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Feeling depressed, lack of concentration, nervousness and no appetite. What treatment should be done?

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Practicing since : 2003
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A hypothetical case.....
XXXXXXX a 29-year-old unmarried woman, comes to the clinic complaining of a depressed mood, sleep problems, lack of concentration, loss of interest and pleasure in things, irritability, nervousness, lack of sex drive, no appetite, and undesired loss of 15 pounds in two months. She looks tired, sad, and gaunt. She moves slowly and occasionally tears up during the interview. She reports feeling this way for about two and a half years, since losing a job in a high-pressure computer start-up company. She had been a "shooting star,” rising fast in the dot-com world.
Prior to her collapse, she had never experienced failure of any kind. The collapse on the job seemed to be precipitated by a sexual affair she initiated with a coworker. As soon as this affair became known, she was criticized by coworkers and threatened by her supervisors with termination unless she ended the affair. Her lover was fired, and in his anger he refused to see her anymore. Thus, she lost her lover and the respect of her coworkers at the same time, and within six weeks was so depressed she could not function. She was then fired.
Since that time, she has taken a number of similar jobs, but has been unable to overcome her doubts that her "luck" would hold. She was afraid that her depression would impair her ability to concentrate and that she would either quit or be fired. She has moved back home with her parents, who are very supportive. Molly's mother brought her to the interview.
During her love affair, XXXXXXX says, she began using cocaine with her boyfriend. After losing her job, she did not give up drugs, but switched to marijuana because it was much cheaper. Although she says that she preferred the rush of cocaine, she could not afford it, and now relishes the calm and numbness that marijuana brings. She smokes at least two marijuana cigarettes per day, often more. She had had one smoke earlier on the day of the interview. Her parents disapprove, though they give her the money for it, since "it helps me relax XXXXXXX XXXXXXX also says that she drinks XXXXXXX two to five" glasses of white wine each evening. "Wine helps me sleep XXXXXXX she reports. XXXXXXX has no medical problems to speak of. Difficult ovulation has always been a problem, but "nothing I can't live with XXXXXXX During ovulation, she tends to become more irritable than normal, and often snaps at people. But after 48 hours, she says, this dissipates. "It's predictable as the trains XXXXXXX she says. Her menstrual periods are uneventful. XXXXXXX has had no accidents or illnesses besides the normal ones of life. No surgeries and no medications complicated her health picture. She has never needed or been to a therapist or psychiatrist prior to this visit. She feels ashamed of coming now.
1.      What would be a hypothetical diagnostic hypotheses regarding Molly?
2.     What other kinds of information would be beneficial you would like to know about Molly?

Posted Sun, 28 Oct 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 1 hour later
Hi and welcome to Healthcare Magic. Thanks for your question...

Molly's hypothetical diagnosis in this scenario would be:

1) Depressive disorder (the differential diagnosis here would be an 'Adjustment disorder with prolonged depressive reaction', but this is not the first possibility since the depressive symptoms in adjustment disorders usually subside within 6 months after the stressor)
2) Alcohol dependence (needs more clarification, e.g. whether she develops withdrawal symptoms on stopping, etc.)
3) Cannabis abuse

Additional information which would be beneficial are:

- Any ideas of hopelessness, helplessness, worthlessness, guilt, suicidal ideas or attempts to self harm (during the current illness as well as in the past)?
- Any psychotic symptoms (like delusions, hallucinations, etc.)?
- Any past history of mania / hypomania (periods of elated / irritable mood, hyperactivity, overconfidence, grandiose / expansive ideas, overtalkativeness, decreased inhibitions, etc.)?
- Molly's pre-morbid personality (anxious traits, coping skills, reaction to stressors, inter-personal relationships, etc.)
- More details on her subsance use pattern, presence of tolerance, withdrawal, etc.
- Any family history of psychiatric problems, especially mood disorders, suicide or substance abuse disorders?
-A detailed mental state examination to assess her thought process, mood, insight, etc. is essential to make a definitive diagnosis.
- Certain clinical rating scales also have to be administered to assess the severity of her depression (like Hamilton's Depression Rating Scale) and rate her overall level of functioning (like Global Assessment of Functioning).

It would be helpful if you let me know why you would like to know this information as I can guide you better and more specifically.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
Follow-up: Feeling depressed, lack of concentration, nervousness and no appetite. What treatment should be done? 9 hours later
I have a course that I'm taking and didn't understand what direction to go. Thank you so much for taking the time to answer the question. This is great.....Thank you so much again. If I need addition assistance, could I use you?
Answered by Dr. Jonas Sundarakumar 15 hours later
Hi again XXXXXXX

Glad that my info was of use to you.

In any clinical case in psychiatry, if you are confused about the diagnosis, try the following tips:

1) First, sieve through the history and pick out the most prominent symptoms (a patient may tell you a lot of information, but your first step is to screen and sort out the important information in a cohrent manner)

2) See if you can piece together the important symptoms into a broad 'psychiatric syndrome' (psychiatric diagnoses are often syndromal. A 'syndrome' is a set of symptoms which are characteristic to a particular disorder. So, try to figure out if the symptoms are "characteristic" of any broad syndrome, e.g. a 'mood syndrome' or 'psychotic syndrome' or an 'anxiety syndrome')

3) If everything fits in to a typical syndrome, then try to sub-classify the syndrome... e.g. if it is a 'psychotic syndrome', then try to figure out if it is an acute psychosis or a schizophrenia or a delusional disorder, etc... if it is 'anxiety syndrome', then try to figure out if it is a GAD or a panic disorder or a atypical symptoms, which are not fitting in, then explore them in detail - are they consequences of the primary syndrome or are they co-morbid disorders. For e.g. a psychotic patient who is severely troubled by constant voices may have some depressive symptoms, but that is not the primary diagnosis - it is rather a consequence of his psychosis.

5) Once you have fixed a tentative working diagnosis, then systematically take a negative history to rule out organicity and any other psychiatric diagnosis. You can have a preconcieved format, so that you don't miss out important negative history.

6) Take a detailed past history to see if the current illness is:
a) an exacerbation of a chronic illness
b) one particular 'episode' of an episodic illness (e.g. bipolar disorder)
c) unrelated to any past illness

7) Take a detailed history about pre-morbid personality. See if it could contribute to or influence the current illness in any way.

8) Similarly, see if personal / psycho-social history, family history, medical history, treatment history, etc. can contribute anything to your diagnosis.

So, the best technique (at least in psychiatry) would be to first form a broad picture of the syndrome you are dealing with and then "build up your case" with all the additional information, rather than just have a checklist of criteria and "search" for a specific a diagnosis.

Remember, in most cases, you should have a reasonable idea of the diagnosis (at least differential diagnosis) with the history itself and mental state examination is usually only confirmatory.

I hope this will help you in your future clinical cases. I woll be happy to help you if you need any assistance in the future. You can catch me at:
Best wishes,
- Dr. Jonas Sundarakumar
Consultant Psychiatrist

(Please leave a review if you are happy with my answer)
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