Case history
Case history
A 43-year-old single woman presents after seeing a television advertisement describing depressive symptoms. She relates that had onset of chronic low grade depression following her parents’ divorce, when she was 9 years old. On questioning she says she has had at least four previous episodes of more severe depression, the first episode at age 15, and most recent episode at age 41; these more severe episodes last from 2 to 6 months, and have resolved with medication treatment, sometimes combined with psychotherapy. During those episodes she has extreme difficulty functioning, feels hopeless and helpless, with passive suicidal ideas (wouldn’t mind being dead but doesn’t have a plan to injure or kill herself), has difficulty concentrating at work, and withdraws from friends and family. After resolution of these more severe episodes, she returns to a baseline state of "mild" depression. At baseline she feels depressed most days, and has symptoms of chronic fatigue and rarely feels pleasure or enjoyment. She is chronically socially avoidant. At the time of psychiatric evaluation, she does not meet criteria for a current major depressive episode. She has been evaluated by her primary care physician for annual check-ups but has never had a significant physical disorder. At present, she is taking no medication except for vitamins, and her thyroid has been tested in the past and is normal. Her vital signs and physical exam are normal.
Other presentations
A common form of the disorder is chronic low-grade depression meeting criteria for "pure" dysthymia in which a patient apparently has never met full criteria for major depressive disorder with antecedent dysthymia. In these cases, patients feel depressed more days than not, with a chronic course, their symptoms lasting for more than two years. In other cases, may have a chronic form of major depressive disorder, lasting more than 2 years, and at times lasting for decades. Patients may also have the onset of persistent depressive disorder following an initial episode of major depression, which does not completely resolve. Sometimes, patients have chronic low-grade depression (dysthymia) with intermittent episodes of major depression; current major depression may or may not be present at the time of clinical presentation.
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