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DEPRESSIVEDISORDER By-X Y Z
Table of contents 01. Case Study 1: Major Depressive Disorder 02. Case Study 2: Persistent Depressive Disorder
01. MAJOR DEPRESSIVEDISORDER A CASE STUDY
SYMPTOMS • Suicidal ideation • Self injury • Auditory hallucination • Profound social withdrawal • Feelings of sadness • Anhedonia • Significant weight loss • Chest pain • Dizziness • Psychomotor agitation • Poor personal hygiene Name- Mr. XGender- MaleAge- 16 yearsOccupation- Student, unemployed
Mr. X was admitted for a psychiatric evaluation after a suicide attempt involving self-inflicted cuts. The emotional distress associated with his father’s death compounded by family dysfunction contributed significantly to the onset of his depressive and psychotic symptoms. Mr. X experienced auditory hallucinations, including his name being called out by an unseen voice. He has a history of self-harming since 6th grade. ROOT CAUSE- unresolved grief surrounding the suicide of his father 4 years ago. Personal History
Past Medical History Mr. X had been under the care of a neurologist for recurrent seizures. Physical health was stable. Family History Mr. X was adopted and had no prenatal or developmental concerns. Death of his father by suicide. Family dysfunction.
ETIOLOGY • The development of Mr. X’s MDD with psychotic features appears to be the result of a complex interplay of genetic predisposition, environmental stressors, and maladaptive coping mechanisms. • The emotional devastation caused by his father’s death likely triggered the onset of Mr. X’s depressive symptoms. • In addition, his mother’s emotional unavailability due to her own struggles exacerbated his sense of abandonment and contributed to the worsening of his depression. • Mr. X’s history of self-harming behavior, which began in the sixth grade, further highlights the role of maladaptive coping strategies in the development of severe mood disorders and psychotic symptoms.
Assessment The Beck Depression Inventory (BDI) indicated that Mr. X was experiencing severe depression. The Columbia-Suicide Severity Rating Scale (C-SSRS) assessed his risk for suicide, categorizing him as a high-risk patient due to the intensity of his suicidal ideation and his prior suicide attempt. The Positive and Negative Syndrome Scale (PANSS) revealed moderate psychotic features, including auditory hallucinations and social withdrawal. The Mini International Neuropsychiatric Interview (MINI) was used to confirm the diagnosis of MDD with psychotic features and to rule out other psychiatric conditions that could mimic his symptoms.
ADDITIONAL ASSESSMENTS Comprehensive family assessment revealed significant dysfunction, particularly regarding the trauma associated with his father's suicide. His nutritional assessment indicated severe weight loss, likely due to his refusal to eat.
Treatment • Pharmacotherapy • Fluoxetine (20 mg/day): — SSRI —Helped stabilize mood swings and mitigate suicidal thoughts • Risperidone (2 mg/day): — Antipsychotic drug —Proved effective in reducing these symptoms and helping the patient reconnect with reality. • Lorazepam (1 mg/day): —Administered to manage acute anxiety and insomnia
Treatment • Cognitive Behavioral Therapy (CBT): —CBT targeted his pervasive feelings of worthlessness and hopelessness. —Through structured sessions, he learned to identify cognitive distortions,such as “all-or-nothing” thinking, and to replace these with more balanced viewpoints. —Behavioral activation was a central component, encouraging Mr. X to participate in enjoyable activities to combat his anhedonia. 2. Psychotherapy
Treatment • Dialectical Behavioral Therapy (DBT): —DBT helped Mr. X with to manage emotional dysregulation and impulsivity. —The mindfulness aspect enhanced his ability to observe his emotional states without judgment. —Emotional regulation skills provided effective strategies for managing his feelings. —Distress tolerance techniques helped him cope with overwhelming emotions, thereby decreasing the likelihood of self-harm. 2. Psychotherapy
Treatment 3. Family Therapy: —Family therapy addressed the dysfunctional dynamics between Mr. X and his mother. —Therapy sessions aimed to improve family communication and address deep-seated feelings of guilt and abandonment. 4. Nutritional Support: —Involving a dietitian ensured the stabilization of Mr. X's physical health and provided adequate energy intake to facilitate psychological healing.
Progress • The pharmacotherapy regimen contributed to the stabilization of mood symptoms, reduction of psychotic features, and alleviation of anxiety. • The integration of CBT and DBT provided Mr. X with a diverse range of skills, enhancing his coping abilities across various areas of his life. Mr. X gained a deeper understanding of how his thoughts, emotions, and behaviors were interconnected. • The interpersonal skills learned during therapy contributed to healthier family dynamics and social interactions. • By addressing both the psychiatric and psychosocial components of Mr. X's condition, the integrated treatment plan proved effective and enduring recovery from Major Depressive Disorder with psychotic features.
