Major Depressive Disorder: Tina's Case Study and Diagnosis

Introduction

Major depressive disorder is a difficult disorder to identify, address, and treat, especially when a single episode of symptoms constitutes the only diagnostic criterion. There is a social tendency to view MDD as a singular and normal response when its episodic symptoms are associated with real-life stressors, and therefore as something a person will likely work through on their own with sufficient effort. This social view of MDD symptoms — particularly in singular episodes — often leaves sufferers with intensified feelings of inadequacy and social isolation, as there is little demonstrated social support for individuals experiencing the symptoms of MDD and other depressive disorders. This dynamic creates a vacuum for the patient and a challenge for clinicians seeking reasonable and effective treatment intervention (Hybels, Blazer, Steffens & Judith, 2006).

Major life stressors can trigger a single episode of major depressive disorder, and with appropriate grief work that episode can result in resolution — or, in the diagnostic sense, remission. Finding a balance between action and inaction on the part of the clinician and the client is therefore essential, as working together toward resolution of a disorder that can seriously impair an individual's ability to function is crucial to recovery and a return to prior normal and productive living. One of the most essential features of major depressive disorder is a persistent inability to feel joy, even when positive events occur in one's life. This experience devalues one's sense of life and affects all desires and drives. Tina, in the case study below, demonstrates symptomology consistent with a major depressive episode and would likely benefit from diagnosis and intervention. This paper reviews Tina's case with regard to the diagnostic criteria for Major Depressive Disorder, offers a possible multi-axial diagnosis, discusses theories associated with her possible MDD, and closes with a discussion of possible treatment options given her diagnosis and theoretical indices for intervention.

Tina's Case Presentation

Tina is a 23-year-old Black woman, currently separated from her husband of five years. She is employed by two companies — one where she works Monday through Thursday mornings, and another where she works Wednesday through Friday evenings and all day Saturday and Sunday. She has not shown up for work consistently over the last four weeks, and has not attended at all in the last two days.

Once an energetic, active, and healthy woman who enjoyed exercising at the local gym three days a week, Tina now spends most of her time in her apartment. She has not been to the gym in over four weeks, and her body movements — once quick and deliberate — are now slow and sluggish. Despite no change in her eating habits, she has been losing weight.

Tina's husband Joe left her for another woman approximately four weeks ago. When she found out, Tina immediately locked herself in her room and cried herself to sleep. That night she slept for about twelve hours straight, but that was the last time she experienced a prolonged stretch of true sleep. Since then, her sleep has been highly erratic — sometimes a few hours during the day, sometimes in the evening. She is unable to sleep for more than four hours at a time and is constantly fatigued.

When she is awake and able to think clearly — which is not always — Tina is fixated on where she went wrong in her marriage. She feels that Joe's departure must mean she was not good enough, just as she believes she was not good enough for her own father to stay when she was seven years old. Her father left her and her mother, reinforcing, in Tina's mind, that she was inadequate even then.

Tina had believed that marrying Joe right out of high school would be wonderful. She had envisioned them both working their way through college and building a successful life together. Instead, she ended up working two jobs to keep food on the table and the rent paid, while Joe spent his time with friends. Tina blames herself, believing that if only she had worked harder, been prettier, or been more sexually available, Joe would have stayed. She was always so exhausted from working that she had nothing left to give him emotionally or physically.

Tina now believes that because of who she is and what she has done, no one will ever love her and she will never have a relationship again. She repeatedly expresses feelings of worthlessness, convinced that her constant working contributed to the collapse of the marriage. She feels like a failure — at life and at love.

Tina believed she and Joe had many friends, but when he left, those friends stopped calling and visiting. Shortly after the separation, she reached out to a few girlfriends, but they eventually tired of her ongoing need for sympathy and stopped answering her calls. As a result, Tina has no one to talk to. It would have helped to speak with her sister, but her sister died by suicide four years ago after becoming deeply depressed over a broken relationship. Tina has had thoughts of suicide as well, though she states she is not yet at the point of acting on them.

