CASE PRESENTATION

-Samraj, Catherine
-Thakur , Pratibha
-Viswanathan , Preethi
 Melancholy journey- Depression thru’ the
ages.
• Once upon a time in….

Greece (Hippocrates )

Rome ( Cicero )

1621 - Robert Burton published Anatomy of Melancholy.

While Sylvia Plath and Ernest Hemingway
received extensive medical treatment for
depression but tragically committed suicide,
other famously depressed people—including
Abraham Lincoln, William James, Georgia
O’Keeffe, Sigmund Freud, William Tecumseh
Sherman, Franz Kafka, and the Buddha—have
taken different paths.

source : http://brucelevine.net/how-7-historic-figures-overcame-depression
“I can never read all the books I want; I can never be all the people I want and live all
the lives I want. I can never train myself in all the skills I want. And why do I want? I
want to live and feel all the shades, tones and variations of mental and physical
experience possible in life. And I am horribly limited.”
― Sylvia Plath
The Unabridged Journals of Sylvia Plath
 FACTS!!!
Source : http://www.healthline.com/health/depression/statistics-infographic
Source : http://www.healthline.com/health/depression/statistics-infographic
Source : http://www.healthline.com/health/depression/statistics-infographic
MAJOR DEPRESSIVE DISORDER
 General Data
• A.B.
• 44/F/Single
• Misamis oriental
• Roman Catholic
• Date of Admission : 02/01/14
• Date of Interview: 03/04/14
• Source of Information: Mother
• Level of reliability : 80 %
 Chief Complaint

Chief Complaint
Hostile Behavior

Patient’s words
“Wala ko kaila sa inyo, hadlok ko sa inyo”

Companion’s words
“Paadmit namo siya kay manakit na”
 Premorbid state

The patient grew up in a nuclear family. She is

the eldest among three children . Her parents are
teachers by profession.The patient was described
to be good and kind ,obedient, extrovert, God
fearing and has only a few close friends.
She lives with her mother , brother and niece in a
two bedroom house with a small store attached at
the front.
 History of Present Illness
• 2006 : Patient’s father met with an accident and
died at the spot. This incidence took place in front
of their house. Unfortunately, she was present at
the site.
• She underwent trauma of her father’s death and
was crying bitterly.
• After the burial , her mother noticed that she
started staying alone, stopped going with her
friends and always crying with difficulty of sleeping
at night.
• Associated with decreased ability of performing
daily chores , as she was always reminded of her
daily activities.
• In 2007: Patient noticed a mass in her left breast .
Sought consult and was diagnosed to be a “breast
cyst” as claimed.
• She was noted to be worried of the cyst being
cancerous . Although the labs revealed that the mass
was benign.
• Associated with decrease in appetite , difficulty of
sleeping and irritability.
• Condition persisted. No consultation sought.
• In 2008 :
• Occupational problem: She was noted to be complaining about
her unemployment.
• Patient completed Bachelors in Education , however failed to pass
the licensure despite giving the exam five times.
• Started helping in household chores. But she has to be reminded
of her tasks.
• Condition persisted . No consultation sought.
• 2009 : Patient started skipping household chores and was noted
staying alone in room associated with smiling and talking alone
with blank stares , irritability and difficulty of sleeping and had
physical fight with her siblings.
• Hence mother sought consult at Cagayan Hospital. Prescribed
unrecalled medication with good compliance.
• Temporary relief noted.
• 2012: Stopped taking medication due to financial problem.
• Condition persisted . Hence medication was resumed but poor
compliance.
• 2013 : Her sister visited them with her family . They invited
patient to accompany them for vacation but she refused.
Mother claimed that she was insecure of her sister’s success
and attention.
• 1 Month PTA : Patient was noted to be roaming around in
house talking to her self, mumbling and smiling alone
associated with restlessness and irritability.
• Refused to take medication and being hostile.
• 2days PTA : Family decided to bring her to faith healer .
• Day of admission : Patient was given herbal medication by
faith healer.
• And went for lunch with her family where she tries to choke
her mother and pulled her hair.
• With the assistance of police patient was brought to this
institute. Hence this admission.
 Past History
• Psychiatric History :

2009 : Consulted as OPD at Cagayan Hospital with unrecalled

mediaction.
The mother also mentioned that the patient was more
withdrawn, than she usually was, with decreased interaction with
his family and friends.
• Has a history of having auditory hallucinations as claimed by
watchers because she sometimes is found talking to herself.
• However patient fails to collaborate with the story.
 Non- Psychiatric Illnesses

