WBR0040: Difference between revisions

Jump to navigation Jump to search
No edit summary
m (refreshing WBR questions)
 
(14 intermediate revisions by 4 users not shown)
Line 1: Line 1:
{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Gonzalo Romero
|QuestionAuthor=Gonzalo Romero (Reviewed by Will Gibson and Yazan Daaboul)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=Neurology, General Principles
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|Prompt=A 47-year-old man presents to his primary care physician after being concerned about his current state of mind. He started developing extreme fatigue 3 weeks ago after his dog passed away, whom he considered his "best buddy" for 15 years. He never got married, but has had a girlfriend for 5 years. The patient reports being an avid swimmer in the past, but no longer has any interest in swimming these days. He has trouble falling asleep every night. The patient reports difficulty concentrating at work to the extent that his supervisors and colleagues are also concerned. He cries inconsolably several times during the day; and he cannot recall any time when he was not feeling down since his loss. When the physician asks about his overall status, he replies: "I feel worthless and think about ending my life”. The patient denies taking any medication or illicit drug use. His blood pressure is 122/84 mmHg, heart rate is 82/min, temperature is 37.1 °C (98.7 °F). On physical examination, he appears unkempt and has a flat affect. What is the most likely diagnosis?
|SubCategory=Neurology, General Principles
|Explanation=This middle-aged man experiences a constellation of symptoms after the recent death of his cherished dog. While the recent onset of his symptoms raises the suspicion that he is experiencing normal [[grief]], the severity and persistence of his symptoms throughout the day, along with the alarming presence of [[suicide|suicidal]] contemplation out of context of his loss, makes major depression a more likely diagnosis. Recall the mnemonic for the diagnosis of [[major depressio]]n: SIG-E-CAPS
|MainCategory=Behavioral Science/Psychiatry
 
|SubCategory=Neurology, General Principles
* '''S'''leep changes
|MainCategory=Behavioral Science/Psychiatry
* '''I'''nterest (loss - also referred to as anhedonia)
|MainCategory=Behavioral Science/Psychiatry
* '''G'''uilt or feelings of worthlessness
|SubCategory=Neurology, General Principles
* '''E'''nergy loss/fatigue
|MainCategory=Behavioral Science/Psychiatry
* '''C'''ognition/concentration problems
|SubCategory=Neurology, General Principles
* '''A'''ppetite/weight changes (usually decreased, sometimes increased)
|MainCategory=Behavioral Science/Psychiatry
* '''P'''sychomotor retardation (lethargy) or agitation (anxiety)
|SubCategory=Neurology, General Principles
* '''S'''uicidal ideations
|MainCategory=Behavioral Science/Psychiatry
 
