A 44-year-old woman comes to the office 2 months after the death of her husband in a motor vehicle collision. She sustained numerous injuries but has made a full recovery. The patient initially says she is doing well but then bursts into tears. She says, "I do have good days, but some days are really bad. Yesterday, for example, when I was going through his clothes, I fell apart and spent the whole day in bed crying." The patient has difficulty falling and staying asleep. When she manages to fall asleep, she wakes up around 3:00 or 4:00 AM and cannot fall back asleep. Sometimes the patient dreams about her husband, which she finds comforting. She says, "The dreams make me feel like I can still be close to him. I also sometimes hear his voice and tell him about the children. The other day I even saw him in the hallway. It was just as if he were back home and it was a normal day." The patient has lost 2.26 kg (5 lb) and has little interest in food. She sometimes wishes she would have died with her husband in the collision so she would not have to be alone, but says, "I would never consider hurting myself because of my children." The patient has no psychiatric history. Physical examination, laboratory tests, and vital signs are within normal limits. Which of the following is the most likely diagnosis?

Question

A 44-year-old woman comes to the office 2 months after the death of her husband in a motor vehicle collision.  She sustained numerous injuries but has made a full recovery.  The patient initially says she is doing well but then bursts into tears.  She says, "I do have good days, but some days are really bad.  Yesterday, for example, when I was going through his clothes, I fell apart and spent the whole day in bed crying."  The patient has difficulty falling and staying asleep.  When she manages to fall asleep, she wakes up around 3:00 or 4:00 AM and cannot fall back asleep.  Sometimes the patient dreams about her husband, which she finds comforting.  She says, "The dreams make me feel like I can still be close to him.  I also sometimes hear his voice and tell him about the children.  The other day I even saw him in the hallway.  It was just as if he were back home and it was a normal day."  The patient has lost 2.26 kg (5 lb) and has little interest in food.  She sometimes wishes she would have died with her husband in the collision so she would not have to be alone, but says, "I would never consider hurting myself because of my children."  The patient has no psychiatric history.  Physical examination, laboratory tests, and vital signs are within normal limits.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1a8_103b_8f63_5187ebaa385e_MD0005_00 This patient exhibits depressive symptoms (sadness, insomnia, decreased appetite) in the context of grieving for her husband. Although some depressive symptoms occur during bereavement, normal grief can be differentiated from major depressive disorder in that the feelings of sadness revolve around the deceased and are less pervasive, typically occurring in waves following reminders of the person. Guilt and suicidal ideation are less common, and self-esteem is preserved. If thoughts of dying are present, they typically involve joining the deceased. Hearing the voice or seeing images of the deceased are also consistent with normal grief and do not indicate a psychotic disorder. This patient's depression and thoughts of death revolve around her deceased husband and are not associated with feelings of worthlessness and hopelessness. In contrast to normal grief, major depressive disorder (Choice C) typically involves persistent and pervasive sadness and anhedonia, self-critical ruminations, and suicidality associated with feelings of worthlessness and hopelessness lasting 2 weeks or more. Bereavement is regarded as a stressor that can trigger a major depressive episode at any time during the bereavement period. If this patient were to develop more persistent and pervasive depression, anhedonia, and hopelessness accompanied by significant functional impairment, a diagnosis of major depressive disorder would be considered, regardless of time of onset. (Choice A) Adjustment disorder is diagnosed when depressive symptoms develop in response to a psychosocial stressor (excluding bereavement) but do not meet the full criteria for a major depressive episode. In adjustment disorders, the stressor can be of any severity or type, excluding bereavement. (Choice B) This patient's auditory and visual hallucinations of her deceased husband are consistent with a normal grief reaction. Brief psychotic disorder is characterized by one or more positive psychotic symptoms lasting more than a day but less than a month. (Choice E) This patient was involved in a life-threatening motor vehicle collision, but she is not experiencing intrusive flashbacks of this event, avoidance, or hyperarousal symptoms that would characterize post-traumatic stress disorder. Her dreams about her husband do not involve the collision and she finds them comforting. Educational objective: Patients experiencing normal grief may report symptoms similar to those of a major depressive episode. In normal grief, a patient may wish to die to join the deceased and may also experience visions or hear the deceased person's voice. Pervasive anhedonia and suicidality related to feelings of worthlessness and hopelessness are not present. References: The removal of the bereavement exclusion in the DSM-5: exploring the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/24136623) The bereavement exclusion and DSM-5: an update and commentary. (http://www.ncbi.nlm.nih.gov/pubmed/25337442)

A 44-Year-Old Woman Comes to the Office 2 Months After