Case Study Cindy Ingram, a 33-year-old stock analyst and married mother of two c
ID: 3446145 • Letter: C
Question
Case Study
Cindy Ingram, a 33-year-old stock analyst and married mother of two children, was brought to the emergency room (ER) after 10 days of what her husband described as “another cycle of depression,” marked by a hair-trigger temper, tearfulness, and almost no sleep. He noted that these “dark periods” had gone on as long as he had known her but that she had experienced at least a half dozen of these episodes in the prior year. He said they typically improved within a few weeks of restarting her fluoxetine. He added that he wondered whether alcohol and clonazepam worsened her symptoms, because she routinely ramped up their use when the dark periods began.
Ms. Ingram’s husband said he had decided to bring her to the ER after he discovered that she had recently created a blog entitled Cindy Ingram’s Best Stock Picks. Such an activity not only was out of character but, given her job as a stock analyst for a large investment bank, was strictly against company policy. He said that she had been working on these stock picks around the clock, forgoing her own meals as well as her responsibilities at work and with her children. She countered that that she was fine and that her blog would “make them as rich as Croesus.”
The patient had first been diagnosed with depression in college, after the death of her father from suicide. He had been a wildly erratic, alcohol-abusing businessman whom the patient loved very much. Her paternal grandmother had several “nervous breakdowns,” but her diagnosis and treatment history were unknown. Since college, her mood had generally been “down,” interspersed with recurrent bouts of enhanced dysphoria, insomnia, and uncharacteristically rapid speech and hyperalertness. She had tried psychotherapy sporadically and taken a series of antidepressant medications, but her husband noted that the baseline depression persisted and that the dark periods were increasing in frequency.
Her outpatient psychiatrist noted that Ms. Ingram appeared to have dysthymia and a recurrent major depression. He also said that he had never seen her during her periods of edginess and insomnia- she always refused to see him until the “really down” periods improved-and that she had refused him access to her husband or to any other source of collateral information.
On examination, the patient was pacing angrily in the exam room. She was dressed in jeans and a shirt that was carelessly unbuttoned. Her eyes appeared glazed and unfocused. She responded to the examiner’s entrance by sitting down and explaining that this was all a miscommunication, that she was fine and needed to get home immediately to tend to her business. Her speech was rapid, pressured, and very difficult to interrupt. She admitted to not sleeping but denied that it was a problem. She denied hallucinations but admitted, with a smile, to a unique ability to predict the stock market. She refused cognitive testing, saying she would decline the opportunity to be a “trained seal, a guinea pig, Mr. Ed, and a barking dog, thank you very much, and may I leave now?” Her insight into her situation appeared poor, and her judgment was deemed to be impaired.
Hello, I need assistance with my casestudy. THis is to meet dsm5 criteria and icd10. References are needed. TY
What is her diagnosis? Give rationale for your choice.
What are the telltale signs that this may be something other than depression?
What symptoms look manic?
What is the importance of this phrase in relation to bipolar disorder: "Who's your daddy and where's your mama?" 177660_7742
What do you think was the impact of fluoxetine?
Do you think the family history has any bearing on her current situation? If so, what?
This criterion is linked to a Learning Outcome What is the incidence of drug and alcohol comorbidity with bipolar spectrum disorder?
Explain self-medicating
How would you have handled this case?
Explanation / Answer
According to the 5th edition of D.S.M, dysthymia has been replaced with 'Persistent Depressive Disorder'. This new condition includes both,major depressive disorder and dysthymic disorder. There's also been another addition in D.S.M5, i.e.
1)Disruptive Mood Dysregulation Disorder( mostly diagnosed in children up to 18 years who exhibit persistent irritability, frequent episodes of extreme behavior)
2) Premenstrual Dysphoric Disorder( marked by extreme sadness,mood swings, irritability, depression, lethargy, insomnia or hypersomnia, out-of-control behavior)
ICD10 points out a few symptoms of depression like loss of appetite,lack of interest in pleasure giving activities,lack of energy, Persistent sadness.
In the case given, it is mentioned that Ms. Cindy Ingram have had episodes of extreme overwhelming behavior and sadness since college days. It is stated that she was first diagnosed with depression after her father's death who was an alcoholic and committed suicide. The patient refuses hallucinations but there's definitely a possibility that she might be in a state of delusion of grandeur which includes false beliefs that a person possess superior qualities. It is often associated with schizophrenia but can also be a symptom of bipolar or psychotic disorder,as well as dementia.
1) It is possible the lady may be diagnosed with Persistent Depressive Disorder with traits of delusion as well. Her symptoms,her lack of sleep,over overwhelming behavior,anger etc comes under depression and her statement, "make them as rich as Croesus", her belief of having unique ability to predict the stock market shows delusional behavior.
2) Her statement and belief mentioned above are the telltales that this could be more than depression and possibly could be manic or psychotic.
3) Bipolar Disorder is often marked by 4 types of illness elepisod,namely,Manic, Major depressive, Hypomanic and Mixed. The phrase "Who's your daddy and where's your mamma?", "Who's your daddy?" Means what is your family history and "where's your mamma?" Means getting additional details of someone who's close to you. The question is important as patient themselves don't accept their manic behavior and a family member could help in bipolar spectrum diagnosis.
4) Fluoxetine is a antidepressant which helps a patient who's delressed. So the imapct of the medicine mentioned in the case study is positive.
5)Yes the family history do have an impact on our current situation. It's mentioned the father was an alcoholic and committed suicide and her paternal grandmother used to have nervous breakdowns. Heredity do plays a role in depression.
Drug and alcohol usually triggers the depressive feeling and the patient should definitely avoid them.
When it comes to self medicating, medicines prescribed by the doctor should be used with relaxation techniques and healthy way of living.
The case mentioned needs proper medication with congnitive therapy and relaxation techniques.