• Benign Breast mass

• Non – hypertensive
• Non- diabetic
• No history of thyroid problems.
• No known food or drug allergy.
• No History of previous hospitalizations or undergoing
any surgical procedures due to any trauma.
• No history of any seizure disorder.
 Family History
(+) Psychiatric illness : Brother ; Diagnosed with
behavioral disorder and substance abuse . Admitted
at local hospital .
(+) Hypertension & Breast cyst : Mother
No history of seizure disorder.
No history of thyroid problems.
 Infancy
• Patient was born to a G1P1 mother via Forceps Delivery with
3 days of labor which was assisted by an OB Gyne at a LH.
• No claimed of hypertension, diabetes, urinary tract infection
and anemia during the course of the pregnancy.
• The baby was born with no other complications.
• She was breastfed for 3 months only and then mixed feeding
started.
• She was taken care of by her mother as a child but as the
mother was a teacher she couldn’t be with her during the day.
• Patients mother claimed that patient received a complete
immunization during childhood.
• The patient grew up in a nuclear family with her
parents.
• Her father was the authoritative figure. He was
always very demanding in every aspect.

• She belonged to a family with a good income.

• Her father was the authoritative figure in the family.
• The patient claims that she was closer to her
mother .
 GROWTH AND DEVELOPMENT

 Gross and fine motor skills are at par with

age of the patient.
• Essentially normal
• Was able to sit w/o support by 7 mos.
• She began walking by he age of 1.
• Achieved toilet training at the age of 4.
• Loves playing with friends.
 Childhood
• The patient was observed to be playful
especially with her friends.
• She managed to be self- motivated and did
her best in school work however she was
never as good as her sister.
• The patient was obedient to her parents and
well-behaved as a child.
 Adolescence
• She was known to be an average student .
• No history of causing trouble in the school or college
environment as claimed by the mother. Since there
were never any reports of bad behavior from her
teachers.
• She never received any honors during her school years,
but she managed to be promoted to the next level.
• She liked shopping and hanging out with friends.
• She usually listens to music and watches movies during
her spare time.
 Adulthood
Social :

• The patient has college degree. Shifted college in 2nd year due
to an argument with her professor. However patient denies
such claims.
• The patient is a non-smoker.
• She never tried using any prohibited drugs.
• She consumes alcohol (beer) around once a month or less.
• The patient usually spends the time with her friends
previously, but now she is usually alone and withdrawn.
• She often accompanies her mother to church on sundays.
Vocational :
• Patient is currently unemployed . In the past, she did work as a
substitute teacher for two months . However , because she did not
pass the board exam she was unable to continue her job. She does
help out at the store that they own. She is financially dependent on
her mother.

Sexual History :
• Patient has never experienced intimate relationships before as
claimed.

• Had on crush on a boy during her college years but she said she was
too shy to approach him.
 Mental Status Examination
Appearance and behavior
• Patient was awake, conscious, cooperative,
attentive and maintained eye-to-eye contact. She
was comfortable sitting on a chair with an erect
posture
• Patient wearing brown t-shirt and white shorts with
slippers , fairly groomed ,nails trimmed and clean,
uncombed hair , seems agitated and restless during
the interview.
• She was wearing clothes appropriate to her age
and sex.
 Mental Status Examination
Speech and Motor activity
• Speech was deliberate, coherent, relevant to
topic with no signs of stuttering, suspicion,
hesitancy and pressure.

No unusual mannerisms.
 Mood and affect
• Patient has depressed mood. She says that
ever since her father died she has been very
worried about her mother and who would
take care of them.
• Her affect was congruent with her mood.
• Patient is cooperative obeys instructions at
the time of examination.
 Speech Pattern
• Patient has deliberate speech character;
organization of talk is relevant but has poor
accessibility.
 Thought content :
• Mother claimed of suicidal Ideations.
• The patient has homicidal ideations and tries to hurt
her siblings at home
• At times she ruminates and regrets the things that
she had done, like when she hit her siblings.

Hallucinations : The mother claims that the patient

would sometimes be found talking to herself even
when no one was round. But the patient says that is
usually because she is stressed.
 Neurovegetative Functions:
• Patient complains of early insomnia.
• The mother noted that she has had an
decrease in appetite .
• However, no changes noted in the weight of
the patient.
 General Sensorium
• Patient is oriented to time, person and place.
• She was able to interpret and answer the
questions posed to her but it took time
before she can finalize her answers.
• Fair attention span.
• Memory : unimpaired .
• Judgment : Unimpaired.
• Abstract Thought : Concrete.
 Mental Status Examination

• Level of insight 2
Slight awareness of being sick and needing help
but denying it at the same time.
Patient expresses that she often feels very
sad and empty and stressed but further says
that she doesn’t need to be placed in this
institution.
 Review of Systems
• General: (-)recent weight loss (-)Anorexia

• Endocrine: (-) cold or heat intolerance

• Eyes: (-) difficulties in vision (-) Discharges

• Ears: (-) hearing difficulties (-) dizziness (-) infections

• Nose: (-) epistaxis (-) anosmia

• Mouth: (-)mouth sores (-)bleeding gum.

