The paper provides a detailed diagnosis of the disorder manifested by the patient in case study 18. Theoretical orientations and historical perspectives on the diagnosis, risk factors, as well as evidence-based and non-evidence-based treatment strategies for the disorder are presented. A separate annotated bibliography indicating the relevance of different sources in the diagnosis and treatment of depression is also provided.
Diagnosis
The psychiatric diagnosis is depression, which is also referred to as major depressive disorder. Depression is a medical condition that interferes with an individual’s feeling, thinking, and acting. It is diagnosed based on the presence of specific symptoms for a minimum of two weeks. These indications include feeling sad, losing interest in activities that were once pleasurable, fluctuations in body weight due to irregular eating patterns or dieting, changes in sleep patterns, suicidal ideations, and extreme fatigue. Other symptoms include impaired thinking, decision-making or concentration, feelings of worthlessness, and an increase in pointless physical activities.
The American Psychiatric Association’s latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) indicates that a diagnosis of depression should be made if a patient presents with at least 5 of the above symptoms within a two-week period. Furthermore, a depressed mood (feeling of sadness) or a loss of interest in activities that were previously enjoyed must be part of the presenting symptoms. However, it is necessary to rule out the involvement of other medical conditions or the effects of substance use in the presentation of the symptoms.
Julia presented with six symptoms of depression, the first of which was a depressed mood. Julia felt sad that she was considered chubby as a small child. She tried to do everything within her means to lose weight. However, she still felt she was overweight and worked to lose more weight. Academics and athletics pressure kept her in a perpetual state of sadness.
Julia felt worthless and inappropriate guilt from eating and thought that it made her gain weight and look physically unappealing. She attributed her poor athletic performance to weight gain, which prompted further dieting. Julia could not sleep well due to anxiety about her academic performance. Therefore, she had very little time to spare and ended up sleeping for very few hours. Rebecca, Julia’s roommate, also acknowledged that she could not sleep.
Julia presented with psychomotor agitation. Rebecca reported that she would wake up in the middle of the night and find Julia pacing up and down in the room instead of sleeping. Julia was always nervous before her races and became defensive whenever anybody questioned her eating habits. Julia also admitted that she did not like it when her mother questioned her diet and contacted her coach and dean.
Julia lost significant weight and had a reduced appetite. Even though Julia targeted weight loss for enhanced athletic performance, she ended up losing excess weight and her appetite. She could no longer enjoy meals. Rebecca also reported that they did not see Julia in the dining hall. Moreover, the few times that she was seen eating, she took very small servings of vegetables that she barely finished. Ultimately, she lost so much weight and appeared thin and wasted.
The sixth indication was the loss of interest in things previously enjoyed like food and hanging out with friends. Julia came from a close-knit family and formerly enjoyed spending time with her family members. However, after spending a semester away in college, she did not want any family member to interfere with her schedule (Gorenstein & Comer, 2015). Consequently, her social life died. She admitted that she cut back on socializing with friends, going out during the weekends, and even interacting with her roommate.
The Use of DSM-5 Diagnostic Manual
Depression is more than feelings of sadness. Therefore, there is a need to distinguish between normal sadness or reactions to external disturbances and depression as a mental health disorder. The DSM-5 diagnostic manual was chosen to identify depression because it facilitates an all or none diagnosis thus eliminating ambiguity. Using the DSM-5 criteria also informs the choice of pharmacological interventions to avoid the redundant use of antidepressants that are reported to increase the risk of cardiovascular events in patients with moderate depression (Tolentino & Schmidt, 2018).
Validity Assessment
The symptoms presented by Julia in the case study pointed out to the diagnosis of major depressive disorder (depression) based on the DSM-5 diagnostic criteria (Sachdev, Mohan, Taylor, & Jeste, 2015). Julia presented with six out of the nine symptoms of depression. These indications were present for more than a semester, which surpassed the two-week threshold described in the DSM-5 criteria. Additionally, she had a depressed mood and lost interest in activities that she previously enjoyed, which are key symptoms that must be present for a diagnosis of depression to be made. Julia was not taking any drugs that could be linked to her symptoms. Moreover, she did not have a history of any medical condition.
The incidence of depression is variable across different age groups, genders, socioeconomic standing, sexual orientation, and ethnicity. This observation is common because the risk factors of depression have a normal distribution regardless of these factors. However, certain groups are more vulnerable to depressive symptoms than others. For example, adolescents are more likely to be depressed because this age is characterized by serious self-identify issues that affect self-esteem and prompt feelings of worthlessness (Mojtabai, Olfson, & Han, 2016). Julia was 17 years old, which placed her in the at-risk age group for depression.
This conclusion is based on findings from a national study that evaluated the prevalence of depression among children and adolescents over a 10-year period. The data used in the evaluation were drawn from the National Surveys on Drug Use and Health (Mojtabai et al., 2016). Additionally, Sachdev et al. (2015) explained the specifics of the relevance of the DSM-5 criteria in the diagnosis of depression.
