Case Analysis Evaluation-48-Year-Old Woman

Jane Sheraton, a 48-year-old woman, presented to the Psychiatry team following concerns raised by a friend about her mental health. She reported feeling consistently sad for the past few weeks, exacerbated by the recent loss of her job, which she deeply valued. Jane expressed a profound sense of hopelessness, describing herself as unable to enjoy anything and no longer participating in activities she once enjoyed, such as running and socializing. She struggled with sleep disturbances, poor appetite, and feelings of guilt, particularly regarding her inability to support her son’s education financially. Jane admitted to suicidal ideation, disclosing thoughts of self-harm and purchasing paracetamol as a means to end her suffering (CGP Grey, 2016). During the consultation, she exhibited signs of psychomotor retardation, tearfulness, and diminished affect, with linear thought processes. Despite partial insight into her condition, Jane believed her feelings of worthlessness were justified, expressing skepticism towards the potential efficacy of treatment. Risk assessment revealed a high risk of self-harm due to suicidal ideation and self-neglect stemming from neglecting basic self-care needs (CGP Grey, 2016).

Differential Diagnosis

Major Depressive Disorder (MDD): This diagnosis involves experiencing a depressed mood or loss of interest or pleasure in activities for at least two weeks, along with additional symptoms such as changes in appetite or weight, sleep disturbances, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide (Marx et al., 2023). In the case of Jane Sheraton, she exhibits many of these symptoms, including persistent sadness, anhedonia (inability to enjoy activities), early morning waking, feelings of worthlessness, and recurrent suicidal ideation (CGP Grey, 2016). Her presentation is consistent with the diagnostic criteria for MDD.
Adjustment Disorder with Depressed Mood: This diagnosis is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor within three months of the onset of the stressor. Symptoms must be clinically significant, causing distress or impairment in social, occupational, or other important areas of functioning (Sarmiento & Lau, 2020). Jane’s recent loss of employment and subsequent financial strain serve as identifiable stressors triggering her depressive symptoms. Her symptoms emerged within a few weeks of losing her job, indicating a temporal relationship between the stressor and symptom onset, supporting the diagnosis of adjustment disorder with depressed mood (CGP Grey, 2016).
Other Specified Depressive Disorder (OSDD): This diagnosis is used when depressive symptoms cause clinically significant distress or impairment but do not fully meet the criteria for MDD or another specified depressive disorder. OSDD encompasses a range of depressive presentations that do not fit neatly into existing diagnostic categories (Sarmiento & Lau, 2020). In Jane’s case, although she exhibits many symptoms consistent with MDD, her lack of engagement in previously enjoyed activities and social isolation may not fully align with typical MDD presentations. Additionally, her suicidal ideation and feelings of worthlessness suggest significant distress, but her insight into her condition may be considered partial, indicating a complexity that may warrant an OSDD diagnosis (CGP Grey, 2016).

Differential Diagnosis Mental Status Examination

Major Depressive Disorder (MDD):

Appearance: Jane appears sad and tearful, with poor eye contact and evidence of psychomotor retardation.
Speech: Her speech could be faster and more varied.
Mood & Affect: Jane describes her mood as consistently low, with blunted affect.
Behavior & Motor Activity: She exhibits psychomotor retardation, describing an inability to engage in activities she once enjoyed.
Thought Process: Her thought process is linear, focusing on feelings of hopelessness and worthlessness.
Thought Content: Jane expresses recurrent thoughts of guilt and suicidal ideation.
Attention & Concentration: Poor concentration is evident, as indicated by difficulty maintaining focus during the consultation.
Memory: No specific deficits in memory are noted in the provided transcript.
Orientation: Jane appears oriented to time, place, and person.
Insight: Jane demonstrates partial insight into her condition, acknowledging her depression but expressing skepticism regarding the potential effectiveness of treatment.
Judgment: Impaired judgment is suggested by her consideration of self-harm and lack of belief in the efficacy of interventions (CGP Grey, 2016).

