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Loss of appetite, won't make eye contact and drinking alcohol. Symptoms of major depressive disorder?

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Part 2

XXXXXXX is now 16 years old. His mother accompanies him to the interview and tells you about XXXXXXX evaluation and successful treatment when he was seven. “He was fine after that treatment worked,” XXXXXXX says, “but lately he’s taken staying to himself all the time. He’s always been a little different, too sensitive, you know. He gets tearful now and then. But lately he’s just been nasty to everyone, irritable. And he just can’t sit still. He’s like a cat on a hot tin roof. He can’t remember half of what I tell him. It’s as if he’s forgotten how to think, sometimes. He can’t keep his mind on anything.” She’s also concerned because he only weighs 130 pounds and has lost twenty pounds in the last six weeks without trying. “He eats like a bird,” she says. “He’s lost his appetite.”

XXXXXXX appears agitated. He sulks, won’t make eye contact, sits as far away from his mother as he can, and rolls his eyes when she talks. Again, his history is unremarkable for medical concerns, or physical or substance use or abuse disorders, and there is no history of abuse, neglect, or domestic violence. His only psychological history of note is his treatment at age seven. He expresses irritability with his mother for “tricking” him into coming to see a shrink. His mother thinks he is angry because he isn’t sleeping well at night, and hasn’t been sleeping well for several months. Further questions about that do not reveal any manic behavioral concerns.

When you talk with XXXXXXX alone, you learn that he has only one male friend, “More of a good acquaintance,” he says. “But he’s like me.” The only other people he has spent time with are a couple of girls who are loners, too, and who “accept” him. “We don’t really trust people much. I’m a lot more like them than I am like “the guys.” He rolls his eyes. “You know the ones who think they’re better than everyone.” He studies his fingernails, which you notice have been polished with a clear nail polish. You ask him about his relationships with “the guys” and he snaps angrily at you. “They’re like my older brother’s friends. A bunch of jocks. To them, I’m a worthless piece of garbage.” He laughs. “And maybe I am. Ha! Maybe!? Who am I kidding? I’m not worth the dirt on the bottom of my brother’s running shoes! Just ask my old man. My brother was a college jock! Daddy’s star! The big college soccer player!”

For the last two months XXXXXXX has not wanted to spend time with anyone, and withdraws to his room whenever he can escape the family. He has withdrawn from his already small group of acquaintances as well as family, and lost interest in almost everything, including band and the theater group, both of which he has dropped out of in the last two months. You get the impression that XXXXXXX has started buying half-pint bottles of vodka from an acquaintance in the past month, but he will tell you no more about this once it comes out. You ask if he feels depressed and he snaps at you irritably that he is not. He denies any reason for not wanting to see people or for his loss of interest in almost everything he used to do. “Nothing’s happened to me, I just don’t want to be around people, any people, including you.” He denies feeling suicidal but mentions playing with his father’s revolver the previous week, holding the muzzle to his head and clicking the trigger to imagine what it would feel like if it was loaded. He thinks about death a lot, he says, “But it’s only an existential dream. We’re all going to die. It’s just a matter of when.” At this, he smiles again, as if to himself.

1.     What are your diagnostic hypotheses for XXXXXXX in this scenario?

Here is my diagnosis…

AXIS I:          296.23 Major Depressive Disorder, single, Severe w/o Psychotic Features
          799.9     Alcohol intoxication (Pending)
AXIS II:     None
AXIS III:     None
AXIS IV:     Social, Family, School
AXIS V:     41     

2. Describe what further diagnostic information you need (what further diagnostic evaluation is warranted).

The dichotomy between XXXXXXX heritage and his residential culture must be difficult for him to resolve. It would be interesting to have him repeat the projective assessments that he did when he was younger

3. From a diathesis-stress perspective, what impact do the cultural, ethnic and psychosexual issues have on XXXXXXX and his family in this scenario, and what other issues may play a role?

4. What would be the suggested course of treatment?

Beck's Depression Inventory (BDI)
Brief Psychiatric Rating Scale (BPRS)

Posted Fri, 21 Dec 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 13 hours later

Yes, I would agree with you that XXXXXXX is going through a severe depressive episode (without psychotic features). It is important to understand that in children and adolescents, depression may not present in a typical way with low mood, hopelessness, crying, negative thoughts, pessimistic views about the future, etc. Often it presents with "externalizing" behaviours like anger, hostility, changes in behavioural patterns, social withdrawal, etc., all of which XXXXXXX is having. In addition, there are significant biological disturbances like loss of appetite, loss of weight and disturbed sleep. There are also hints of suicidal ideas from his recent behaviour (though he may be denying it). so, your Axis I diagnosis is correct.

Now, like in the previous part, there are even stronger hints regarding a problem with his sexuality - either his sexual identity or sexual orientation... not being confortable with friends of the same sex and feeling "accepted" by friends of the opposite sex. So, I would also include a ? evidence to make a definitive diagnosis (I had mentioned in my previous answer that one of the core features for diagnosis - "persistent dislike or discomfort with being in the assigned sex and wanting to be a person of the opposite sex" - is still lacking)

Also, a diagnosis of "Alcohol abuse" (305.00) is appropriate for his alcohol problem. A diagnosis of "Alcohol intoxication" has to be made only if the person is currently under the influence of alcohol.

Rest of the Axis diagnosis is fine.

Question 2:
* Further exploration into his sexuality is definitely important and warranted, because the depression could actually be secondary to his problems with sexuality.

* XXXXXXX also definitely needs a risk assessment for suicidality. He seems to have access to his father's revolver and the severe depression may be putting him at high risk for suicide.

* Like you have mentioned, a further exploration into the role of cultural issues and the family dynamics can also add valuable information to the diagnostic evaluation.

* Further exploration would also be useful in the areas of possible problems at school, problems with peers, academic performance and any other psycho-social stressors.

Question 3: From the perspective of a diathesis-stress model, in XXXXXXX case,

Diathesis: The genetic basis of depressive disorders could be conferring on him a 'pre-existing vulnerability'

Stress: Cultural and ethnic differences, leading on to problems in cultural acclamatization, problems in adjusting with peers, etc. could be a stress pushed him to go into depression.

So, the environmental stress when superimposed on a genetically predisposed or vulnerable individual results in the pathogenisis of the depressive disorder.

Question 4:

Treatment approach:
- Rating scales for depression: Beck's is a self-rated depression inventory and in XXXXXXX case, may not be very reliable - because XXXXXXX seems to be guarded and denying many of his symptoms. A clinician-rated scale like Hamilton's Drepression Rating Scale (HDRS), would be more useful.
- Yes, I agree that since he has many non-specific symptoms like anger, aggression, etc., a BPRS would be useful to determine the overall severity of his problems, and for evaluation of treatment response

In the treatment plan, psychotherapy would play a major role since XXXXXXX seems to have multiple psychological issues causing him immense distress and social dysfunction. In addition, he may need anti-depressant medication, since his depressive symptoms are severe and due to the suicidal risk.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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