A 71-year-old woman is brought to the emergency department by her daughter due to severe fatigue, poor appetite, and a 5-kg (11-lb) weight loss over the past month. The patient's daughter says, "It's been 3 months since my dad died from colon cancer. We've all had a hard time dealing with that, but my mom is just not herself-I've never seen her like this before. She is convinced she is dying and lies in bed most of the day. She used to enjoy going out with friends and would offer to babysit her grandchildren and cook for us. Now, she eats only when I bring over meals I have prepared for her." The patient says, "My insides are rotting away from cancer. I deserve to die for all the terrible things I said to my husband over the years." Physical examination shows no abnormalities. Mental status examination demonstrates orientation to person, place, and time as well as psychomotor slowing and restricted range of affect. The patient has no suicidal ideation. Laboratory evaluation and imaging studies are unremarkable. Which of the following is the most likely diagnosis?

Question

A 71-year-old woman is brought to the emergency department by her daughter due to severe fatigue, poor appetite, and a 5-kg (11-lb) weight loss over the past month.  The patient's daughter says, "It's been 3 months since my dad died from colon cancer.  We've all had a hard time dealing with that, but my mom is just not herself-I've never seen her like this before.  She is convinced she is dying and lies in bed most of the day.  She used to enjoy going out with friends and would offer to babysit her grandchildren and cook for us.  Now, she eats only when I bring over meals I have prepared for her."  The patient says, "My insides are rotting away from cancer.  I deserve to die for all the terrible things I said to my husband over the years."  Physical examination shows no abnormalities.  Mental status examination demonstrates orientation to person, place, and time as well as psychomotor slowing and restricted range of affect.  The patient has no suicidal ideation.  Laboratory evaluation and imaging studies are unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's 1-month history of anhedonia, weight loss, fatigue, excessive guilt and recurrent thoughts of death, in addition to mental status examination findings of psychomotor retardation and delusions (belief that she is dying of cancer and deserves punishment), is most consistent with a diagnosis of major depressive disorder (MDD) with psychotic features. MDD with psychotic features is a severe subtype of MDD in which the patient develops psychotic symptoms during a depressive episode. Delusions and hallucinations are commonly mood-congruent and have depressive themes (eg, deserving punishment, worthlessness, body is rotting), although mood-incongruent psychotic symptoms (unrelated to depressive themes) can also occur. Identifying the presence of psychotic features in a patient with MDD is important because treatment differs from nonpsychotic depression. Patients who have MDD with psychotic features require combined treatment with an antidepressant and antipsychotic or electroconvulsive therapy. (Choices A and B) Brief psychotic disorder is characterized by ≥1 psychotic symptom lasting ≥1 day and ≤1 month followed by full return to the previous level of functioning. In delusional disorder, ≥1 delusions must be present for ≥1 month. Mood symptoms, if present, are not a prominent part of either illness. These psychotic disorders would not explain this patient's severe depressive symptoms. (Choices C and G) Patients with illness anxiety disorder are excessively concerned about having a serious, undiagnosed general medical condition. Somatic symptom disorder is characterized by excessive anxiety and thoughts about the seriousness of ≥1 somatic symptom. Neither diagnosis explains this patient's severe depression with associated somatic delusions and delusions of guilt. (Choice E) Although bereavement may have triggered this patient's depression, her symptoms are severe and meet the criteria for MDD with psychotic features. Persistent complex bereavement disorder (also referred to as complicated grief) is characterized by intense yearning for the deceased that persists for at least 6 months to a year after the loss. It is not associated with psychotic features. (Choice F) Schizoaffective disorder is differentiated from MDD with psychotic features by the presence of delusions and/or hallucinations for ≥2 weeks in the absence of MDD mood symptomatology. There is no evidence that this patient has ever experienced psychotic symptoms outside of her current MDD episode. Educational objective: Major depressive disorder with psychotic features is characterized by an episode of major depression accompanied by delusions and/or hallucinations, often with depressive themes. Treatment involves combined antidepressant and antipsychotic medication or electroconvulsive therapy. References: Challenges in the treatment of major depressive disorder with psychotic features. (http://www.ncbi.nlm.nih.gov/pubmed/23599251) Risk of psychosis in recurrent episodes of psychotic and nonpsychotic major depressive disorder: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/29792050)

A 71-Year-Old Woman Is Brought to the Emergency Department by Her