Adjustment Disorder with Depressed Mood:

Appearance: Similar to MDD, Jane appears sad and tearful, with evidence of psychomotor retardation.
Speech: Her speech could be faster and more varied.
Mood & Affect: Consistent low mood with blunted affect.
Behaviour & Motor Activity: Psychomotor retardation is evident, reflecting decreased activity levels.
Thought Process: Linear thought processes focused on recent stressors such as job loss.
Thought Content: Recurrent thoughts of worthlessness and hopelessness related to the identified stressor.
Attention & Concentration: Poor concentration is evident, likely influenced by preoccupation with the stressor.
Memory: No specific deficits in memory are noted in the provided transcript.
Orientation: Jane appears oriented to time, place, and person.
Insight: Similar to MDD, Jane demonstrates partial insight into her condition, acknowledging the impact of the stressor but expressing doubt about the potential effectiveness of treatment.
Judgment: Impaired judgment is suggested by her consideration of self-harm in response to the stressor (CGP Grey, 2016).

Other Specified Depressive Disorder (OSDD):

Appearance: Similar to MDD and Adjustment Disorder, Jane appears sad and tearful, with evidence of psychomotor retardation.
Speech: Slow and monotonous speech patterns.
Mood & Affect: Consistently dejected and emotionally numb.
Behaviour & Motor Activity: Psychomotor retardation is evident, reflecting decreased activity levels.
Thought Process: Linear thought processes, with a focus on feelings of hopelessness and worthlessness.
Thought Content: Recurrent thoughts of guilt and suicidal ideation.
Attention & Concentration: Poor concentration is evident, likely influenced by preoccupation with depressive symptoms.
Memory: No specific deficits in memory are noted in the provided transcript.
Orientation: Jane appears oriented to time, place, and person.
Insight: Jane demonstrates partial insight into her condition, similar to MDD and Adjustment Disorder, expressing doubt about the potential effectiveness of treatment.
Judgment: Impaired judgment is suggested by her consideration of self-harm and lack of belief in the efficacy of interventions, similar to MDD and Adjustment Disorder (CGP Grey, 2016).

Differential Diagnosis Etiology

Major Depressive Disorder (MDD):
- It is a multifactorial condition with various contributing factors. Biological factors such as genetics, neurotransmitter imbalances (particularly serotonin, norepinephrine, and dopamine), and structural and functional abnormalities in the brain can predispose individuals to develop depression. Environmental factors such as significant life stressors, trauma, chronic illness, and substance abuse can also increase the risk of developing MDD. Additionally, psychological factors like negative thought patterns, low self-esteem, and maladaptive coping mechanisms play a role in the etiology of MDD (Marx et al., 2023).
Adjustment Disorder with Depressed Mood:
- Significant life stressors or changes, such as job loss, relationship issues, financial difficulties, or medical diagnoses, typically trigger it. The onset of depressive symptoms occurs within three months of the identified stressor. Unlike MDD, where symptoms persist beyond the resolution of the stressor, symptoms typically remit once the stressor is alleviated or the individual adapts to the situation (Sarmiento & Lau, 2020). The etiology is primarily related to the individual’s inability to cope effectively with the stressor, leading to the development of depressive symptoms.
Other Specified Depressive Disorder (OSDD):
- It encompasses a heterogeneous group of depressive presentations that do not meet the full criteria for MDD or another specified depressive disorder. The etiology of OSDD may vary depending on the specific symptoms and circumstances presented by the individual. Similar to MDD and Adjustment Disorder, biological factors (e.g., genetics, neurotransmitter imbalances) and psychosocial stressors (e.g., trauma, loss, interpersonal conflicts) can contribute to the development of depressive symptoms in OSDD. Additionally, personality traits, coping styles, and social support networks may influence the onset and course of OSDD (Sarmiento & Lau, 2020).

