WU Intake Case of 33 year old Woman Question
Using the transcript can you assist in doing a mental status exam The template is attached
Transcript: – I’m 33 years old now
and probably the first time that I saw anyone
in the mental health field I was 22
and I think my first diagnosis was PTSD.
I was raised in a really volatile, abusive home.
My father died of alcoholism when I was 21
and so it was just really, it was a really traumatic
thing to go through.
I had a lot of anxiety,
I actually gave myself a bleeding ulcer.
So I saw someone,
I was just having a lot of panic attacks
and really severe anxiety
and just couldn’t be around anything
that reminded me of my father.
So that was the first time
that I had gone to see anybody.
I saw a psychiatric nurse practitioner
at the university I attended.
But I think, I mean I had been,
I remember having feelings of depression
when I was as young as five or six.
– Depression is different for different people.
When you were struggling with it,
tell us how that felt.
– Well, I’ve also kind of had a lot of different
severity, I guess, of depression.
At it’s…
I’d just experience just kind of
a lot of sadness, crying spells,
and just not being able to concentrate.
And then something, you know,
that’s probably on the lighter end.
And on the more severe end,
it was, just, you know,
the best way I could describe it
was just feeling like I was just a prisoner of my own mind.
And just feeling this constant state of fear and despair
and just, you know, just feeling like
things were just not going to get better
and just, probably at it’s worst,
it’s just that complete lack of hope
and just, not really wanting to continue on anymore.
And just not really caring if I lived or died.
– Did it get to the point that
you thought of taking your life?
– Um, a few times.
I’ve never really made a plan,
but it was something that I thought about a lot
for about a year
but I never, I guess I was,
too afraid to actually try something
because I was worried that
I basically wouldn’t succeed.
– Did you, as you’re looking back,
sometimes we see people that look back and say,
“I’ve been depressed for as far back as I can remember.”
And it sounds like that’s how you see yourself?
– Mmm-hmm. I remember as, being as young as
four, five, and six years old
and feeling like nobody loved me.
– Okay.
And it sounds like nothing was enjoyable in your life.
You were withdrawing from friends, from hobbies?
– Yeah, it was, well I was,
the situation that I was living in was really bad.
I was really isolated.
But definitely withdrawing from friends,
that was another thing.
I just didn’t want to be around anybody
and nothing was enjoyable to me at all.
Really the only thing I could do,
the only thing I could kind of
get up the gumption to do every day
was take care of my dog.
– And I take it from what you say,
in that year and a half it was there nearly every day
that you were feeling that depressed,
that hopeless about things.
– Yeah, I cried every single day
for like 500 days, I think.
And I just didn’t really,
I don’t, I didn’t have it in me to keep going.
– Sometimes when people get very depressed
they may hallucinate or hear voices or see things
that other people don’t note.
Did you ever experience that?
– Mmm-mmm.
– Or sometimes people may feel paranoid,
people are out to get them, or harm them,
when they’re depressed.
– No. I mean I definitely had
feelings like that the universe was out to get me
and I kind of had some big, black target on my back,
but I never felt like any individual was out to get me,
but I definitely felt like the world was.
– Okay. Now sometimes also when people have real low moods
they may also have abnormally high moods
where they feel euphoric, elated,
top of the world type of feelings.
Have you ever experienced that?
– No. That sounds nice, though. (laughs)
– Okay. Now, we all get irritable at times.
Have you ever had periods where irritability
would be there for days or weeks on end?
– Yeah, when I was in my most severe depression,
that was, I think how it was manifesting,
was I just felt so irritable
and so internally just kind of amped up
about everything.
– Okay. Now sometimes women notice
changes in their depression
around the time of their menstrual period.
Have you noticed any changes in your mood
related to your menstrual cycle?
– Yeah, it was definitely
way, I mean I, it was definitely
just way, way more severe, like,
a week before my period.
And it was every month I noticed that
when I was feeling my absolute worst,
it was always around that same time.
Where I just felt like I literally
just could not handle anything.
And just particularly, you know,
just having a lot of suicidal thoughts as well.
– How about your appetite.
Was there any specific change in that?
– Definitely.
I had to force feed myself.
I just had no appetite at all.
Just nothing sounded good to me.
It was really difficult and I never felt hungry.
– You’re bringing up some points
that depression and anxiety often go hand in hand.
You mentioned, for example,
some panic attacks.
Can you tell me what would happen
during a panic attack?
Yeah, I’ve never really,
I’d never really experienced panic attacks
until I was in this kind of really deep, deep depression.
And, I mean, I could not catch my breath.
I could not control the thoughts in my mind at all.
I would just start freaking out about,
you know, it was always just this
what’s going to happen to me,
what’s going to happen to me,
you’re always going to be miserable,
like it’s always going to be like this.
