A 62-year-old woman comes to the office for a checkup. Her husband died 5 months ago in a biking accident, which she witnessed. She has little appetite, resulting in weight loss of 3.17 kg (7 lb), and tends to wake up two hours before her alarm clock rings. The patient feels overwhelmed at having to manage the household finances, saying, "My husband always took care of the bills so I wouldn't have to worry." She avoids cycling, a hobby she shared with her husband, but continues to volunteer at a children's hospital. The patient has no nightmares or suicidal thoughts. During the visit, she tears up intermittently but smiles when sharing a memory of a vacation she took with her husband. Which of the following is the best explanation for this patient's condition?
Major depressive episode & grief reaction | |
Major depressive episode | Grief reaction |
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This patient's sadness, insomnia, and decreased appetite are consistent with a normal grief reaction precipitated by the loss of a loved one (bereavement). In a normal grief reaction, the sadness revolves around feelings of loss and typically occurs in "waves" intermixed with positive memories of the deceased. For most, the natural mourning process lasts 6-12 months and is followed by the integration of grief, in which the individual continues to feel transient but less pronounced sadness, and life plans/routines have adapted to living without the deceased.
Normal grief can resemble a major depressive episode as both may include intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss. However, this woman's positive memories about her husband, ability to continue volunteering, and lack of other depressive symptoms (eg, hopelessness, feelings of low self-worth, guilt, suicidal ideation) make major depression less likely (Choice B). A major depressive disorder can be diagnosed during a grief reaction if a sufficient number and severity of depressive symptoms are present.
(Choice A) Dependent personality disorder is diagnosed when there is a lifelong pattern of excessive need to be taken care of, leading to submissive, clingy behavior and fears of separation.
(Choice D) Persistent complex bereavement disorder (also known as complicated grief) is characterized by prolonged grief for >12 months, difficulty accepting the death, persistent yearning for the deceased, and inability to reengage with life. This patient's symptom duration is within the range seen in normal grief and she is showing signs of adapting to living without the deceased.
(Choice E) Persistent depressive disorder is a chronic depression that persists for at least 2 years.
(Choice F) Although this patient witnessed her husband's accident and avoids cycling, her symptoms are not consistent with post-traumatic stress disorder as she is not re-experiencing the event (eg, nightmares, flashbacks) or having symptoms of trauma-related reactivity (eg, hypervigilance, heightened startle response).
Educational objective:
Normal grief presents with symptoms similar to those of a major depressive episode. However, in normal grief, pervasive anhedonia, worthlessness, and suicidality are not present.