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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