A 29-year-old woman comes to the office due to persistent fatigue. The patient has been experiencing daily exhaustion and has "no energy to do little things." Her symptoms began 3 years ago after she closed her jewelry-making business due to financial problems. The patient used to enjoy creating unique jewelry pieces but has had no interest in making anything since her business closed. She has felt unhappy throughout this time, avoiding friends and social gatherings, and is hopeless that her life will improve. She has had no changes in appetite or sleeping patterns, problems with concentration, or suicidal thoughts. Physical examination and laboratory evaluation are unremarkable. Which of the following is the most likely diagnosis?
Differential diagnosis of depressed mood | |
Major depressive disorder |
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Persistent depressive disorder (dysthymia) |
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Adjustment disorder with depressed mood |
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Normal stress response |
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SIGECAPS = Sleep disturbance, loss of Interest, excessive Guilt, low Energy, impaired Concentration, Appetite disturbance, Psychomotor agitation/retardation, and Suicidal ideation. | |
For the past 3 years, this patient has had an unrelenting depressed mood (eg, unhappy throughout this time), low energy, and feelings of hopelessness. In the absence of additional depressive symptoms (eg, changes in appetite or sleeping patterns, problems with concentration, suicidal thoughts), her presentation is consistent with a persistent depressive disorder (PDD), also known as dysthymia.
To diagnose PDD, there must be the presence of depressed mood and ≥2 of the following over a period of ≥2 years (without a symptom-free period >2 months):
While there is significant overlap with major depressive disorder (eg, depressed mood and/or anhedonia can occur in both), PDD can be differentiated from major depression by the number of concurrent depressive symptoms (eg, guilt, psychomotor disturbance, suicidal ideation, impaired concentration, appetite change, sleep disturbance); ≥5 depressive symptoms (not seen in this patient) need to be present for ≥2 weeks to diagnose major depressive disorder (Choice D).
(Choice A) In adjustment disorders, symptoms occur within 3 months of the onset of the stressor(s) and do not persist for more than 6 months after the stressor or its consequences have terminated. However, adjustment disorders are superseded and not diagnosed if criteria for another disorder (eg, PDD, MDD) are met.
(Choice B) Although this patient is avoiding friends and social gatherings, this is better attributed to her depressed mood and fatigue rather than avoidant personality disorder. In addition, this patient's avoidance started 3 years ago, whereas avoidant personality disorder is characterized by onset in early adulthood with a pervasive pattern of inhibition, feelings of inadequacy, and hypersensitivity to evaluation.
(Choice C) Chronic fatigue syndrome (CFS) is characterized by ≥6 months of significant reduction in activity with accompanying fatigue not relieved by rest, drastic worsening of symptoms after activity (ie, post-exertional malaise), and sleep impairments plus cognitive impacts (ie, "brain fog"). While this patient has low energy and fatigue, the absence of a history of sleep or concentration difficulties makes CFS unlikely.
Educational objective:
Persistent depressive disorder (ie, dysthymia) is characterized by chronic depressed mood and accompanying depressive symptoms lasting for ≥2 years. It can often be differentiated from major depressive disorder by the number of concurrent depressive symptoms (eg, ≥5 needed for major depression).