Differential Diagnosis Diagnostic Screening Tools

Major Depressive Disorder (MDD):
- Screening Tools:
  - Patient Health Questionnaire-9 (PHQ-9): A self-administered questionnaire assessing nine symptoms of depression over the past two weeks. It provides a severity score ranging from 0 to 27, with higher scores indicating more significant depressive symptoms.
  - Beck Depression Inventory-II (BDI-II): A self-report inventory of 21 items assessing the severity of depressive symptoms. Scores range from 0 to 63, with higher scores indicating more severe depression (Marx et al., 2023).
- Examination Specifics:
  - MSE: Assess for symptoms consistent with MDD, such as persistent low mood, anhedonia, feelings of worthlessness, psychomotor retardation or agitation, changes in sleep or appetite, poor concentration, and suicidal ideation.
  - Physical Examination: Rule out medical conditions that may mimic or exacerbate depressive symptoms, such as hypothyroidism, vitamin deficiencies, or neurological disorders.
  - Laboratory Testing: Consider thyroid function tests, complete blood count (CBC), comprehensive metabolic panel (CMP), and vitamin B12 and folate levels to rule out underlying medical causes of depression (Marx et al., 2023).
Adjustment Disorder with Depressed Mood:
- Screening Tools:
  - Life Events Checklist (LEC): A questionnaire assessing exposure to potentially traumatic life events, including job loss, financial difficulties, relationship problems, or health-related stressors.
  - Adjustment Disorder New Module (ADNM): A structured clinical interview assessing symptoms of adjustment disorder, including depressive mood, anxiety, and impaired social or occupational functioning (Boland et al., 2020).
- Examination Specifics:
  - MSE: Evaluate for symptoms consistent with Adjustment Disorder, particularly the presence of depressive mood in response to an identifiable stressor within three months of its onset.
  - Psychosocial Assessment: Explore the nature and impact of recent stressors on the individual’s emotional well-being and functioning.
  - Differential Diagnosis: Distinguish Adjustment Disorder from other mood disorders (e.g., MDD) by assessing the temporal relationship between symptom onset and the identified stressor (Boland et al., 2020).
Other Specified Depressive Disorder (OSDD):
- Screening Tools:
  - Structured Clinical Interview for DSM-5 (SCID-5): A diagnostic interview used to assess for various mental disorders, including OSDD, by gathering detailed information on symptoms, severity, and duration.
  - Clinician-Administered Rating Scales: Various rating scales and checklists tailored to the individual’s presentation may be utilized to assess specific depressive symptoms and associated impairments (Boland et al., 2020).
- Examination Specifics:
  - Mental Status Examination: Conduct a comprehensive assessment of depressive symptoms, paying attention to the presence of clinically significant distress or impairment that does not fully meet the criteria for MDD.
  - Psychosocial Evaluation: Explore contextual factors contributing to the individual’s depressive symptoms, such as psychosocial stressors, personality traits, coping strategies, and social support networks.
  - Differential Diagnosis: Rule out other mood disorders (e.g., MDD, Bipolar Disorder) and medical conditions that may mimic depressive symptoms, ensuring that the presentation aligns with the diagnostic criteria for OSDD (Boland et al., 2020).

Case Analysis

Based on the presented case, the likely diagnosis for Jane Sheraton is Major Depressive Disorder (MDD). Her symptoms align closely with the diagnostic criteria for MDD, including persistent low mood, anhedonia, psychomotor retardation, feelings of worthlessness and guilt, poor concentration, and recurrent thoughts of suicide (Marx et al., 2023). Additionally, Jane’s symptoms have persisted for several weeks and are associated with significant impairment in social and occupational functioning, indicative of a major depressive episode. Furthermore, her history of job loss serves as a significant psychosocial stressor, consistent with the triggering events often seen in Adjustment Disorder. However, the persistence and severity of Jane’s symptoms, along with their impact on her daily life, are more characteristic of MDD.

Treatment Plan

Pharmacologic Treatment:
- Selective Serotonin Reuptake Inhibitors (SSRIs), such as sertraline or escitalopram, are recommended as first-line pharmacotherapy for MDD due to their efficacy and tolerability (Stahl, 2020).

Start sertraline 50 mg once daily, with titration as needed based on clinical response and tolerability, aiming for a therapeutic dose of 50-200 mg/day (Stahl, 2020).
Monitor for adverse effects, including gastrointestinal upset, insomnia, and sexual dysfunction.
Consider augmentation strategies with other antidepressants or adjunctive agents (e.g., atypical antipsychotics) if the response is inadequate (Stahl, 2020).