Where my heart would be racing,
I couldn’t take a breath in,
and it would just kind of,
I mean there was a time in my life where
I was, I mean it was,
like one, throughout the day I would have these attacks,
like multiple panic attacks throughout the day.
– [Catherine} So something you think that would be helpful
that I didn’t ask you,
that you’d like to highlight.
– I, you know, I was,
I’ve been misdiagnosed with things.
I was diagnosed as bipolar,
and I do not think nor does any other doctor
or therapist I’ve seen
ever actually think that I was bipolar.
– Maybe we can focus a little bit about,
you’ve had some treatment,
over the years, it sounds like,
why don’t you tell me a little bit about
what depression and anxiety is like
in your life now.
– I’m doing a lot, a lot better.
I”m still not where I want to be.
But, now, just thinking about like,
I mean, I’m in a much more stable place now
where I’m, I’m living in a place that I like.
I’m in my own apartment,
and I’m in the city,
It’s something I still struggle with,
but, I mean,
looking back on how depressed I was
over the past couple of years,
it’s like I didn’t even recognize myself.
Like it just wasn’t me.
– You talked about having your own place.
Professionally, or school-wise,
are things where you like them to be?
– No, and that’s kind of still something
I’m struggling, I mean that’s,
I’m in the process of applying to grad school right now,
and that’s something that,
it’s difficult for me
because I still kind of,
I struggle with a lack of confidence in myself
and it’s really hard for me to,
it’s just kind of hard for me to take that leap forward
because I think that I’m just afraid that
if it doesn’t work out,
I’m afraid like if I apply to grad school
and I don’t get in,
that I’ll just kind of fall apart.
So there’s,
I’m not at,
you know, like I said,
I’m not where I want to be yet.
– There are things in your life
that you enjoy, that give you pleasure at this point?
– Mmm-hmm.
Since I’ve moved to Chicago in May
and I’ve enjoyed living here
and I have friends here,
and so I, I’m working part time somewhere that I like.
So I definitely feel more
like there’s,
that there’s I guess more things in life
to enjoy, whereas before,
nothing, nothing helped.
– Okay. How about those panic feelings.
Is that still there as prominent or as prevalent?
– No, not at all.
I mean I, I don’t usually get panic attacks.
I mean I still have a lot of kind of anxiety
and worry, but not any like actual panic attacks.
– Okay. What would you like people to understand
about what depression is like?
I think you’ve put a very good face on it,
but what do you think is a misconception,
or that people don’t understand?
– I mean, something that has been really hard for me,
is that people that don’t really understand depression
seem to think that it’s something
that you can just snap out of.
I heard so many people say,
“Oh, well you just need to go for a walk in the sunshine”,
or “You just need to..” you know,
It’s kind of, it’s really hard, you know,
because it makes you feel even worse
if there’s people around you that don’t understand
what depression is
and that it’s not something that you can
will yourself out of.
– Well it sounds like you’ve really
gone through hell and back.
It sounds like things aren’t where you want them to be,
but it sounds like you see a light at the end of the tunnel
at this point.
– Mmm-hmm.
What’s so different is that I do just
kind of have this renewed sense of hope.
– You know, I thought that this woman
gave such a wonderful picture
of the pain of depression.
As many of our patients,
she describes being depressed
almost for her whole life,
since the age of four to six.
And described, I thought the phrase,
“Prisoner in my mind” was a key one
of how painful depression is.
And really how that has affected her life.
She described those classic symptoms,
somatic symptoms,
she couldn’t eat, nothing sounded good,
she couldn’t sleep,
cognitive symptoms that patients struggle with,
she couldn’t concentrate,
how nothing felt enjoyable,
how she thought of death,
and actually talked about suicide
or thought about suicide for a year.
And I think, it was interesting,
she described about crying,
I don’t remember the exact number of days,
for more than 500 days straight.
So I think she gave such a picture
of how incredibly painful depression is,
and how, particularly if you have it
from that early stage in life,
it sort of colors all of your milestones
and developmental steps.
– What was it like to be with her?
– I think she’s one of those patients that
makes you feel very sad,
but also gives you a lot of hope,
as a clinician, at the same time.
She is clearly someone that still struggles
but has made some steps forward.
I thought she gave a wonderful
description of how people sometimes
don’t understand how depression affects you.
You know, they tell you to go buy something,
go for a walk, put on a happy face,
and despite wanting to do that,
that that pain really keeps you a prisoner
and keeps you from doing anything enjoyable.
– Rich, did you think she was depressed in the interview?
– That was really interesting to me,
because when she was talking about
this terrible depression and feeling like she’s a prisoner
and the only thing in life that she got out of
was walking her dog.
She really didn’t have any effective changes.
But when she was starting to talk about
where she was at now,
and how she still had to struggle,
that’s when she started tearing up.