Theoretical Orientation
The theoretical orientation associated with this diagnosis is the humanistic approach. Humanistic psychology is a viewpoint that accentuates examining all personal aspects and highlights ideas such as self-efficacy, free will, and self-actualization to help an individual to attain their maximum potential as opposed to focusing on dysfunction (Rowan, 2016). The central conviction of humanistic psychology states that people are naturally good.
However, mental and social disturbances stem from divergences from this instinctive tendency. Another supposition is that humans have free will that can be exploited by inspiring them to engage in endeavors that can propel them to their full potential. Therefore, the need for accomplishment and growth is a crucial promoter of all behavior, which pushes people to try out new things, enhance their performance, undergo inner growth and self-actualization.
In the case study, Julia’s actions were motivated by the need to achieve self-actualization through impeccable academic and athletic performance. Similarly, using the humanistic approach to handle her situation could help her to transform her inherent motivations towards self-actualization but in a healthy and acceptable way. Therefore, a humanistic approach is a useful guide for the development of a personalized treatment regimen for the patient.
A Historical Perspective of Depression
The earliest explanations of depression were recorded in the second millennium B.C. in Mesopotamia (Horwitz, Wakefield, & Lorenzo-Luaces, 2016). Depression, which was referred to as melancholia, was considered a spiritual condition that was linked to demonic possession. Therefore, priests were called upon to deal with affected patients. This notion was prevalent among the Babylonians. Ancient Greeks, Egyptians, Chinese, and Romans. Exorcism strategies such as beatings and starvation were used to drive the demons out. However, Greek and Roman physicians later suspected biological involvement, which led to the use of treatment methods such as exercise, music, massage, baths, and drugs containing poppy extracts.
Hippocrates, a Greek physician, proposed that an imbalance in body fluids such as blood, phlegm, yellow and black bile was responsible for depressive symptoms. Conversely, Cicero, a Roman philosopher, hypothesized that psychological reasons such as fear, anger, and grief caused depression. The belief that depression was a spiritual disorder persisted until the 17th century when Robert Burton published a book outlining the psychological causes of depression. Further discoveries about the heredity of depression were realized in the 18th and 19th centuries. These findings informed the current knowledge of depression, its causes, and treatment methods.
Risk Factors
Several factors increase the risk of depression and can be grouped as biological, psychological, or social factors. The main biological factors are genetics, illnesses, and medications, whereas social and psychological factors include bereavement, personality, conflict, abuse, life events, and substance abuse. Having a family history of depression increases the likelihood of developing the condition. It is hypothesized that depression is transmitted genetically, even though the precise mechanisms involved are unknown.
Losing a loved one can also cause depression. As much as sadness and grief are conventional responses to bereavement, the stress associated with these occurrences can trigger the signs of depression, for example, feelings of worthlessness, losing interest in previously enjoyed activities, and suicidal ideations (Wolanin, Gross, & Hong, 2015).
Conflict can be a risk factor when an individual experiences personal disorder or disagreements with family or friends. Experiencing various forms of abuse such as physical, verbal, emotional, or sexual abuse can also increase the likelihood of developing depression. Major life events are other known risk factors for depression. However, these events may not necessarily be bad things. Occurrences such as graduating, moving, having a baby, getting a new job, or getting married can cause depression. On the other hand, negative events such as losing one’s job, retiring or divorcing can also lead to depression.
Depression may co-occur with other illnesses or be a response to health conditions such as longstanding pain, sleep problems, anxiety, and attention deficit hyperactive disorder (ADHD). Some medications taken to treat or manage other medical conditions could trigger depressive symptoms. For example, steroids, hormonal replacement therapy, methyldopa, and varenicline are associated with depression (Maina, Mauri, & Rossi, 2016). Abusing drugs such as cocaine and amphetamines or excessive alcohol consumption are also associated with depression, especially during withdrawal. Conversely, social isolation could also cause depression. Personality problems such as low self-esteem generate pessimism and increase a person’s resistance to stress thus predisposes them to depression.
Treatment
Several treatment options exist for depression, including evidence-based pharmacological interventions, psychotherapy, and electroconvulsive therapy (ECT) as well as non-evidence-based self-help strategies. Pharmacological intervention entails the administration of antidepressants to alter brain chemistry and alleviate the symptoms of depression. Notable improvements can be seen within the first two weeks of treatment initiation.
However, it may take approximately two to three months for the full benefits of antidepressants to be realized. The patient may need to continue taking the drugs for at least six months after the symptoms have resolved to lower the likelihood of recurrence. Studies show that antidepressants are beneficial in treating depression compared when compared to placebos (Khan & Brown, 2015).