Non-pharmacologic Treatment:
- Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT) should be initiated as adjunctive treatment to pharmacotherapy, focusing on identifying and modifying negative thought patterns and improving interpersonal relationships (Stahl, 2020).
- Encourage regular physical activity, as exercise has been shown to have antidepressant effects and improve overall well-being.
- Supportive therapy and psychoeducation can help the patient develop coping strategies and enhance resilience.
Patient/Family Education:
- Educate the patient and family about the nature of MDD, emphasizing that it is a medical condition requiring treatment and not a personal weakness.
- Discuss the expected timeframe for improvement with treatment, emphasizing the importance of adherence to medication and therapy.
- Provide information on potential side effects of medication and strategies for managing them (Stahl, 2020).
Referrals:
- Refer the patient to a psychiatrist or mental health professional for ongoing management and monitoring of antidepressant therapy.
- Consider referral to community resources, support groups, or peer-led programs for additional support and social connection (Stahl, 2020).
Follow-up:
- Schedule regular follow-up appointments every 2-4 weeks initially to monitor treatment response, assess for adverse effects, and provide ongoing support.
- Adjust medication dosage or treatment approach based on clinical response and tolerability.
- Collaborate with the patient and other healthcare providers to develop a long-term management plan, including relapse prevention and wellness maintenance strategies (Stahl, 2020).

References

Boland, R., Verdiun, M., & Ruiz, P. (2021). Kaplan & Sadock’s synopsis of psychiatry. Lippincott Williams & Wilkins.

CGP Grey. (2016, September 7). The Rules for Rulers [Video file]. Retrieved from https://www.youtube.com/watch?v=5fK3IDR-Rp8Top of Form

Marx, W., Penninx, B. W., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1), 44. https://doi.org/10.1038/s41572-023-00454-1

Sarmiento, C., & Lau, C. (2020). Diagnostic and statistical manual of mental disorders: DSM‐5. The Wiley Encyclopedia of Personality and Individual Differences: Personality Processes and Individual Differences, 125-129. https://doi.org/10.1002/9781119547174.ch198

Stahl, S. M. (2020). Prescriber’s guide: Stahl’s essential psychopharmacology. Cambridge University Press.

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Question

(This section should contain a summary of the presented case: History, symptoms present, etc.)

Differential Diagnosis

(This section should contain possible differential diagnoses applicable to the case presentation that was reviewed. In this section list the differential diagnosis and then define them; identify how the differential diagnosis is supported based on the information provided in the case study. Provide no less than 2 and no more than 4 differential diagnoses.)

Case Analysis Evaluation-48-Year-Old Woman

Differential Diagnosis #1

Differential Diagnosis #2

Differential Diagnosis #3

Differential Diagnosis Mental Status Examination

(This section should provide the expected or provided mental exam findings for each differential diagnosis (not all criteria may be completed under each differential diagnosis).

______________ Disorder presents with mental examination findings consistent with the following:

Appearance:
Speech:
Mood & Affect:
Behavior & Motor Activity:
Thought Process:
Thought Content:
Attention & Concentration:
Memory:
Orientation:
Insight:
Judgement:

(Complete this for each differential diagnosis).

Differential Diagnosis Etiology

(Provide the etiology for each of the selected Differential Diagnosis)

Diagnosis #1

Diagnosis #2

Diagnosis #3

Differential Diagnosis Diagnostic Screening Tools

(Provide the screening tools that would be utilized to support the differential diagnosis – if applicable; include examination specifics, laboratory testing, etc.)

Diagnosis #1

Diagnosis #2

Diagnosis #3

Case Analysis

(This section should include a discussion of the likely diagnosis and how the diagnosis is supported by the presented patient)

Treatment Plan

(The treatment plan should include pharmacologic treatment, non-pharmacologic treatment, patient/family education, referrals, follow-up, etc.)

References

(References should be in APA 7^th edition format; must provide scholarly support for all provided information)

Case Analysis Evaluation-48-Year-Old Woman