Ms. A, a moderately obese 32-year-old white woman, initially presented to our office in January 1997 for a refill of her estrogen replacement medication, which she had been taking since her hysterectomy for endometriosis after the birth of her fourth child in 1995. She complained of increasing problems with depressed mood, for which she had been treated by her previous physician with fluoxetine, 20 mg/day, for the past year. Although her current level of depressive symptomatology fell short of major depression, a careful history uncovered multiple past episodes that met those criteria. Ms. A related feeling “depressed and moody” since her teenage years. Paroxetine and other antidepressants administered for previous depressive exacerbations usually caused increased lethargy and little improvement in mood. While fluoxetine initially helped decrease her tearfulness and increase her energy and goal-directed behavior, the improvement had lasted only a few weeks. Her mood aberrations were not related merely to estrogen replacement or adherence problems. Ms. A denied current use of alcohol or illicit drugs and smoked cigarettes about 1 pack per day for 20 years. She also drank 1 or 2 servings of caffeinated beverages per day. A physical examination and routine laboratory work were unrevealing. Her TSH level was normal. She was advised to exercise, reduce her fast-food intake, consider psychotherapy, and increase her fluoxetine dose to 40 mg/day.
When seen next, Ms. A complained of continued hypersomnia and daytime lethargy, increased appetite, frequent crying, headaches, and memory problems. Increasing her fluoxetine dose from 20 mg to 40 mg seemed to help for a while, but then gradually stopped working—the same pattern of response noted on initiation of fluoxetine treatment. We asked her to describe the timing and quality of her initial improvement on the increased dose. After only 2 to 3 days on 40 mg of fluoxetine, she went from lying in bed much of the day to playing kickball in the backyard with her children. Her hypersomnia reversed abruptly to her needing only 3 to 4 hours of sleep per night. Ms. A described feelings of elation and of having her mind filled with ideas and activities, racing from one thought to another. She became markedly more talkative and social. Those around her noticed her behavior as distinctly different than usual. This sudden and dramatic response lasted about 1 week, ended suddenly, and was followed by a steady decline in energy and motivation over the next several weeks. When asked if these episodes had ever occurred in the past, Ms. A described experiencing similar brief periods of expanded mood that occurred every 2 to 3 weeks, typically lasting from 2 to 3 days, but occasionally as long as 5 days. She recognized these periods as being time limited and would try to make the best of them by shopping and doing housework, often late into the night.
Notable Family History
She described her mother as an emotionally unpredictable individual who controlled much of Ms. A’s life by being both her employer and her baby-sitter. Her father was an often depressed individual “who probably should have been on medicine.” Both Ms. A and her mother have a pattern of divorce and remarriage to the same individual—her mother has been married 4 times to 2 different men, while Ms. A has been married 3 times to 2 different men.
Progress of Treatment
Psychotherapy was encouraged to help her deal with parenting concerns, financial pressures, and ongoing relationship problems with her mother and ex-husbands. Two weeks later, she reported a decrease in lethargy and sadness and less pronounced mood swings. Early improvement was also evidenced by her initiation of psychotherapy and attempts to establish more structure at home and boundaries in her interactions with family members. However, she related to us a pattern of growing conflict with her mother regarding autonomy issues.
After numerous missed appointments, Ms. A returned 8 months later complaining of a sinus infection. She explained that shortly after her last visit her mother had convinced her to stop taking both the lithium and the fluoxetine. Ms. A stated that she was no longer interested in ongoing treatment for depression and was unwilling to discuss her decision. All subsequent efforts to reestablish a therapeutic relationship with her failed.
Please submit a written assignment addressing the following items:
• Based on the case information alone what psychiatric disorder(s) seem most likely? Provide support for your proposed diagnoses.
• What type of additional information would you be most interested in to confirm your diagnosis?
• Provide a diagnostic rationale citing case history & DSM 5 criteria that Ms. A might qualify for and possible diagnostic rule-outs.
• To what extent do you think Ms. A may be a danger to herself?
• What other information would be useful in determining her risk?
• Consider potential cultural variables that impact the understanding of this case.
Please submit your assignment by Sunday 11:59pm CST. Your assignment will be graded using the Written Assignment Rubric found in the course. 3-4 page double spaced/APA format/Including references