02. PERSISTENT DEPRESSIVE DISORDER/ DYSTHYMIA A CASE STUDY
CHIEF COMPLAINTS • Considerable weight loss • Refusal to eat but not lack of appetite • Intense fear of being fat and gaining weight • Self perception of herself as being fat and wanting to lose more weight • Social retreat • Sadness • Lack of motivation to do other things than getting thinner • Loss of interest or pleasure in any activity • Insomnia nearly every day • Diminished ability to concentrate in learning Name- StellaGender- FemaleAge- 14 yearsOccupation- Student
Personal History • First symptoms appeared two years before in a context of school bullying (some of the children said the was ugly and stupid). • Also, educational and familial pressure to have very high grades in school and to learn continuously. • Made herself suffer by cutting herself with a blade (she had many cicatricial marks) – this activity was performed for at least 8 months and it was not noticed by her family or anybody else. ROOT CAUSES- - Bullying at school - Academic and Parental validation - Negative Cognitive Triad - Ruminative Thinking
Starve herself to death Self punishment Social retreat Worthlessness and disturbing thoughts Eating problems Loss of interest in pleasurable activities Insomnia Dressed by covering herself Others could read her mind Compulsions Behavioural Patterns
FFPI - The Five Factor Personality InventoryLow scores in all aspects Young Schema Questionnaire YSQ - S3Its results revealed the presence of maladaptive schemas (high scores) OPT (explanatory style)with a score of 28 specific to an pessimistic person Dysfunctional Attitude Scale DAS-A with a score of 180 – reflecting a very high level of dysfunctional attitudes ASSESSMENTS 01 02 03 04
Unconditional Self-Acceptance Questionnaire (USAQ) revealing a low level of self-acceptance The Hamilton depression scale result is a score of 28 suggesting a very severe depression. Attitudes and Beliefs Scale ABS II with a score of 163- that means irrational modes of thinking such as demandingness, awfulizing, ASSESSMENTS 05 06 07 Raven Standard Progressive Matrices score was 57 equivalents of an IQ in the 115-130 range, her intellect is Grade I: “Intellectually superior,” 08
Diagnosis Obsessive-Compulsive Disorder-Having recurrent and persistent thoughts, urges and images, intrusive and unwanted, causing anxiety and distress.The girl attempts to suppress them with other thoughts (counting, repeating words) and actions such as repetitive behaviours (washing, checking, stirring) meant to reduce the anxiety. Persistent Depressive Disorder (Dysthymia)-Early onset (with the following symptoms: insomnia, fatigue, low self-esteem, feelings of hopelessness, poor concentration that lasted for more than a year). Anorexia Nervosa (criterion A and B of restriction of food intake leading to significantly low body weight and intense fear of gaining weight). It is to be considered a disharmonic personality structure (with great impairments in personality functioning having difficulties in identity, self direction, empathy and intimacy areas, identity, negative affectivity anxiety, depression, guilt, shame, and self-harm behavioural manifestation, avoidance of socio-emotional experiences, withdrawal from interpersonal interactions.
TREATMENT The parents psychoeducation aimed to inform them about positive change techniques, medication management and compliance and crisis management, how to be aware of family dynamics, conflicts, communication pattern, problem solving, and attentive to social and clinical needs for their daughter. They were also recommended family support groups, which they refuse. Intervention tools that were used are-1. Psychoeducation2. Cognitive behavioural therapy3. Psychiatric medication.
Progress • In the first three sessions - clinical psychological evaluation with the techniques and instruments mentioned previously. • In the next three weeks - we start to develop psychoeducation programme for her and her family (there were 5 separate sessions with the girl, 3 sessions with the parents and 2 family therapy sessions) • After four weeks of therapy, the girl had her first visit to psychiatristShe was hospitalized for two weeks and got medication for the problems diagnosed. • The next three weeks were dedicated to diminishing self-destructive behaviours (hitting, cutting, starving) and limiting the number of compulsions. • Because in this time thanked to medication and therapy some of the anorexia symptoms, compulsions and depression symptoms diminished.
Progress (contd.) • The parents decided to stop the medication and rely on therapy and also pressing the girl to assume healing through her own will. • In few days her mental health status became worse and she was hospitalised again for two weeks. After this experience of relapse, they decided to continue medication and therapy. • For one year, the girl attended twice a week therapy session in the first month, and weekly after that, and periodic visits at the psychiatrist for patient and medication evaluation. • Even now, after 5 years she still needs psychotherapeutic support (once every two weeks), and she might need for the following few years considering the fragility of her emotions, and the complex nature of psychopathology.
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