has had recurrent thoughts of committing suicide. Three times a week, he is thinking about ending his life, but he does not have a specific suicide plan. Patient A reports that these suicidal impulses are strong, but he has always felt he can control them.
When asked, Patient A agreed that he has occasionally experienced periods when he feels hyper and ‘high’. He feels restless during these times, more self-confident than usual and only needs 4 hours of sleep to feel rested and energised. These very active periods last for about a week every time and he spends his time mostly outdoors, walking a lot or being generally very busy and productive. Patient A tends to be more talkative during these periods and reports that (positive) thoughts are constantly racing through his head. In these times other people feel like he is not like his usual self, but he has never caused serious harm to himself or others or got into trouble while being in this state. He has, however, lost some friends because of being rude during these periods and his spending levels were higher than usual, although this has not caused significant debt.
Additional information:
Patient A is currently unemployed. He felt harassed and bullied at work and lost his job after getting violent against a work colleague leading to a prison sentence. At a separate occasion, Patient A threw a bottle at his father during an argument.
Patient A left school at age 16 with no qualifications. In his childhood he was daydreaming a lot which he thinks definitely affected his grades. He was often acting very disruptive in class. He did have friends in his childhood and enjoyed playing hide and seek and board games with them.
Patient A is currently single. He had 4 significant relationships in the past, each lasted about 1 year. His parents got divorced when he was a teenager and he has 4 siblings and 1 child to whom he feels close. Patient A reported that he is not aware of a family history of psychiatric or neurological disorders.
There is no history of alcohol abuse, hallucinations or delusions. There are no focal neurological symptoms or physical health conditions.
Dx, diff dx
Patient B is a 44-year-old mother of 3 children: one baby, one 8 and 10 year old. She has experienced various episodes of feeling low and empty since her early twenties which lasted for months up to one year. Patient B describes her mood as being depressed most of the day, nearly every day for several weeks now. She shows diminished interest in almost all activities that she usually enjoys. Her appetite is decreased, and she has lost 6 kg in weight. Her sleep is disrupted as she has trouble falling asleep at night, and she wakes up very early in the morning. She is very fidgety and restless whilst feeling very tired. Patient B describes feelings of being low in self-esteem, but she would not call this feeling worthless. She feels guilty about the house being untidy, for being overweight, and for not being there for her children. She thinks she has ruined her children’s lives because of not taking enough time to play with them. This will lead them to being unhappy in the future like she has always been. Patient B reports that she has problems concentrating which make it impossible for her to read or watch TV. The first time when she experienced such an episode of low mood, she attempted to take her own life in order to stop feeling miserable. She has recurrent thoughts of death. This current episode of feeling low started within 4 weeks of the birth of her third child. During the pregnancy she felt anxious and isolated herself. Patient B has not only lost pleasure in everything; she does not even feel temporarily better when something good happens. Patient B describes her depressed mood as being of a distinct quality, different from the kind of feeling experienced after the death of a loved one. She feels like her feelings are numbed entirely.
Patient B reports that extremely upsetting things have been happening in her life. Her father sexually assaulted her when she was 9 years old. She has feelings of hatred towards her father and has stopped speaking to him. Memories, including thoughts, images and perceptions of these incidences keep coming back in form of thoughts and nightmares that she cannot get rid of. When she is reminded of them, she gets deeply upset and angry, but does not show any physical symptoms like irregular breathing. Since the incidences occurred, Patient B has made a special effort to avoid thinking or talking about what happened and avoids people, and places that arouse recollections of the assaults. Since the traumatic incidences, she feels detached from others and numb. Very often she has outbursts of anger, is very watchful and jumpy. All these problems have lasted for years since she can remember. This has also affected her trust in people and she is unable to enjoy sexual intimacy.
Additional information:
Patient B has a history of recreational drug use that has not caused problems, depressive symptoms were not related in onset to the onset of drug use and she has experienced depressive episodes independently of drugs.
Patient B did not have learning or concentration problems at school, or problems with discipline. She did not have a best friend as a child but felt like being friends with everyone.
Patient B finished her qualification with her A-levels and worked as a sales assistant.
Patient B had 3 significant relationships (including her marriage), all 3-7 years long.
Patient B does not report a family history of psychiatric or neurological disorders. Her parents are still married. She has 3 brothers but is only in contact with the older one of them.
There is no history of alcohol abuse or of hallucinations, delusions, or hypomanic symptoms. There are no focal neurological symptoms or physical health conditions.
