Description and Analysis of a Case of Severe Depressive Disorder - Essay Example

?Major Depressive Disorder: Case Study Number Isabella Morales Diagnosis According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), diagnoses can be divided into 5 axes. In axis I, Isabella exhibits insomnia, lack of appetite, lack of interest in friends and activities, feelings of hopelessness, marijuana and alcohol abuse. In axis IV, Isabella has a history of sexual abuse by an adult tenant. In axis V (Global Assessment of Functioning Scale), Isabella can be classified in the range 41-50. This is due to impairment of school functioning, interpersonal relationships, thinking and mood. She does not qualify in the 51-60 range because she shows several impairments in the listed areas. In addition, she does not qualify to be placed in the 31-40 range since she still maintains a good relationship with her brother and in class she is still able to make a score, though in the range of Cs and Ds. There are certain specific characteristics for major depression. According to the DSM-IV-TR, there are 9 specific symptoms to be considered. At least five of the following symptoms have been there 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. These are stated as follows: 1. Depressed mood most of the day, nearly every day, as indicated either by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide (DSM-IV-TR, 2000). In further consideration of these symptoms exhibited by our subject, it is clear that these symptoms caused a clinically significant impairment and distress on her social and academic life. In further analyzing the symptoms according to the DSM-IV-TR, the symptoms are not direct physiological effects of a substance like drug abuse or a medication, and neither are they related to a general medical condition. These symptoms are not accounted for by bereavement, have persisted for more than two months and are characterized by a marked impairment, strong preoccupation with feelings of worthlessness, suicidal ideation and psychomotor retardation. For these reasons, we qualify Isabella to be suffering from major depressive disorder. When considering differential disorders, it would have been very likely to think that Isabella had symptoms of adjustment disorder with depressed mood. In this case, a psychological response occurs to a specific identifiable event or stressor that causes significant behavioral or emotional symptoms. These then cause decreased performance or temporary changes in a person’s interactions or performance. An event that warrants this view is Isabella’s constant sexual abuse by the tenant who threatened to kill her mother if these incidents of abuse were reported. However, according to the DMV-IV-TR, the symptoms should occur within at least 3 months of the stressful event and should not last longer than 6 months after resolution of these circumstances. But in this case, it had been longer than 3 months since Isabella had been sexually abused (Mdguidelines, 2010). Dysthymic disorder was ruled out because these symptoms had persisted for less than two years. Etiology Major depressive disorder is attributed to several causes that can be classified into: bio/medical, psychosocial and environmental. Bio/medical causes Depressive syndromes often occur in the context of medical and neurological disorders. Many antidepressants escalate the synaptic levels of serotonin which is a monoamine neurotransmitter. They may also increase the levels of two other neurotransmitters: dopamine and norepinephrine. This observation led to the formulation of the monoamine hypothesis of depression that postulates that insufficiency of certain neurotransmitters is the cause of the certain features of depression (Iqbal et al., 1989). A longitudinal study that supports the monoamine hypothesis was carried out that revealed a moderating effect of the serotonin transporter (5-HTT) gene on stressful events of life to predict depression. According to Caspi et al. (2003), “a functional polymorphism in the promoter region of the serotonin transporter (5-HT T) gene was realized to regulate the influence of stressful life events on depression.” People with one or two copies of the short allele of the 5-HTT promoter polymorphism showed more symptoms of depression, diagnosable depression, and suicide tendencies in regarding stressful life events than people that are homozygous for the long allele. Serotonin helps to control other neurotransmitter systems, thus decreased serotonin levels allow these systems to act in an unusual and erratic manner. Aspects of depression may be a result of this deregulation (Mandell & Knapp, 1979). Altered neuroplasticity has been shown to play a significant role in major depressive disorder. In a study by Jurysta et al. (2010), “Sleep characteristics, patterns and cardiac sympatho-vagal