A 31-year-old woman comes to the office due to fatigue and weight gain. She has felt tired over the past 2 months and is upset that she has been craving junk food and has gained 8 pounds. She says, "I have been under some stress at work lately, and I guess I've been eating and sleeping more as a way to cope and escape. I know I've gained weight but I feel slow-like my legs are in cement blocks." The patient sleeps 10-12 hours a day but still feels tired throughout the day. She is feeling "down" and stopped socializing with friends "because I feel that I look awful and don't want to be around anybody." However, she was able to enjoy a recent family reunion and was excited to meet her newborn nephew for the first time. The patient has no medical or psychiatric history. She has 1-2 glasses of wine 3 times a week and uses cannabis approximately once a month. Physical examination is normal. On mental status examination the patient appears sad and tired but is able to smile when appropriate. Laboratory evaluation, including complete blood count and thyroid function tests, is within normal range. Which of the following is the most likely diagnosis?

Question

A 31-year-old woman comes to the office due to fatigue and weight gain.  She has felt tired over the past 2 months and is upset that she has been craving junk food and has gained 8 pounds.  She says, "I have been under some stress at work lately, and I guess I've been eating and sleeping more as a way to cope and escape.  I know I've gained weight but I feel slow-like my legs are in cement blocks."  The patient sleeps 10-12 hours a day but still feels tired throughout the day.  She is feeling "down" and stopped socializing with friends "because I feel that I look awful and don't want to be around anybody."  However, she was able to enjoy a recent family reunion and was excited to meet her newborn nephew for the first time.  The patient has no medical or psychiatric history.  She has 1-2 glasses of wine 3 times a week and uses cannabis approximately once a month.  Physical examination is normal.  On mental status examination the patient appears sad and tired but is able to smile when appropriate.  Laboratory evaluation, including complete blood count and thyroid function tests, is within normal range.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's 2-month history of depressed mood (eg, feeling "down"), social isolation (loss of interest), fatigue (loss of energy), hypersomnia, leaden paralysis ("my legs are in cement blocks"), and weight gain is most consistent with the atypical subtype of major depressive disorder (MDD). A core feature of atypical depression is mood reactivity (ie, positive responsiveness to pleasant events); other characteristic features include increased appetite or weight gain, hypersomnia, leaden paralysis (heavy feeling in limbs), and hypersensitivity to rejection. This patient's ability to enjoy the family reunion and smile during the interview are examples of the mood reactivity characteristic of the atypical subtype. In contrast, the melancholic subtype of MDD is characterized by weight loss, insomnia, and pervasive anhedonia with an inability to respond to positive events. (Choices A and C) MDD can be differentiated from adjustment disorder and a normal stress response by the number and severity of symptoms and the degree of functional impairment. Adjustment disorder involves depressive symptoms developing within 3 months of a stressor with resultant functional impairment but insufficient number and severity of symptoms to meet the criteria for MDD. A normal stress response is not excessive or out of proportion to the severity of the stressor and does not cause functional impairment. functional impairment (Choice D) Persistent depressive disorder (dysthymia) requires a chronically depressed mood for ≥2 years. (Choice E) The extent of this patient's alcohol and cannabis use is unlikely to be causing her symptom severity and impairment. Educational objective: Atypical features of major depressive disorder include hypersomnia, hyperphagia, heavy feelings in limbs, hypersensitivity to rejection, and mood reactivity (ability to respond to positive events). References: Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29498147) Clinical patterns and treatment outcome in patients with melancholic, atypical and non-melancholic depressions. (http://www.ncbi.nlm.nih.gov/pubmed/23110213)

A 31-Year-Old Woman Comes to the Office Due to Fatigue