|SubCategory=Neurology, General Principles
The diagnosis of major depression requires the presence of a depressed mood plus 5 of the 9 SIG-E-CAPS criteria with symptoms lasting greater than 2 weeks. This patient has sleep disturbances (S), [[anhedonia]] (I), feelings of worthlessness (G), loss of energy (E), decreased ability to concentrate at work (C), flat affect (P), and most importantly suicidal ideation (S). With 7 of the 9 criteria and symptoms lasting 3 weeks, this patient meets the criteria for major depression.
|MainCategory=Behavioral Science/Psychiatry
|AnswerA=Normal grief
|MainCategory=Behavioral Science/Psychiatry
|AnswerAExp=Although individuals with normal [[grief]] may present with symptoms similar to major depression, normal grief becomes unlikely in the presence of extreme symptoms that are continuously present and associated with suicidal ideation. In contrast, normal grief is characterized by a depressed mood that lasts generally up to 6 months after one's loss. Unlike major depression, normal grief may improve when the patient is surrounded by support. Treatment for normal grief includes psychotherapy. Use of medication in normal grief is not recommended.
|SubCategory=Neurology, General Principles
|AnswerB=Major depression disorder
|Prompt=A 47-year-old male presents to the outpatient clinic for follow up with his primary care physician after being concerned about his current state of mind. He started developing extreme fatigue 3 weeks ago after his dog passed away, whom he considered his "best buddy" for 15 years. He never married, but has had a girlfriend for 5 years. The patient reports being an avid swimmer in the past, but no longer has any interest in it. He has had trouble falling asleep at night and wakes up early being unable to go back to sleep. He works as a regional manager for a paper company; his boss and clients have complained recently that he seems to lack concentration at work. Sometimes he has had thoughts of worthlessness. He cries inconsolably when the doctor asks about the dog and says “I just can’t stop seeing my dog everywhere I go, I have thought and planned about ending my life”. He denies taking any medication or illegal substances. On physical exam, his vitals are stable, he appears unkempt and has a flat affect. What is the most likely diagnosis?
|AnswerBExp=[[Major depression]] disorder (MDD) lasts for at least 2 weeks and is characterized by a depressive mood associated with at least 5 out of 9 symptoms (see SIG-E-CAPS below). Treatment usually includes [[psychotherapy]] and antidepressants (usually [[SSRIs]]).
|Explanation=This middle aged man experiences a constellation of symptoms after the recent death of his cherished dog. While the recent onset of his symptoms raises the suspicion that he is experiencing normal grief, the severity of his depression and suicidal contemplation makes major depression the correct diagnosis.
|AnswerA=Normal Grief
|AnswerAExp=Normal [[Grief]] is incorrect because this patient is experiencing severe symptoms after his dog’s death. The treatment includes psychotherapy, medication is not needed.
|AnswerB=Major depression
|AnswerBExp=<font color="Green">'''Correct.'''</font> [[Unipolar depression|Major depression]] or unipolar disorder lasts for at least 2 weeks and they are severe. They include anhedonia, lack of motivation, intense sadness, sleep changes, feeling of worthlessness, weight or appetite changes, psychomotor retardation, delusions or hallucinations. The treatment includes psychotherapy and antidepressants (usually SSRIs). [http://www.wikidoc.org/index.php/Clinical_depression_differential_diagnosis]
|AnswerC=Bipolar disorder
|AnswerC=Bipolar disorder
|AnswerCExp=<font color="red">'''Incorrect.'''</font> [[Bipolar disorder]] or Manic-depression: include symptoms of major depression in addition to manic episodes (elevated persistent mood, grandiose thoughts, low frustration tolerance, increased energy levels, appetite and weight loss, uninhibited behavior, increased libido, flight of thoughts). It alternates between depression and mania. The depression phase is what disables the patient.
|AnswerCExp=[[Bipolar disorder]] is characterized by symptoms of major depression that alternate with manic episodes. The episodes of [[mania]] consist of elevated mood, grandiose thoughts, low frustration tolerance, increased energy levels, decreased appetite, uninhibited behavior, increased libido, and "flight of ideas".
|AnswerD=Dysthymia
|AnswerD=Dysthymia
|AnswerDExp=<font color="red">'''Incorrect.'''</font> [[Dysthymia]] it is a mild form of depression that usually lasts at least 2 years (chronic). It includes depressed mood, loss or interest in regular activities. It does not require pharmacological treatment.
|AnswerDExp=[[Dysthymia]] is a mild, but chronic form of [[depression]] that often lasts more than 2 years. Patients typically display depressed mood and loss of interest in regular activities. Therapy consists of [[psychotherapy]] and antidepressants, most commonly [[SSRIs]].
|AnswerE=Cyclothymia
|AnswerE=Cyclothymia
|AnswerEExp=<font color="red">'''Incorrect.'''</font> [[Cyclothymia]] it is chronic (at least 2 years) and milder form of bipolar. Often the patient does not identify the condition. As with bipolar, the patient alternates between manic and depressive symptoms.  It does not require pharmacological treatment.
|AnswerEExp=[[Cyclothymia]] is a type of chronic mood disorder widely considered to be a milder or subthreshold form of [[bipolar disorder]]. [[Cyclothymia]] is characterized by numerous mood disturbances, with periods of hypomanic symptoms alternating with periods of mild or moderate [[depression]].
|EducationalObjectives=Major depression is characterized by the presence of depressed mood plus 5 out of 9 SIG-E-CAPS symptoms lasting for at least 2 weeks. Although normal grief may have similar symptoms that usaully last up to 6 months after the loss of a loved one, patients with normal grief do not typically experience continuous depressed mood throughout the day and generally have no suicidal ideations.
|References=First Aid 2014 page 507
|RightAnswer=B
|RightAnswer=B
|WBRKeyword=Psychiatry, Behavioral science, Depression, Grief, Suicide
|Approved=Yes
|Approved=Yes
}}
}}