• GI: (-)change in bowel habits (-)Diarrhea (-)constipation (-) nausea (-) vomiting.
Pulmonary: (-)hemoptysis (-) wheezing
• Cardiac: (-)Orthopnea (-) syncope

• Vascular: (-)varicosities or phlebitis.

• Genitourinary: (-) polyurea (-) dysuria

• Neurological: (-) seizures (-) history of head trauma

• Musculoskeletal: (-) Joint stiffness (-) pain or cramps.

• Psychiatry: (-) history of hallucination (-) illusion (-) depression.

 PHYSICAL EXAMINATION
• General survey
Awake, Alert, Coherent, Oriented, Afebrile, Not in Respiratory distress.

Vital Signs

• Blood pressure - 120/90mm Hg

• Pulse Rate - 78bpm
• Respiratory Rate - 19cpm
• Temperature - 36.1C
• Weight - 69 kgs
• Height : 5ft.
• BMI : 29.71
• HEENT: Warm to touch, good skin turgor(-)clubbing or cyanosis(-) skin rash (-) pallor
 
• Head: Normo-cephalic, Atraumatic normal hair distribution with normal texture, (-)
lesions.

• Eyes:Anicteric sclera, pink palpebral conjunctiva, pupils, equal, round and reactive to light
and accommodation
 
• Ears: Symmetrical ear Pinnae (-) discharge (-) deformity
 
• Nose: Pink nasal mucosa, Septum midline(-) discharge (-) tenderness
•  Mouth& Throat: Pink buccal mucosa,Tongue and uvula were midline(+) Poor dentition,
(-) bleeding gums, fissures, ulcers (-)exudates.
 
• Neck: Trachea Midline, (-) thyroid enlargement (-) neck masses (-) palpable lymph nodes
• BREAST :
• Both sides symmetrical noted to be pendulous.
• No nipple discharge and retraction noted .
• On palpating left breast immovable mass noted of
2x2 cm at the upper outer quadrant.
• There has been no change in size noted since the
time of admission.
• THORAX AND LUNGS:
• Inspection - Symmetric lung expansion
• Palpation - (-) Tenderness or Pain, (-) palpable masses .
• Percussion – Equal tactile fremitus on both sides 
• Auscultation –Clear breadth sounds (-) Wheezes, (-) crackles.

• CARDIOVASCULAR SYSTEM:
• Inspection - Adynamic precordium
• Palpation- (-) Heaves or thrills  
• Auscultation- Distinct Heart sounds, (-) murmurs,PMI heard at 5th
ICS, 6cm from Midsternal line
• ABDOMEN:
• Inspection – Flat , Soft (-) Scars (-) mass (-) Lesion (-)
rashes
• Auscultation- Normo-active bowel sounds (15 sounds/min)
• Percussion – Tympanic on percussion.
• Palpation – Liver, spleen not palpable, Soft non (-) tenderness
elicited, (-) Palpable mass.

• EXTREMITIES
• No edema, swelling, tenderness, cyanosis, clubbing. CRT<2sec.
• Full pulse, good reflex and range of motion.
 CRANIAL NERVES
• I—no anosmia
• II—visual fields full by confrontation; visual acuity intact.
• II and III— direct and consensual papillary reactions to light were intact .
• III, IV, and VI— Extraocular movement intact.
• V—light touch sensation to face was intact; also able to masticate.
• VII—was able to move facial muscles by closing the eyes, puffing the cheeks and
smiling.
• VIII—auditory acuity was intact.
• IX and X—gag reflex intact; able to swallow without difficulty.
• XI—no shoulder lag.
• XII—tongue was in the midline and was able to move from side to side and from
floor to palate.
 Gait and motor :
• Patient was able to walk without support.
 Sensory :
• same sensory perception on all sides
• ( pain, touch, vibration )
Salient Features
(+) Mass noted in
left breast
MOOD CHART
DIFFERENTIAL DIAGNOSIS
Differential diagnosis for MDD
Adjustment disorder with depressed mood
Alcohol use disorders
Anxiety disorders
Generalized anxiety disorder
Mixed anxiety-depressive disorder
Panic disorder
Posttraumatic stress disorder
Obsessive–compulsive disorder
Eating disorders
Anorexia nervosa
Bulimia nervosa
Mood disorders
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Dysthymic disorder
Major depressive disorder
Minor depressive disorder
Mood disorder due to a general medical
condition
Recurrent brief psychotic disorder
Substance-induced mood disorder
Schizophrenia
Schizophreniform disorder
schizoaffective Disorder
 SCHIZOAFFECTIVE DISORDER
It is a mental disorder characterized by disordered thought process ( psychosis) and abnormal
emotions ( mood disorder).