Diagnostic Assessment and Multi-Axial Diagnosis

The occurrence of MDD in Tina's case is clearly in need of clinical review. Her behaviors and feelings indicate a need for appraisal and intervention, as the depression she is experiencing is affecting her ability to function both at work and at home. Without treatment, her functioning may deteriorate further.

Under the DSM-IV-TR multi-axial system, Tina would receive a diagnosis of Major Depressive Disorder, Single Episode on Axis I. She has not reported a prior episode of this kind, and her presentation is not better explained by any psychotic disorder, nor does she exhibit signs of mixed episodes including mania. Her episode is clearly linked with melancholic features as a specifier. The criteria for this modifier that Tina meets include: loss of pleasure in all or nearly all activities, a distinct quality of depressed mood representing a novel experience for her, early morning awakening at least two hours before her regular time, marked psychomotor retardation (reported sluggishness and inability to move quickly), significant weight loss, and excessive or inappropriate guilt.

The likely full diagnosis is Major Depressive Disorder, Single Episode with Melancholic Features. Axis II does not apply, as Tina does not present with a marked personality disorder. Axis III is also non-applicable, as there is no evidence of an underlying medical or neurological condition that could account for her presentation. Axis IV is appropriate to explore, given that Tina has experienced several major psychological stressors across her lifetime and is presently experiencing abandonment. These include: her father's desertion when she was a child, the suicide of her only sister several years prior, and the acute grief associated with her very recent marital separation. On Axis V, Tina would likely code between 41 and 50, reflecting serious impairment in social and occupational functioning that has worsened over recent weeks — from inconsistent work attendance to complete absence, and from limited social contact to near-total isolation (APA, DSM-IV-TR, 2000, pp. 348–350).

Additional diagnostic testing beyond the case narrative may be warranted. One potentially valuable quantitative assessment tool is the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; Endicott, Harrison, & Blumenthal, 1993). Given that quality of life and melancholic features are central to Tina's symptomology, scaling and formal assessment are significant in this case. The Q-LES-Q is described as:

…a self-report measure of the degree of enjoyment and satisfaction an individual experiences in various areas of daily living…[a] 15-item overall satisfaction and enjoyment summary subscale of the Q-LES-Q, that includes items covering domains such as physical health, mood, work, household activities, relationships, daily functioning, sexual issues, economic status, living/housing situation, and overall life satisfaction. Scores on this scale are reported as percentages, with higher scores indicating increased satisfaction. The Q-LES-Q has been shown to have sound psychometric properties when compared to similar measures, and an internal consistency of .74 (Craigie, Saulsman & Lampard, 2007, p. 1150).

Tina's responses on this questionnaire could help a clinician determine the scope of her present MDD episode, assess her levels of overgenerality (discussed below), and explore the possibility that this is not a truly singular episode — that prior, less severe episodes may correspond to earlier periods of serious loss, such as her father's desertion or her sister's suicide.

Conclusion

Tina's situation is clearly indicative of the need for intervention, especially given her heightened anxiety, suicidal ideation, and the pervasive effect this episode of MDD is having on her current functioning. The symptoms she is experiencing are consistent with a DSM-IV-TR diagnosis of Major Depressive Disorder, Single Episode with Melancholic Features. This diagnosis points directly to the need for a treatment plan that incorporates cognitive behavioral therapy alongside antidepressant medication and, likely, an initial course of anti-anxiety medication tapering within six weeks.

Tina may also need support in rebuilding a social network that can assist her in processing feelings of loss and inadequacy. Her divorce and the depressive episode have significantly eroded her social support system, and she is in need of social connectivity and re-engagement with emotional relationships to help counteract her persistent feelings of worthlessness — feelings she traces to abandonment by both her father and her husband. The broader social and cultural tendency to minimize or dismiss depressive symptoms has further undermined Tina's ability to remain socially engaged and to interrupt her cycle of obsessive thinking, a dynamic that likely reinforces and deepens her depressive concerns (Hybels, Blazer, Steffens & Judith, 2006).

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