A 30-year-old man comes to the office due to chronic fatigue. When he is not working, the patient is often at home sleeping; he estimates that he sleeps approximately 12 hours a day. He has felt down since being passed over for a promotion last month and copes by overeating. The patient says he has never had a lot of energy and can remember only a few times since high school when he felt happy—a month he spent with his grandparents in Florida and a brief period when he felt really good after starting his first job. He has worked as a computer programmer since graduating from college. The patient socializes with friends but avoids dating due to his weight, saying, "I just know I will be rejected because I'm fat." Apart from obesity, the patient has no other medical conditions. He smokes marijuana 3 times a week, which he began doing in his mid-20s, to "help me relax and feel better about myself." He also drinks 4 cups of coffee before going to work on weekdays, which he says helps with his energy level. There is a family history of bipolar disorder in a maternal uncle. Vital signs and physical examination are unremarkable. Which of the following is the most likely diagnosis?
Persistent depressive disorder (dysthymia) | |
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This patient's chronic depression since adolescence, accompanied by overeating, hypersomnia, and low self-esteem, is consistent with persistent depressive disorder (dysthymia). Diagnosis requires that the patient has had persistent depressive symptoms for ≥2 years and has never been without depressive symptoms for >2 months at a time. In DSM-5, persistent depressive disorder also encompasses patients who have met the full criteria for major depressive disorder at some point during the illness.
(Choice A) Although this patient came to the office after being passed over for a promotion, his depressive symptoms have been present since adolescence and meet the criteria for persistent depressive disorder. Adjustment disorders are not diagnosed if the patient meets the criteria for another disorder.
(Choices B and D) This patient's brief periods of feeling better likely represent normal (not elevated) mood, and he lacks other symptoms of hypomania (eg, inflated self-esteem, increased energy, decreased need for sleep, pressured speech) required for the diagnosis of bipolar II disorder. Cyclothymic disorder involves ≥2 years of numerous periods with hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or major depressive episodes.
(Choices C and E) Although medical conditions should always be considered before making a psychiatric diagnosis, this patient's long-standing history of chronic sadness, low energy, and low self-esteem are more likely due to dysthymia. Chronic fatigue syndrome (also referred to as systemic exertion intolerance disease) is characterized by relatively sudden onset of overwhelming fatigue, often associated with an infection such as mononucleosis. Hypothyroidism is less likely in this patient who does not report other typical symptoms (eg, cold intolerance, constipation, dry skin, recent weight gain) and has a normal physical examination.
(Choice G) Although the use of substances such as marijuana and caffeine can affect mood, energy levels, and sleep patterns, this patient reports long-standing symptoms beginning in high school, prior to the use of substances, making dysthymia the more likely diagnosis. Patients with mood disorders often self-medicate to manage their symptoms.
Educational objective:
Persistent depressive disorder (dysthymia) refers to a depressed mood lasting most days for ≥2 years. It includes patients with pure dysthymia and those with intermittent or persistent major depressive episodes.