A 29-year-old woman comes to the office due to persistent fatigue over the last 4 years. She has also felt unhappy during this period, ever since being let go from her previous job. The patient describes her fatigue as "having little energy to do things." When asked what she enjoys, she replies that "everything in life is a chore" and that she feels hopeless that her life will improve. The patient has no suicidal thoughts, problems with concentration, or changes in appetite or sleeping patterns. She used marijuana as a teenager and drinks 1 or 2 glasses of wine on weekends. Detailed workup, including urine toxicology screen, is negative. Which of the following is the most likely diagnosis?

Question

A 29-year-old woman comes to the office due to persistent fatigue over the last 4 years.  She has also felt unhappy during this period, ever since being let go from her previous job.  The patient describes her fatigue as "having little energy to do things."  When asked what she enjoys, she replies that "everything in life is a chore" and that she feels hopeless that her life will improve.  The patient has no suicidal thoughts, problems with concentration, or changes in appetite or sleeping patterns.  She used marijuana as a teenager and drinks 1 or 2 glasses of wine on weekends.  Detailed workup, including urine toxicology screen, is negative.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3623_a625_9249_25575aa3e3f7_MD0001_00 This patient's chronic depression, fatigue, and hopelessness are consistent with a diagnosis of persistent depressive disorder. Diagnosis requires depressed mood more days than not for at least 2 years (1 year in children) and at least 2 other depressive symptoms (Table). In DSM-5, persistent depressive disorder includes both "pure dysthymic syndrome" and chronic major depression or dysthymia with concurrent or intermittent major depressive episodes. This patient would be diagnosed with "pure dysthymic syndrome" as she has never met the criteria for a major depressive episode. Diagnosis of persistent depressive disorder requires ruling out medical and substance-induced etiologies and differentiation from other psychiatric disorders. Persistent depressive disorder is treated with antidepressants, psychotherapy, or a combination of these. (Choice A) Although this patient relates the onset of her depression to losing her job 4 years ago, her symptoms meet the criteria for persistent depressive disorder. Adjustment disorders are not diagnosed if criteria for another disorder are met. In adjustment disorder, symptoms occur within 3 months of the onset of the stressor(s) and do not persist for more than 6 months after the stressor or its consequences have terminated. (Choice B) Patients with borderline personality disorder may experience intermittent depressive symptoms. This patient does not exhibit a pervasive pattern of impulsivity and unstable mood, relationships, or self-image characteristic of borderline personality disorder. (Choice C) The presence of depressive symptoms for more than 2 years rules out a diagnosis of major depressive disorder. Persistent depressive disorder can occur as a pure dysthymic syndrome, as in this patient, or with persistent or intermittent major depressive episodes. (Choice E) Substance-induced mood disorder is diagnosed when depressive symptoms develop during or within a month of substance intoxication or withdrawal. This patient's urine screen is negative for substances, and the extent of her alcohol use would not explain her depressive symptoms. Educational objective: The DSM-5 diagnosis of persistent depressive disorder (dysthymia) is characterized by chronic depressed mood and at least 2 other depressive symptoms lasting for at least 2 years. __________ References: Efficacy and acceptability of acute treatments for persistent depressive disorder: a network meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24448972) DSM-5 and psychotic and mood disorders. (http://www.ncbi.nlm.nih.gov/pubmed/24986345)

A 29-Year-Old Woman Comes to the Office Due to Persistent