indexes of 10 depressive patients were compared to 10 control men across the first three non-rapid eye movement (NREM)-REM cycles.” A study of interaction between normalized high frequency (HF) and delta power bands was done using coherence analysis. It was found that patients had increased sleep latency, stage 1 and wake durations. Disorders in cardiovascular controls and an altered neuroplasticity indicate that major depressive disorder is related to an altered link between cardiac vagal influence and delta sleep (Jurysta et al., 2010). The hypothalamic-pituitary-adrenal axis (HPA): This is a link of endocrine structures usually activated in the body’s reaction to stressors of different caliber. Major alterations of the HPA system have been proved in depressed patients. Evidence proves involvement of a dysfunctional glucocorticoid receptor (GR) system in these alterations (Barden, 2004) Heredity factors are known to predispose to depressive disorders. In community-residing elderly twins, heredity accounted for 18% of the variation in depressive symptoms. Elderly people are less likely to have depressed relatives than younger patients. Diagnosis of depression because of a general medical condition is given when anhedonia, or depressed mood, occurs in patients that are already diagnosed with an illness that is linked with depression. Nearly 25% of individuals with a myocardial infarction or ones undergoing cardiac catheterization have major depressive disorder, and a similar number have minor depression. This shows that the higher the total medical burden, the higher the risk of depression. In addition, others postulate that stress, major depression and medical illness are reciprocally linked (Alexopoulus, 2005). Psychosocial causes Several psychological factors have been suggested to cause depression including personality attributes, neurotism, cognitive distortions and emotional control. In recent studies, it was found that older patients with personality disorders were four times more likely to experience maintenance or reemergence of depressive disorders in comparison to those without (Alexopoulus, 2005). The effects of stressful life events has been found to be modified by cognitive/personality types in their association with origins of depression in later life late-onset depression, adjusting for medical illness and reduced physical functioning (Alexopoulus, 2005). Older adults with a low level of neurotism are less likely to develop depressive disorder as opposed to those with high neurotism (Blazer & Hybels, 2005). Cognitive distortions have been shown to cause late life depressive disorders and symptoms. Depressed people may overreact to life events or misinterpret these events and exaggerate their antagonistic outcomes. Higher levels of emotional control and mastery have been shown to be directly associated with fewer symptoms of depression in older adults, and to buffer the adverse impact of disability (Blazer & Hybels, 2005; Alexopoulus, 2005). Social A strong relationship exists between stressful life events (like serious personal illness, bereavement or life-threatening illness of someone else) and social difficulties (like housing, health difficulties of a close person, and difficulties in marital and family relationships) with the beginning of major depression in late life. It has been found in studies that bereavement is associated with symptoms of depression in older adults. For instance, in a study of 1810 older adults dwelling in communities, the beginning of clinically significant depressive symptoms in a 3-year follow-up has been predicted by the death of a partner or other relatives. Chronic stress or strain has been associated with depressive symptoms in individuals. The rate of depressive symptoms in caregivers of people suffering from dementia is 43-47%. Socio-economic disadvantage has been shown to be associated with the prevalence and progression of depressive symptoms in a sample of community dwellers (Alexopoulus, 2005). Environmental Causes In a study to investigate the relationship between depressive symptoms of older adults over time and the characteristics of the neighborhood in which they lived, it was found that in multivariable models that adjusted for individual-level covariates that included income, an assortment of neighborhood characteristics predicted worsening of the symptoms of depression. An analysis of factors suggested that these characteristics operated in 3 groups: neighborhood socioeconomic influences, stability of residence, and racial/ethnic composition, with positive neighborhood socioeconomic influences significantly protecting against worsening symptoms. Life stressors, personality trait neuroticism, African American race, and daily contact with social networks were also related to worsening symptoms (Beard et al., 2009). Treatment