Psychotherapy involves talking to the patient. A psychiatrist and other family members may take part in the process. Different forms of psychotherapy in depression include cognitive, behavioral, cognitive-behavioral therapy (CBT), interpersonal, psychodynamic, and dialectical behavioral therapy. Cognitive therapy focuses on the idea that thoughts influence emotions and that wellness comes from identifying negative thought patterns and transforming them into positive thoughts (Gibbons et al., 2016).
Behavioral therapy, conversely, strives to alter undesired conduct. The tenets of operant conditioning are valuable in reinforcing good behaviors and getting rid of negative behaviors. A combination of the two approaches results in CBT. Dialectical therapy is a form of CBT that empowers patients to handle stress, control their emotions, and enhance their interactions with other people. Psychodynamic therapy assumes that unresolved conflicts are responsible for depression. Therefore, treating the condition should involve addressing any pending interpersonal and individual conflicts.
ECT is mainly used in patients with severe depression that is unresponsive to antidepressants or psychotherapy. It entails using electrical currents to stimulate the brain for short periods (Leaver et al., 2016). The patient is usually sedated before treatment. Successful outcomes may be noted after six to twelve treatments at the rate of two to three sessions per week. A proficient medical team encompassing a psychiatrist, a nurse, and an anesthesiologist is needed to execute this treatment.
Self-help measures include encouraging the patient to engage in regular physical exercise, eating balanced diets, and having adequate sleep. Regular exercise creates a positive mood thus reducing the symptoms of depression. Patients are also discouraged from taking alcohol, which is a known depressant.
Evidence-based methods have proven efficacy in the management of depression. Conversely, non-evidence-based minimize some of the symptoms of depression. However, there is insufficient proof of their significance in the management of depression to warrant their recommendation as standalone therapies for the treatment of depression.
Conclusion
The case study showed that the Julia was suffering from depression. This diagnosis was backed by evidence from the DSM-5 criteria. No comorbid conditions were identified. A humanistic approach was used to understand the diagnosis and inform therapy based on the presenting evidence.
Annotated Bibliography
Gibbons, M. B. C., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J.,… Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry, 73(9), 904-912.
This article compares the efficacy of two psychotherapeutic modalities in depression. The findings inform clinicians about the most efficient approach to use for various patient situations.
Khan, A., & Brown, W. A. (2015). Antidepressants versus placebo in major depression: An overview. World Psychiatry, 14(3), 294-300.
Differences between placebo and antidepressant outcomes are necessary to direct the treatment of depression using pharmacological agents. This article facilitates specific treatment of depression by highlighting the efficacy of various antidepressants compared to placebos.
Leaver, A. M., Espinoza, R., Pirnia, T., Joshi, S. H., Woods, R. P., & Narr, K. L. (2016). Modulation of intrinsic brain activity by electroconvulsive therapy in major depression. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 1(1), 77-86.
Electroconvulsive therapy is among the most effective treatments for depression. This article elucidates its mechanisms on brain activity to guide future neurostimulatory treatments.
Sachdev, P. S., Mohan, A., Taylor, L., & Jeste, D. V. (2015). DSM-5 and mental disorders in older individuals: An overview. Harvard Review of Psychiatry, 23(5), 320-328.
An accurate diagnosis of depression is necessary to facilitate effective treatment. This paper points out changes to the DSM-5 criteria and how it affects the diagnosis and treatment of depression.
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9, 450. Web.
Depressive symptoms manifest at varying levels of severity, which should be considered during treatment. This article explains how the DSM-5 criteria can be used to diagnose and categorize depression based on severity to inform treatment.
References
Gibbons, M. B. C., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J.,… Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry, 73(9), 904-912.
Gorenstein, E. E., & Comer, R. J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers.
Horwitz, A. V., Wakefield, J. C., & Lorenzo-Luaces, L. (2016). History of depression. In R. J. DeRubeis & D. R. Strunk (Eds.), The Oxford handbook of mood disorders (pp. 11-23). Oxford, United Kingdom: Oxford University Press.
Khan, A., & Brown, W. A. (2015). Antidepressants versus placebo in major depression: An overview. World Psychiatry, 14(3), 294-300.
Leaver, A. M., Espinoza, R., Pirnia, T., Joshi, S. H., Woods, R. P., & Narr, K. L. (2016). Modulation of intrinsic brain activity by electroconvulsive therapy in major depression. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 1(1), 77-86.
Maina, G., Mauri, M., & Rossi, A. (2016). Anxiety and depression. Journal of Psychopathology, 22(4), 236-250.
Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6), 1-12.
Rowan, J. (2016). The reality game: A guide to humanistic counselling and psychotherapy (3rd ed.). London, UK: Routledge.
Sachdev, P. S., Mohan, A., Taylor, L., & Jeste, D. V. (2015). DSM-5 and mental disorders in older individuals: An overview. Harvard Review of Psychiatry, 23(5), 320-328.
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9, 450. Web.
Wolanin, A., Gross, M., & Hong, E. (2015). Depression in athletes: Prevalence and risk factors. Current Sports Medicine Reports, 14(1), 56-60.