Schizoaffective disorder has features of both schizophrenia and affective disorders (now
called mood disorders).

In current diagnostic systems, patients can receive the diagnosis of schizoaffective

disorder if they fit into one of the following six categories:

(1) patients with schizophrenia who have mood symptoms;

(2) patients with mood disorder who have symptoms of schizophrenia;
(3) patients with both mood disorder and schizophrenia;
(4) patients with a third psychosis unrelated to schizophrenia and mood disorder;
(5) patients whose disorder is on a continuum between schizophrenia and mood
disorder; and
(6) patients with some combination of the above
 DSM V criteria - SCHIZOAFFECTIVE

• An uninterrupted period of illness during which, at some time, there is either

a major depressive episode, a manic episode, or a mixed episode concurrent
with symptoms that meet Criterion A for schizophrenia.
Note: The major depressive episode must include Criterion A1: depressed
mood.
• During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent mood
symptoms.
• Symptoms that meet criteria for a mood episode are present for a substantial
portion of the total duration of the active and residual periods of the illness.
• The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
• Specify type:
Bipolar type: if the disturbance includes a manic or a mixed episode (or a
manic or a mixed episode and major depressive episodes)
Depressive type: if the disturbance only includes major depressive
episodes
 RULE IN RULE OUT
• (+) Major Depressive epi (A)
• During the same period of illness, there
have been delusions or hallucinations for at • Cannot be completely ruled out
least 2 weeks in the absence of prominent
mood symptoms. (B)

• The disturbance is not due to the direct

physiological effects of a substance (e.g., a
drug of abuse, a medication)

•Patients with schizoaffective disorder are

likely to exhibit antisocial behavior and to
have a markedly flat or inappropriate affect.

•(+) Violent behavior

• (+) family hx- Brother

 Schizophrenia
• Schizophrenia is a clinical syndrome of variable, but profoundly disruptive,
psychopathology that involves cognition, emotion, perception, and other
aspects of behavior.

• The expression of these manifestations varies across patients and over time,
but the effect of the illness is always severe and is usually long lasting.
 DSM V criteria - SCHIZOPHRENIA
A. Two (or more) of the following, each present for a significant portion of time during a1 -month period
(or less if successfully treated). At least one of these must be (1 ), (2), or (3):
• 1. Delusions.
• 2. Hallucinations.
• 3. Disorganized speech (e.g., frequent derailment or incoherence).
• 4. Grossly disorganized or catatonic behavior.
• 5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioningin one or
more major areas, such as work, interpersonal relations, or self-care, ismarkedly below the level
achieved prior to the onset (or when the onset is in childhoodor adolescence, there is failure to
achieve expected level of interpersonal, academic,or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month periodmust include
at least 1 month of symptoms (or less if successfully treated) that meet CriterionA (i.e., active-
phase symptoms) and may include periods of prodromal or residual symptoms. During these
prodromal or residual periods, the signs of the disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in CriterionA present in an attenuated form (e.g.,
odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic featureshave been ruled
out because either 1 ) no major depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms,
they have been present for a minority of the total duration of the active and residual periods of the
illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., adrug of abuse,
a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in
addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if
successfully treated).
 RULE IN RULE OUT

(+) Major Depressive Episode

• Can be ruled out using MSE ( mood and
affect)
• (+) Hallucinations
• (+) Disorganized behavior • Otherwise cannot be ruled Out.

• No hx of substance abuse • Onset of age- 25 yrs

• (+) Social withdrawal

• Interpersonal Conflicts

• (+) Family History

•(+) suicidal ideation

 BIPOLAR DISORDER
• Bipolar disorder, or manic-depressive illness (MDI), is one of the
most common, severe, and persistent mental illnesses.
• It is a mental illness characterized by episodes of
* elevated or agitated mood  MANIA
* Episodes of depression  DEPRESSION
 DSM-V-TR Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Unspecified

• Criteria, except for duration, are currently (or most recently) met for a manic,
a hypomanic, a mixed, or a major depressive episode.
• There has previously been at least one manic episode or mixed episode.
• The mood symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• The mood symptoms in Criteria A and B are not better accounted for by
schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder not
otherwise specified.
• The mood symptoms in Criteria A and B are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication, or other treatment)
or a general medical condition (e.g., hyperthyroidism).
• Specify if:
Longitudinal course specifiers (with and without interepisode recovery)
With seasonal pattern (applies only to the pattern of major depressive
episodes)
With rapid cycling
 DSM-V- Diagnostic Criteria for Bipolar II Disorder

• Presence (or history) of one or more major depressive episodes.

