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Dr. Andrew Rynne

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Have loss of appetite, getting suicidal ideas and feeling depressed. Required treatment?

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Dr. Jonas Sundarakumar

Psychiatrist

Practicing since :2003

Answered : 2190 Questions

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Posted on Thu, 20 Dec 2012 in Mental Health
Question: In this case, we will assume the previous information wasn’t true…….

You ponder the case of XXXXXXX and conclude that you have more questions than answers. You again interview XXXXXXX and her mother. In the course of this second interview, you learn the following:

• Prior to the interview, XXXXXXX has delivered to you some of the vials and flasks under XXXXXXX bed, and requests that you have them tested. You do so, and learn that they are old home canning supplies, with residues of tomatoes, corn relish, and pickled turnips.
• You interview XXXXXXX alone. In questioning her about the episodes of violent behavior in XXXXXXX XXXXXXX seems to be telling a different story. XXXXXXX seems more to have "chipped XXXXXXX not broken, the furniture. XXXXXXX collects antiques, and uses them as furniture. She has asked XXXXXXX to be very careful when sitting on them, but she is not. XXXXXXX notes that she tries very hard to create a warm home, and even though these pieces are valuable, she wants them to be used by the family.
• The incident with the car in the garden may have occurred when XXXXXXX tried to drive, but was unfamiliar with the standard transmission. The car lurched into reverse, went through the garden, and XXXXXXX ran screaming to her room, pummeling herself on the face and chest. XXXXXXX states that she never actually saw the interaction between the housekeeper and XXXXXXX but was told of it by the housekeeper. XXXXXXX says that XXXXXXX is turning out just like her other daughter. This time, she wants to "get on top of it" fast, and she wants you to persuade XXXXXXX to enter an inpatient eating disorder program.
• The mood swings and disengagement from school and friends sound robust. XXXXXXX reports many convincing behavioral examples of these.
• You interview XXXXXXX alone. Initially, she is unresponsive. You eventually ask her why she would keep old canning supplies under her bed. XXXXXXX hardened look softens, and she says: "They belonged to my grandmother; I like to keep her stuff near me, no matter what it is XXXXXXX She begins to talk about her grandmother, how much she misses her since her death last year. She says that she felt her grandmother was the only person in the family who accepted her, other than her new friend XXXXXXX who has been through a lot herself, with her suicide attempts and all.
• XXXXXXX and XXXXXXX have been spending a lot of time together at the cabin, but she does not like to talk about it with her mother, because she thinks her mother would not accept or understand their relationship. Recently, though, XXXXXXX has become very depressed again, and has decided to "take a break" from everyone. XXXXXXX has not seen XXXXXXX for more than a week, and tears up at this point.
• You ask about XXXXXXX eating habits. She says she just is not hungry anymore.
• Finally, you ask XXXXXXX about the marks on her arms. She looks down at the floor and says, "I was kind of trying it on for size. I go to the high bridge over the river at night, climb onto the fence, and look down at the river. The wire on top of the fence cuts into my arms. I wouldn't do anything, though XXXXXXX XXXXXXX states she does this two or three times a week.

1. What would the new diagnostic AXIS hypotheses would be just for this scenario?

Again, like you mentioned before, since the limited information given is insufficient to make a definitive diagnosis. But if I had to put it would be
Axis I:     311 Depression disorder NOS
     V62.82 Bereavement
Axis II: None – nothing to indicate that she has a borderline personality disorder
AXIS III:     None
Axis IV:      Family problems, social problems, problems at school
Axis V:     65

2. What further diagnostic evaluation do you believe is warranted?
3. What other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?

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Answered by Dr. Jonas Sundarakumar 17 hours later
Hello and welcome to Healthcare Magic. Thanks for your query.

You are on the right track. I agree with your Axis I differential diagnoses of a Depressive disorder / Bereavement, with Depressive disorder being my first priority since
- her depressive symptoms seem to be out of proportion to the the expected grief reaction
- biological disturbances like loss of appetite
- suicidal ideas.

I would probably put Axis II as ?Boderline personality "traits", since her mother confirms the mood swings and erratic behaviour and during the interview, there are some hints of emotional instability and self-harming. But, like you said the limited information is insufficient to make a diagnosis of a Borderline personality disorder. Axis III & IV remains unchanged. For Axis V, I would give a score of 30 - 40, since she seems to be suffering from significant socio-occupational dysfunction (disengagement from school and friends).

Further diagnostic evaluation would include:
...a more detailed and targetted history
- to check for a other features of a major depression
- history of past depressive or manic episodes
- presence of any psychotic symptoms
- exploration for substance abuse
- exploring her personality, to check whether she would fulfill the criteria for a borderline personality disorder

...if possible, corroborative history from some one else in a different setting, say a school friend or a more unbiased history from some other relative, say her sister or dad.

...and a detailed mental status examination.

Other psychological measures would include:
- Depression inventories, for example Beck's depression inventory
- Personality inventories
- Brief Psychiatric Rating Scale (BPRS) to rate the level of severity of her symptoms.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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