So even though she’s much better than she used to be,
she still is very, you know,
it sounds like she still struggles
and is really quite anxious
and wanting to do more with her life
and feeling like she really can’t at this point.
– So Cathy, you feel that
she meets the symptomatic criteria for a major depressive
episode or disorder?
– Well, I think she, in my view,
she described two things.
One is this chronic level of depression,
more days than not for decades really.
I think she was 30 and described onset
at a very young age.
And she sort of described that
picture of what we used to call double depression,
where it was sort of a long,
more days than not depression,
but then she’d have these episodes
that were quote severe,
and sort of rob her of any enjoyment in her life
or being able to move forward in her life.
– I cried every single day for like 500 days, I think.
And I just didn’t, I just didn’t really
I didn’t have it in me to keep going.
– But that pattern of that chronic, unrelenting depression
that waxes and wanes,
but never goes away,
I thought she described that quite eloquently.
– Yeah, it’s unusual to see someone where the
depressive disorder has been that persistent
for so long. More typically we’ll see individuals
who have discrete episodes of depression
with periods in between in which they are feeling
relatively okay.
But that picture of the double depression
where you’ve got that chronic, persistent,
low grade depression, and on top of that,
clearly, some more serious episodes
of major depression.
– I think, you know, talking about DSM-5 for a minute,
it’s probably a good segue,
has tried to wrestle with that.
So we now have major depression
which by and large is the similar symptoms
we have from DSM-4.
But dysthymia has now been replaced
with Persistent Depressive Disorder.
And really, I think what the research tried to show
was that there are people who have dysthymia,
but there are also people that have
chronic major depression,
which sometimes can be just about impossible
to sort through.
Persistent Depressive Disorder
has to have two of the five major criteria,
changes in sleep, appetite, energy,
hopelessness, concentration,
whereas major depression needs five or more.
It’s still that sense of these people with chronic.
I think you’re right.
The good news about major depression
is that most people do recover.
But we see people that have this chronic, unrelenting
pattern, and I think she put a good face on that.
– So, if I’m understanding what you’re saying,
it sounds like you’re saying
that she would meet the criteria
for Major Depressive Disorder,
but she might also meet the criteria
for this Persistent Depressive Disorder.
Perhaps you would need more longitudinal information
to make certain that these were always present,
really, since an early age.
– What I would probably say is
she meets criteria for Persistent Depressive Disorder,
and under the new nomenclature,
that she has a history or Major Depressive Disorder.
I didn’t get the sense at that exact time i saw her
she probably met all criteria for major depression.
– But she’s had episodes that would qualify.
– Right.
– Okay.
– Well depression is not all that she had.
She describes some other symptoms.
– Well I think the other thing that this woman
manifests very clearly, and came out strongly,
is the anxiety component.
And that’s a specifier for Major Depressive Disorder,
so this is clearly someone who has had depression
with anxious distress.
And she described that pretty strongly
and it sounds like that has almost always
been a component to her depression.
It’s interesting she started out with describing
the anxiety component to her depression.
She also reports a clear history of panic attacks.
It doesn’t sound like she’s having them now,
but clearly in the past there’s been episodes
in which panic was a prominent feature of her condition.
– One of the things that stood out for me was,
I didn’t really hear her really indicate
that she had a period of remission historically
and that this has been something
that’s been very pervasive for her
and sort of sounded like has become
almost a way of life
and something that she’s really had to wrestle with.
And I heard her use the word “isolated”
a number of times.
And to me it gave me the sense
that she’s really struggled to have a sense of belonging.
– One of the things she talked about
in the quest for graduate school
is this sense of, I’ll probably fail, you know,
why try, what if it doesn’t work out,
how devastating that would be.
And i think we see people not only with
major depression, but chronic depression
that they have such negative feelings about themselves.
This is a woman who’s clearly trying.
But you can see how that depression has affected
not only her view of herself and her self esteem,
but how she views the world around her.
I think also, compounding the little we knew
about her history as she talked about her father
being an alcoholic, which also distorts,
even if she wasn’t depressed,
how she learns to relate,
and then his loss when she was –
– She describes her upbringing as traumatic.
– Right. Very traumatic.
– I was raised in a really volatile, abusive home
and my father died of alcoholism when I was 21,
and so it was just really, it was really traumatic.
I remember being as young as four, five, and six years old
and feeling like nobody loved me.
– So whether that added to the depression,
whether that was another source,
whether she had some vulnerability for it
and this also increased her depression.
But it certainly had to distort
how she learned how to relate to people,
what’s safe in the world, how she fits into the world,
how she protects herself.
– What about bipolar?
She also, she brought that up.
As somebody who is this depressed for this long,
it’s not surprising somebody might bring that up
as a possibility.
– I think one of the ironies that I thought
is that oftentimes people don’t consider bipolar disorder.