• Presence (or history) of at least one hypomanic episode.
• There has never been a manic episode or a mixed episode.
• The mood symptoms in Criteria A and B are not better accounted for by schizoaffective
disorder and are not superimposed on schizophrenia, schizophreniform disorder,
delusional disorder, or psychotic disorder not otherwise specified.
• The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
• Specify current or most recent episode:

Hypomanic: if currently (or most recently) in a hypomanic episode

Depressed: if currently (or most recently) in a major depressive episode

 RULE IN RULE OUT
(+) Hostile Behavior
• Bipolar 1 may be more common in young
• (+) Family History- Brother adults

• (-) involvement in goal directed activities

• (+) Major Depressive episode
• (-) inflated self esteem
• (+) Impairment in functioning
No episode of mania or hypomania.
• No hx of substance abuse

• (+) Social withdrawal

• Sleep Disturbances

• (+) Decrease in appetite

• (+) Interpersonal Conflicts- Sister

•(+) suicidal ideation

 Schizoid Personality Disorder
• Schizoid personality disorder is diagnosed in patients who
display a pattern of social withdrawal. Their discomfort with
human interaction, their introversion, and their bland,
constricted affect are noteworthy. Persons with schizoid
personality disorder are often seen by others as eccentric,
isolated, or lonely.
 DSM V criteria – SCHIZOID PD
• A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more)
of the following:
– neither desires nor enjoys close relationships, including being part of a
family
– almost always chooses solitary activities
– has little, if any, interest in having sexual experiences with another
person
– takes pleasure in few, if any, activities
– lacks close friends or confidants other than first-degree relatives
– appears indifferent to the praise or criticism of others
– shows emotional coldness, detachment, or flattened affectivity
• Does not occur exclusively during the course of schizophrenia, a mood
disorder with psychotic features, another psychotic disorder, or a pervasive
developmental disorder and is not due to the direct physiological effects of a
general medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add premorbid,
e.g., schizoid personality disorder (premorbid).
 RULE IN RULE OUT

•(+) Behavoral changes

• (+) previous history of halluciantion
• (+) Major Depressive episode
• Can be ruled out using MSE ( mood and
affect)
• (+) history of halluciantion and delusion

• No hx of substance abuse • (-) Close relationships – Friends

• (+) Social withdrawal

• (+) Emotional Detachment

 BRIEF PSYCHOTIC DISORDER
• Brief psychotic disorder is defined as a psychotic condition
that involves the sudden onset of psychotic symptoms,
which lasts 1 day or more but less than 1 month. Remission
is full, and the individual returns to the premorbid level of
functioning. Brief psychotic disorder is an acute and
transient psychotic syndrome
 DSM V criteria - BPD
Presence of one (or more) of the following symptoms:
– delusions
– hallucinations
– disorganized speech (e.g., frequent derailment or incoherence)
– grossly disorganized or catatonic behavior
• Note: Do not include a symptom if it is a culturally sanctioned response pattern.
• Duration of an episode of the disturbance is at least 1 day but less than 1
month, with eventual full return to premorbid level of functioning.
• The disturbance is not better accounted for by a mood disorder with psychotic
features, schizoaffective disorder, or schizophrenia and is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a
general medical condition.
• Specify if
• With marked stressor(s) (brief reactive psychosis): if symptoms occur
shortly after and apparently in response to events that, singly or together, would
be markedly stressful to almost anyone in similar circumstances in the person's
culture
• Without marked stressor(s): if psychotic symptoms do not occur shortly after,
or are not apparently in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the person's
culture
• With postpartum onset: if onset within 4 weeks postpartum
 RULE IN RULE OUT
• (+) hallucinations • abrupt onset (48 hrs-2 weeks)

• Duration of an episode of the • Younger age (15-30)

disturbance is at least 1 day but less than
1 month, with eventual full return to • (-) impaired memory
premorbid level of functioning.
•(+) Major depressive episode
• Not due to the direct physiological
effects of a substance (e.g., a drug of •(+) Medical Condition- Breast Mass
abuse, a medication)
• Onset- Younger adults
• (+) previous episode of mood disorder