Dx, diff dx
Patient C is a 32-year-old woman, who has been feeling low and anxious most of the day, nearly every day, since she gave birth to her daughter a few weeks ago. Patient C reports that she cannot deal with her daughter crying. She then feels very upset and very tight in her chest and stomach. When her daughter is crying, Patient C is very fearful that she is going to do something wrong. Patient C is very concerned that something could happen to her daughter when she goes out with her and prefers to stay in the house most of the time. Patient C reports about having recurrent thoughts that someone could attack her and her daughter while they are out, although she knows this is unlikely. Patient C feels that she is still interested in things and able to enjoy them if she can be distracted from her worries, such as when her best friend visits. Her appetite has not changed, her sleep pattern is disrupted. It takes her very long to fall asleep. Patient C mentions that she has very violent nightmares of physical harm to herself or her child. Patient C reports to feel very restless but does not think others would notice her moving around more. She feels exhausted all the time. She thinks she is struggling to be a good mother and partner, but she does not feel worthless. She feels guilty for being down and not able to function like other mothers. Even though Patient C enjoyed reading novels or newspapers in the past, she stopped because she cannot really follow the story she is reading anymore. Patient C does not think she would be better off dead.
Patient C reports that her high anxiety and worries started before her feelings of low mood. For more than 6 months now, more days than not she worries excessively that something bad could happen to her. Since then it became difficult for her to sit still and she often felt keyed up and on edge. It is also since then that she feels tired easily and that she has great difficulty concentrating on anything. Very often she feels irritable and her muscles are tense. Before Patient C began to feel highly anxious so often, she has not been taking any drugs, diet pills or medicines, nor did she increase her caffeine intake or suffered from any physical illness.
Additional information:
Patient C reports that her mother suffered from untreated postnatal depression.
A few years ago, Patient C constantly worried about if she had locked her door when she left the house. At times she was slightly late for work, because she would sit in her car worrying about if her door was locked. She would spend 15min going through an elaborate routine of locking her door. She thinks these routines have not stopped her from doing important things and she was not particularly bothered by them.
Patient C reports that nowadays, when she has a ‘bad’ day, she still takes a photo of herself locking the door when she is going somewhere, just to make sure that she actually really did lock it. She fears the consequences of getting burgled if she makes the mistake of not locking her door. She feels slightly embarrassed by these behaviours, calls them ‘ridiculous’, and tries to hide them when her family is around. She mentions that she is very anxious of doing something wrong and that she has no trust in herself.
There is no history of alcohol or drug abuse or of hallucinations, delusions, or hypomanic symptoms. There are no focal neurological symptoms or physical health conditions.
Dx, diff dx
Patient D is a 40-year-old woman, who reports that she has often been feeling low over the last month after her partner ended their relationship after 5 years. She mentions that her mood has been going up and down over this period with about 50% good and bad days. She has lost interest in many things she usually enjoyed. She has not enjoyed her holiday for example, but she has still been able to enjoy going out with her friends. Patient D reports that she has had a decreased appetite and that she has lost weight over the last 2 weeks. She has a general difficulty in getting to sleep, because she is ‘light sensitive’ which has not changed over the past two weeks. Patient D does not feel restless or being slowed down, she feels very tired however, and it appears difficult for her to get motivated to do things. Patient D thinks she cares too much about what others think of her but feels that she has good qualities and that her job performance maintains her self-worth. Patient D does not feel particularly guilty. Patient D has trouble concentrating and making decisions but is able to do her job normally. She does not think about death or hurting herself in any way, but her symptoms appear to be bothering her to quite a high degree.
Additional information:
Patient D never had learning or concentration problems and has always been very attentive in school. She never had problems with discipline.
Patient D went to different primary schools; she enjoyed playing games in larger groups of friends.
Patient D was married for 5 years and had another 5-year long relationship. She had a couple of short-term relationships. In general, she is satisfied with her job and her friendships.
Patient D has no family history of neurological or psychiatric disorders.
Patient D has no children, but one older brother. Her parents were married until her mother’s death. When her mother passed away, Patient D was 8 years old. Her father remarried. Patient D thinks her father got engaged in his new relationship too early after her mother’s passing. She thinks this has impacted on her and her older brother. Patient D had counselling in the past to adapt to the loss of her mother, but no other episodes of elevated or lowered mood.
There is no history of alcohol or drug abuse or of hallucinations, delusions, or hypomanic symptoms. There are no focal neurological symptoms or physical health conditions