There are three ways of treating major depressive disorder, namely physical, psychological and self help therapy. Physical treatment involves medication, Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS). Psychological treatment uses Mindfulness Therapy, Cognitive Behavior Therapy (CBT), Interpersonal Therapy (IPT), Psychotherapy, Counseling and Narrative Therapy. Self help and other therapy involves music, relaxation, massage therapy, alcohol and drug avoidance, yoga, good nutrition, bright light therapy, acupuncture, exercise and flower remedies (aromatherapy). Sleep is another treatment as depression is associated with poor sleep patterns. Total or partial sleep deprivation sessions can be prescribed (Wigney et al., 2007; APA, 2000). Interpersonal psychotherapy focuses on the social and interpersonal triggers that may result in depression. Here, the therapy takes a structured track with a set number of weekly routine (mostly 6-12) as in the case of CBT. However, the emphasis is on relationships with others. Sigmund Freud’s psychoanalysis that stresses the resolution of unconscious mental conflicts is used by practitioners to treat clients with major depression (Wigney et al., 2007). Medication is the combination of different antidepressants such as Selective Serotonin reuptake inhibitors (SSRIs). This includes sertraline (Zoloft, Lustral) and are the primary medications considered due to their relatively mild side effects and wide effect on the symptoms of depression and anxiety, as well as reduced risk in overdose, contrasted to the Tricyclics (TCAs) alternatives. Others are Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs), Antipsychotics, mood stabilizers, augmenting agents and Irreversible Monoamine Oxidase Inhibitors (MAOIs). Fluoxetine is the only antidepressant recommended for people under the age of 18 (Wigney et al., 2007). Electroconvulsive therapy (ECT) is a treatment where seizures are induced electrically for therapeutic effect in anaesthetized patients. It has a quicker effect than the other therapies and is often the “last resort” for severe major depression. Cognitive Behavioral Therapy for insomnia can also help to alleviate insomnia without additional medication (Wigney et al., 2007). Before any treatment is commenced, a thorough assessment is required. The type of depression has to be identified basing on the particular symptoms described by the patient – not their severity. There will be variations in the degree of severity of the symptoms within each type of depression and there is a different treatment regime (algorithm) for each type of depression. The types of depression that are more biological in their origins require physical treatments. Sometimes depression resolves of its own accord – but if not treated may last for several months (Wigney et al., 2007). References Alexopoulos, G. S. (2005). Depression in the elderly. The Lancet, 365(9475), 1961- 70. Retrieved from http://search.proquest.com/docview/199011386?accountid=13108 American Psychiatric Association (April 2000). Practice guideline for the treatment of patients with major depressive disorder. American Journal of Psychiatry, 157 (Supp 4), 1–45. PMID 10767867. Barden N. (2004). Implication of the hypothalamic-pituitaryadrenal axis in the physiopathology of depression. J Psychiatry Neurosci 29, 185–193. Beard, John et al. (2009). Neighborhood characteristics and change in depressive symptoms among older residents of New York City. American Journal of Public Health, 7,1308-14. Blazer, D., & Hybels, C. (2005). Origins of depression in later life. Psychological Medicine, 35, 1241–1252. Caspi, A., et al. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 30 (5631), 386-89. Retrieved from Bibcode 2003Sci...301..386C. doi:10.1126/science.1083968. PMID 12869766 Jurysta, F., Kempenaers, C., Lancini, J., Lanquart, J., van de Borne, P., & Linkowski, P. (2010). Altered interaction between cardiac vagal influence and delta sleep EEG suggests an altered neuroplasticity in patients suffering from major depressive disorder. Acta Psychiatrica Scandinavica, 121(3), 236-239.  Retrieved March 30, 2012, from Research Library. (Document ID: 1960209331). Mandell A.J., & Knapp, S. (1979). Asymmetry and mood, emergent properties of serotonin regulation: A proposed mechanism of action of lithium. Archives of General Psychiatry 36(8), 909–16. doi:10.1001/archpsyc.1979.01780080083019. PMID 454111 MDGuidelines: Adjustment Disorder with Depressed Mood. (2010). http://www.mdguidelines.com/adjustment-disorder-with-depressed-mood National Institute of Mental Health: Depression. Retrieved 29th Mar, 2012 from http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml Wigney, T., et al. (2007). Journeys with the Black Dog, inspirational stories of bringing depression to ‘heel’, excerpts from the BDI writing competition. Read More