• (+) interpersonal conflicts

•(+) family hx- Brother

 Adjustment Disorder with Depressed mood
• The adjustment disorders are a diagnostic category characterized by an
emotional response to a stressful event.
• Typically, the stressor involves financial issues, a medical illness, or a
relationship problem.
• Women are diagnosed with the disorder twice as often as men, and single
women are generally overly represented as most at risk.
• Stressors may be single, such as a divorce or the loss of a job, or multiple, such
as the death of a person important to a patient, which coincides with the
patient's own physical illness and loss of a job.
• symptoms do not necessarily begin immediately.
 DSM V criteria –Adjustment Disorder
• The development of emotional or behavioral symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the
stressor(s).
• These symptoms or behaviors are clinically significant as evidenced by either
of the following:
-- depressed mood
– marked distress that is in excess of what would be expected from
exposure to the stressor
– significant impairment in social or occupational (academic) functioning
• The stress-related disturbance does not meet the criteria for another specific
Axis I disorder and is not merely an exacerbation of a preexisting Axis I or
Axis II disorder.
• The symptoms do not represent bereavement.
• Once the stressor (or its consequences) has terminated, the symptoms do
not persist for more than an additional 6 months.
 RULE IN RULE OUT
(+) Death in family- Father
• Cannot be completely ruled out
• (+) Major Depressive episode
•(+) Medical Condition

• (+) Impairment in functioning

• No hx of substance abuse

• (+) Social withdrawal

• Sleep Disturbances

• (+) Decrease in appetite

• (+) Interpersonal Conflicts- Sister

•(+) Violent behavior

 Dysthymia
• The person who suffers from this
disorder must not have gone for
more than 2 months without
experiencing two or more of the
following symptoms:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty
making decisions
• Feelings of hopelessness
MAJOR DEPRESSIVE DISORDER

296.34 Severe With Psychotic

Features
• Major Depressive Disorder (MDD) is a medical
illness that affects how you feel, think and
behave causing persistent feelings of sadness
and loss of interest in previously enjoyed
activities. Depression can lead to a variety of
emotional and physical problems. It is a
chronic illness that usually requires long-term
treatment.
 DSM-5
• Criteria A.
• Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning: at least one of the symptoms is either
• (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by

either subjec tive report (e.g., feels sad, empty, hopeless) or
observation made by others (e.g., appears tearful).
2. 2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation).
• 3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly
every day.
• 4. Insomnia or hypersomnia nearly every day.
• 5. Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down).
• 6. Fatigue or loss of energy nearly every day.
• 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delu sional) nearly every day (not merely self-reproach or guilt about being sick).
• 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(ei ther by subjective account or as observed by others).
• 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation with out a specific plan, or a suicide attempt or a specific plan for
committing suicide
• B. The symptoms cause clinically significant distress or impairment in social, occupa tional,
or other important areas of functioning.
• C. The episode is not attributable to the physiological effects of a substance or to another
medical condition. Note: Criteria A-C represent a major depressive episode. Note:
Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat ural
disaster, a serious medical illness or disability) may include the feelings of intense sad ness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understand
able or considered appropriate to the loss, the presence of a major depressive episode in
addition to the normal response to a significant loss should also be carefully considered.
This decision inevitably requires the exercise of clinical judgment based on the individual’s
history and the cultural norms for the expression of distress in the context of loss.
• D. The occurrence of the major depressive episode is not better explained by schizoaf
fective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other
specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There
has never been a manic episode or a hypomanie episode.
 Grief Vs. MDD
• In grief the predominant affect is feelings of emptiness and loss, while in
MDD it is persistent depressed mood and the inability to anticipate
happiness or pleasure.
• The dysphoria in grief is likely to decrease in intensity over days to weeks
and occurs in waves, the so-called pangs of grief. These waves tend to be
associated with thoughts or reminders of the deceased. The depressed
mood of MDD is more persistent and not tied to specific thoughts or
preoccupations.
• The pain of grief may be accompanied by positive emotions and humor that
are uncharacteristic of the pervasive unhappiness and misery characteristic
of MDD.
• The thought content associated with grief generally features a
preoccupation with thoughts and memories of the deceased, rather than
the self-critical or pessimistic ruminations seen in MDE.
• In grief, self-esteem is gener ally preserved, whereas in MDD
feelings of worthlessness and self-loathing are common.
• If self derogatory ideation is present in grief, it typically involves
perceived failings vis-à-vis the deceased (e.g., not visiting
frequently enough, not telling the deceased how much he or she
was loved).
• If a bereaved individual thinks about death and dying, such
thoughts are generally focused on the deceased and possibly
about "joining" the deceased, whereas in MDE such thoughts
are focused on ending one's own life because of feeling
worthless, undeserving of life, or unable to cope with the pain of
depression
 Why Psychotic?
• Psychotic symptoms tend to develop after an
individual has already had several episodes of
depression without psychosis.
• A. Delusions ( inadequacy , guilt )
• B. Hallucinations ( auditory )
 Predisposing Factors
• the condition or element that is used to make
susceptible of disease or disorder