And in somebody with refractory depression
that is something we should always consider
so it is interesting that she was erroneously
given that diagnosis, when oftentimes, as clinicians,
we’re not asking all the questions
to rule in or rule out
the various types of bipolar disorder.
And we’re not always putting it back in the deferential
if somebody doesn’t respond to treatment.
So I think with her,
it’s a terrific thing to consider,
particularly when you see somebody who is unresponsive.
– So let’s think about what the future holds
for this young lady.
What’s your prognosis?
– Well, I think it’s clear it’s already been a long
journey for her.
A long struggle.
And the good news is she’s made a lot of progress.
As is clear though,
she still suffers from both depression and anxiety.
But it sounds like what has worked for her
and works for many people with depression
is to learn how to be engaged in the world.
More active, pursue goals,
she’s interested in graduate school.
And to the degree that she can be helped to
sustain that engagement in satisfying activities,
to pursue goals, to connect with other people,
she can continue to do well.
– I think that one of the things on the negative side,
in terms of prognosis,
is that she had onset at such a young age.
We know people before the age of 20 with onset
have a poor prognosis.
The fact that she really has not had
more than two months, from what we can gather,
of remission.
On the other hand,
I think one of the things that would help us
with the prognosis
is to get a sense of what her treatment has been.
Not only from a pharmacological point of view,
but I think even more at this juncture with this woman,
from a psychotherapy point of view.
What I was so struck with is
number one, a very lovely young woman,
underneath, who is struggling with depression.
But also, as we talked about earlier,
just about mentally, she’s learned so many negative things
about herself.
She would be, in some respects,
a poster child for cognitive behavioral therapy.
So I’d be interested to see
what types of treatment has she had,
and has that treatment been aggressive
to lead to her remission.
She’s certainly improved.
– Let’s imagine that we’re in a position
to design a treatment program for her.
What would be the ideal treatment for her?
What pieces would we want to see?
– I agree that she would be a good candidate
for some cognitive behavioral therapy.
She definitely alluded to a core belief
of some sort of inadequacy,
and she’s pretty fearful of taking risks.
One thought that I had too,
was maybe, potentially some group work.
Maybe CBT group work
to sort of get at that relational aspect as well
and that sense of belonging
that many other people experience something that she does.
– What about medication?
Obviously this woman has most likely
been treated with medication.
– So the key to me would be,
what has she been on,
what dose, how long.
And has she had augmenting strategies,
you know, has she had electroconvulsive therapy,
other types of therapy.
Because our goal always has to be remission.
The good news is it sounds like the anxiety,
certainly the panic attacks, have greatly improved.
– In some ways, the challenge in this patient
is that you might select a treatment for her
and she might get better, but not well,
and then the dilemma for the clinician is,
am I satisfied with this? Or to your point,
do we press on with something more invasive,
even considering electroconvulsive therapy,
to try to make her well.
And I don’t know that there’s a right answer for that,
but that’s a question that usually gets debated
in these kinds of cases.
– Right, and I think, to John’s point,
it’s a question of what the patient wants.
I think as clinicians,
we always have to strive for full remission,
because one of the things we know is that
partial remission will beget more illness down the line.
– Well I think something that has happened,
and will be important going forward,
is that she now better understands what her illness is.
So this is someone, from a young age,
who thought something was wrong with her.
Who was depressed, who was anxious,
who probably blamed herself
and didn’t understand these feelings.
Probably felt alienated,
didn’t know what depression was
and when people talked about it,
didn’t relate to it,
so the fact that she now understands
that she has a depressive illness,
I think is very important for her.
– The criteria for Major Depressive Disorder in DSM-5
are largely the same?
– Largely the same.
Major depression, one of the key features
must either be depressed mood
or loss of interest in things
and often in a beginning clinician,
they may say, “Mrs Jones, are you depressed?”
they say no, and they say okay, I can move on to
the next rule out.
But they must ask both of those things.
So I think the only subtle change that I see
in the definition of depression
is that it includes hopelessness now,
just not depressed or sad.
The other big change has been that dysthimia
as a disorder no longer exists
and Persistent Depressive Disorder
now combines what used to be thought of
as dysthimia and chronic major depression.
The last major change on the depressive disorders,
which now have their own chapter,
rather than subsumed under mood disorders,
is that premenstrual dysphoric disorder
has been taken out of the appendix,
keeps going back and forth,
depending on how many DSM’s you’ve seen,
is now back as a disorder.
And I think Richard brought up some of the specifiers
across all mood disorders have changed.
That you can have anxious distress,
which we commonly see depression-anxiety,
and you can have mixed features.
So those patients that are maybe what we used to call
dysphoric mania,
they’re depressed, but otherwise have racing thoughts,
inability to sleep,
you now have that specifier
to try to understand that patient.
– It sounds like this woman is struggling
with a serious mood disorder.
But as we are hopeful,
we can extend that hope to this young woman
and wish for her a better life.
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