Patient ××, female, 36 years old. She came to the clinic on March 21, 2011 because of “poor mood, hearing people’s voices out of thin air and calling them harmless for nearly 4 months”.
History: The patient started to have mental abnormality at the end of 2010 without any obvious cause, mainly manifesting insomnia, poor mood, reluctance to participate in social activities, hearing people’s voices out of thin air, and although she could go to work, she often felt low in energy and felt that it was meaningless to be a human being, and even had thoughts of death, denying any suicidal behavior. In the past two months, the condition worsened, the patient said for no reason that there are many people in the unit to harm him, unwilling to go to work, returned home to become fearful, from time to time cover the ears, shaking his head, eyes wide open in fear as if looking for something in the house. Sometimes he did not sleep at night, mumbling and even cursing into the air. Once told his family that he had been preparing to jump from the balcony because someone was trying to assassinate him. He heard many people talking about himself and planning to kill him. He was in a very bad mood, did not want to eat, often did not bathe, and had little interest in many things. There was no fever, convulsions, coma, etc. before and after the exacerbation of the disease, and no suicidal actions.
Past and personal history: no history of major physical illness, trauma, etc. He was usually outgoing, had good interpersonal relationships, was not addicted to alcohol or tobacco, and denied a history of smuggling. Family relations were good.
Family history: His uncle had a history of mental disorder, the details of which were not known.
No abnormal signs in physical examination.
Auxiliary examination: no special cranial CT, biochemical related examination, etc.
Mental examination: clear consciousness, complete orientation, passive contact, still cooperative in examination, age and appearance match, neatly dressed. He complained of poor mood, crying constantly, with anxiety and fear of insecurity in the consultation room. She spoke in a low voice, answered questions and thought coherently. He said that he was being followed and felt that many people wanted to harm him and had thoughts of death. Feels sorry for his family and has a strong sense of guilt. No self-awareness. Memory, fair intelligence.
Diagnosis: depression with psychotic symptoms
Treatment history.
1. First day prescription.
Lysop 5mgQd.
Quetiapine 50Qn
2. Lysop was gradually increased to 20mg/d over 4 days and quetiapine was gradually increased to 600mg/d over one week.
3.After 5 days, the patient’s mood improved slightly and there was improvement in anxiety.
Around 4 or 10 days, the patient’s mood gradually improved and the self-conscious hallucinations disappeared. With the disappearance of hallucinations, the paranoid symptoms gradually disappeared. The patient tolerated the drug well with no obvious side effects. in early July, the patient showed manic manifestations such as excessive talking and exaggeration. Lysop was reduced to 10 mg/d, and Depakene was gradually added to 1,5/d (on July 22, valproic acid blood concentration was 90,50ug/ml). The patient’s mood stabilized after three weeks. At present, the patient is behaving normally and adheres to outpatient follow-up.
Treatment experience.
1. Lysop is more effective in depression with anxiety symptoms and has a faster onset of action.
2. Depression with significant anxiety may be a special type of mental disorder
The DSM-5 to be released on the diagnosis of depressive disorders may appear changes.
(1) Change 1: New mixed anxiety-depressive disorder.
a. The patient has 3 or 4 of the symptom criteria for depressive disorder (must include depressed mood and/or pleasure deficit) and also has anxiety disturbance.
b. The symptoms persist for at least 2 weeks and the patient does not currently meet other DSM-IV diagnostic criteria for depression or anxiety, both of which must be present at the same time.
c. Anxiety disturbance can be identified if 2 or more of the following are met: unreasonable worry, preoccupied unpleasant worry, difficulty relaxing, muscle tension, and fear of something terrible that might happen.
(2) Change 2: Mixed trait type will replace the classification of mixed episodes
The criteria for the initial proposed mixed character type
a. Applied to manic, hypomanic, and depressive episodes.
b. Mixed trait type, which refers to the entire episode of affective disorder, with symptoms that are below the diagnostic threshold of both episodes.
3, Depression with psychotic symptoms is currently classified as a subtype of depression, but several conditions suggest that it may be a separate class of disorders.
The risk of suicide is higher in this disorder than in major depressive disorder without psychotic symptoms, and it is more likely to recur. The depressive symptoms of this lesion are distinctly different from those of depression without psychotic symptoms, for example, patients in this group are prone to severe psychomotor agitation, have a rare diurnal heavy night rhythm, and have mostly Type A personality behavior prior to the illness. The prognosis of this lesion is relatively poor. This lesion is better treated with ECT. Patients with this disease may have MRI changes such as enlarged ventricles and sulci.
4. Depression with psychotic symptoms is not well recognized clinically and is easily misdiagnosed.
Depression with psychotic symptoms is a relatively common type of depression. According to statistics, this type of patient accounts for 25% of the number of depression inpatients. It is often misdiagnosed as depression without psychotic symptoms or schizophrenia, leading to inappropriate treatment.
5. Depression with psychotic symptoms presents a high probability of bipolar depression.
The presence of psychotic symptoms during the first major depression, a positive family history, and an extroverted personality before the disease may predict that such patients are more likely to develop bipolar disorder eventually.