• Gender
• Age
 Precipitating Factors
• An element that causes or contributes to the
occurrence of the disorder :

• Poor relationship with other siblings

• Poor interpersonal relationship
 Perpetuating Factors
• Factors or conditions that maintain the
disabling symptoms in the individual

Fathers Death
Sisters success
Financial Problems
Her own failure
 Psychodynamics
A Freudian slip when you say one thing BUT mean your mother.
-- Author unknown
 Healthy Psyche
OK Guys – I’m in charge.
Anything you want has to go
through me.

OK.
OK.

Ego

Id Superego
 Neurotic Psyche
Listen up! I’m in charge, and you are not
here to enjoy yourselves. Get ready for a
double-size portion of anxiety with a side
order of guilt!

No fun.
>whimper<

Superego

Id Ego
 “Anger turned inward “

• A Neurotic father who was inconsistent (both overindulgent

and demanding), lacking in warmth, inconsiderate, angry, or
driven by his own selfish needs created an unpredictable,
hostile world for her as a child.
• As a result, she felt alone, confused, helpless and ultimately,
angry.
• However, as a child she also knew that the powerful parents
are her only means of survival. So, out of fear, love, and guilt,
she represses anger toward the parents and turns it inwards
so that it becomes an anger directed towards herself.
• A "despised" self-concept starts to form.
• At the same time, she also strives to present a perfect,
idealized (and therefore acceptable) facade to the
parents as a means of compensating for perceived
weaknesses that makes her "unacceptable".
• Caught between the belief that she is unacceptable,
and the imperative to act perfectly to obtain parental
love, she becomes "neurotic" or prone to experiencing
exaggerated anxiety and/or depression feelings.
• As an adult when there is any psychological stressor
the patient reverts back to a the oral phase.
• Anaclitic depression involves a person who feels dependent upon relationships
with others and who essentially grieves over the threatened or actual loss of
those relationships. Anaclitic depression is caused by the disruption of a
caregiving relationship with a primary object and is characterized by feelings of
helplessness and weakness. A person with anaclitic depression experiences
intense fears of abandonment and desperately struggles to maintain direct
physical contact with the need-gratifying object.
• Introjective depression occurs when a person feels that they have failed to
meet their own standards or the standards of important others and that
therefore they are failures. Introjective depression arises from a harsh,
unrelenting, highly critical superego that creates feelings of worthlessness,
guilt and a sense of having failure. A person with introjective depression
experiences intense fears of losing approval, recognition, and love from a
desired object.
• Interpersonal theory a depressed person's negative
interpersonal behaviors cause other people to reject them.
In an escalating cycle, depressed people, who desperately
want reassurance from others, start to make an increasing
number of requests for reassurance, and the other people
(to whom those requests are made) start to negatively
evaluate, avoid, and reject the depressed people.
• Depressed people's symptoms then start to worsen as a
result of other people's rejection and avoidance of them.
• IPT has been designed to help depressed people break out
of this negative spiral.
 Behavioral Theories
• Peter Lewinson argued that depression is caused by a
combination of stressors in a person's environment and a
lack of personal skills.
• depressed people typically have a heightened state of self-
awareness about their lack of coping skills that often leads
them to self-criticize and withdraw from other people.
• depressed people become positively reinforced for acting
depressed when family members and social networks take
pity on them and provide them with special support
because they are "sick".
 The biology of Depression
• The neurotransmitter serotonin is involved in regulating many
important physiological functions, including sleep, aggression,
eating, sexual behavior, and mood. Serotonin is produced by
serotonergic neurons.

• The neurotransmitter dopamine is also linked to depression.

Dopamine plays an important role in regulating our drive to seek
out rewards, as well as our ability to obtain a sense of pleasure.

• Norepinephrine helps our bodies to recognize and respond to

stressful situations.
• Glutamate
 NEUROPLASTICITY
we are constantly throughout our lives generating new neurons and
neuronal pathways within certain areas of the brain involved in
memory and emotion.

In addition, research suggests that antidepressant medications and

electroconvulsive therapy (ECT) seem to increase the growth of
new neurons in these key brain areas.