Latest revision as of 23:08, 27 October 2020

 
Author PageAuthor::Gonzalo Romero (Reviewed by Will Gibson and Yazan Daaboul)
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Behavioral Science/Psychiatry
Sub Category SubCategory::General Principles
Prompt [[Prompt::A 47-year-old man presents to his primary care physician after being concerned about his current state of mind. He started developing extreme fatigue 3 weeks ago after his dog passed away, whom he considered his "best buddy" for 15 years. He never got married, but has had a girlfriend for 5 years. The patient reports being an avid swimmer in the past, but no longer has any interest in swimming these days. He has trouble falling asleep every night. The patient reports difficulty concentrating at work to the extent that his supervisors and colleagues are also concerned. He cries inconsolably several times during the day; and he cannot recall any time when he was not feeling down since his loss. When the physician asks about his overall status, he replies: "I feel worthless and think about ending my life”. The patient denies taking any medication or illicit drug use. His blood pressure is 122/84 mmHg, heart rate is 82/min, temperature is 37.1 °C (98.7 °F). On physical examination, he appears unkempt and has a flat affect. What is the most likely diagnosis?]]
Answer A AnswerA::Normal grief
Answer A Explanation [[AnswerAExp::Although individuals with normal grief may present with symptoms similar to major depression, normal grief becomes unlikely in the presence of extreme symptoms that are continuously present and associated with suicidal ideation. In contrast, normal grief is characterized by a depressed mood that lasts generally up to 6 months after one's loss. Unlike major depression, normal grief may improve when the patient is surrounded by support. Treatment for normal grief includes psychotherapy. Use of medication in normal grief is not recommended.]]
Answer B AnswerB::Major depression disorder
Answer B Explanation [[AnswerBExp::Major depression disorder (MDD) lasts for at least 2 weeks and is characterized by a depressive mood associated with at least 5 out of 9 symptoms (see SIG-E-CAPS below). Treatment usually includes psychotherapy and antidepressants (usually SSRIs).]]
Answer C AnswerC::Bipolar disorder
Answer C Explanation [[AnswerCExp::Bipolar disorder is characterized by symptoms of major depression that alternate with manic episodes. The episodes of mania consist of elevated mood, grandiose thoughts, low frustration tolerance, increased energy levels, decreased appetite, uninhibited behavior, increased libido, and "flight of ideas".]]
Answer D AnswerD::Dysthymia
Answer D Explanation [[AnswerDExp::Dysthymia is a mild, but chronic form of depression that often lasts more than 2 years. Patients typically display depressed mood and loss of interest in regular activities. Therapy consists of psychotherapy and antidepressants, most commonly SSRIs.]]
Answer E AnswerE::Cyclothymia
Answer E Explanation [[AnswerEExp::Cyclothymia is a type of chronic mood disorder widely considered to be a milder or subthreshold form of bipolar disorder. Cyclothymia is characterized by numerous mood disturbances, with periods of hypomanic symptoms alternating with periods of mild or moderate depression.]]
Right Answer RightAnswer::B
Explanation [[Explanation::This middle-aged man experiences a constellation of symptoms after the recent death of his cherished dog. While the recent onset of his symptoms raises the suspicion that he is experiencing normal grief, the severity and persistence of his symptoms throughout the day, along with the alarming presence of suicidal contemplation out of context of his loss, makes major depression a more likely diagnosis. Recall the mnemonic for the diagnosis of major depression: SIG-E-CAPS
  • Sleep changes
  • Interest (loss - also referred to as anhedonia)
  • Guilt or feelings of worthlessness
  • Energy loss/fatigue
  • Cognition/concentration problems
  • Appetite/weight changes (usually decreased, sometimes increased)
  • Psychomotor retardation (lethargy) or agitation (anxiety)
  • Suicidal ideations

The diagnosis of major depression requires the presence of a depressed mood plus 5 of the 9 SIG-E-CAPS criteria with symptoms lasting greater than 2 weeks. This patient has sleep disturbances (S), anhedonia (I), feelings of worthlessness (G), loss of energy (E), decreased ability to concentrate at work (C), flat affect (P), and most importantly suicidal ideation (S). With 7 of the 9 criteria and symptoms lasting 3 weeks, this patient meets the criteria for major depression.
Educational Objective: Major depression is characterized by the presence of depressed mood plus 5 out of 9 SIG-E-CAPS symptoms lasting for at least 2 weeks. Although normal grief may have similar symptoms that usaully last up to 6 months after the loss of a loved one, patients with normal grief do not typically experience continuous depressed mood throughout the day and generally have no suicidal ideations.
References: First Aid 2014 page 507]]

Approved Approved::Yes
Keyword WBRKeyword::Psychiatry, WBRKeyword::Behavioral science, WBRKeyword::Depression, WBRKeyword::Grief, WBRKeyword::Suicide
Linked Question Linked::
Order in Linked Questions LinkedOrder::