In contrast, chronic stress seems to decrease cell growth in these

areas. Based on this evidence, we can conclude that a decreased
number of neurons in the emotional centers of the brain can lead
to slower reactivity and depressive symptoms.
 GENETICS
• when one identical twin is depressed, the
other twin will also have depression 76% of
the time.
• Major Depressive Disorder is 1.5 to 3 times
more common among first-degree biological
relatives of affected individuals.
 IMAGING
• The ventromedial cortex is much smaller in individuals
affected by depression.
• The ventromedial cortex allows people to switch from one
mood to another mood, as well as to experience pleasure
and positive reinforcement.
• Reduction in the number of glial cells in this portion of their
brains.
• The function of certain glial cells is to supply neurons with
energy.
• less activity in the prefrontal cortex of the brain, and more
activity in the limbic system.
 PSYCHOIMMUNONEUROLOGY
• Psychologically and socially stressful events
such as the death of a loved one, severe abuse
or trauma, marital separation, social failures,
social isolation, or long-term caregiving can
also weaken our immune systems.
COGNITIVE THEROY ( BECK & ELLIS)
• 1) I am defective or inadequate
• 2) All of my experiences result in defeats or
failures
• 3) The future is hopeless.
• faulty information processing.
• BANDURA - Depressed people tend to hold
themselves solely responsible for bad things in
their lives and are full of self-recrimination and
self-blame. In contrast, successes tend to get
viewed as having been caused by external
factors outside of the depressed person's
control.
• JULIA ROTTERS – loci of control
• Seligman's - Learned Helplessness
 ETHNOMEDICAL ASPECTS

individualistic vs. collectivistic orientation

 Stressful experiences often take away a person's sense of control (promoting a sense

of helplessness or hopelessness) and can cause great emotional upheaval and pain.

• A variety of social or relational interactions or events can trigger depression.

• Some common examples include:
• Death of a loved one
• Divorce or marital problems such as infidelity
• Loss of a job, financial problems, or poverty leading to homelessness
• A chaotic, unsafe, and dangerous home life such as violence in the family
• Abusive relationships that undermine self-confidence
• Social failures such as friendships
• Moving to another city
• Experiences that cause learned helplessness in which one believes that they
have no control in life
• Serious trauma such as abuse, neglect, rape, etc.
• Social isolation
 LIFESTYLE FACTORS
• Abusing drugs and alcohol
• Overwork
• Poor diet, including excess caffeine or sugar
• Lack of exercise
• Poor sleep
• Lack of leisure time as well as fun and
recreational activities
 PERSONALITY DISORDER
• A. A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of
the following:
• (1) neither desires nor enjoys close relationships, including being part of a family
(2) almost always chooses solitary activities
(3) has little, if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others
(7) shows emotional coldness, detachment, or flattened affectivity
• B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder and is not due to the direct physiological effects of a
general medical condition.
 Breast Mass
• A breast cyst is a fluid-filled sac within the breast. One breast can have
one or more breast cysts. They're often described as round or oval lumps
with distinct edges. In texture, a breast cyst usually feels like a soft grape
or a water-filled balloon, but sometimes a breast cyst feels firm.
 FINAL MULTI-AXIAL DIAGNOSIS

• AXIS I : Schizoaffective Disorder

• AXIS II : Defense mechanism : Denial
• AXIS III : Breast mass, left
• AXIS IV : Poor support system.
Unemployed.
No access to psychiatric health care.
Financial instability.
AXIS V : Serious symptoms - Presence of suicidal ideations ,
impairment in social situations and unemployed.
MANAGEMENT
• Fluoxetine
antidepressant
selective serotonin reuptake inhibitor
The American Psychiatric Association includes antidepressant therapy among it first-line options
for the treatment of depression, particularly when there is "a history of prior positive response to
antidepressant medications, the presence of moderate to severe symptoms, significant sleep or
appetite disturbances, agitation, patient preference, and anticipation of the need for
maintenance therapy"

• Olanzapine
• Thienobenzodiazepine
• atypical antipsychotic
• Family therapy
• Group therapy
• Behavioral Therapy
• Cognitive behavioral therapy
 PROGNOSIS
• However in our patient due to :
• poor accessibility to psychiatric health care
facility.
• Financial problems.
• Lack of proper support system.
• There is poor prognosis.
 BIBLIOGRAPHY
• DSM -5 criteria
• http://psychcentral.com/blog/
• http://bjp.rcpsych.org/
• Kaplan’s book of Psychiatry
• http://ajp.psychiatryonline.org/journal.aspx?j
ournalid=13