Case Study

Gary, a 62-year-old man, presented in your clinic with his son. You noticed that Gary had ​not shaven
in a couple of weeks​, he had ​several stains on his shirt​, and had ​loose fitting clothes​. Upon
introducing yourself, Gary ​did not smile and tended to look down at the floor​. His son reported that
his father has ​“not been himself.”​ Gary stated that a few months ago, he ​started to feel “down”​ and
was ​less interested in seeing friends/family and caring for his garden​. Gary started to become tearful
and reported that these feeling have been​ getting worse​. He stated that for the ​past month, he has
felt sad “all the time.”​ His son stated that Gary has not seen any of his friends over the past month,
and his father’s garden is now overgrown with weeds. His son stated that he has recently been
checking in on his father, cleaning his house, and bringing meals so his father does not ​lose any
more weigh​t. Gary stated that while he appreciates his son bringing him meals, he​ does not feel like
eating.​ He stated that he ​does not have the energy​ to do things he used to do. For example, he
stated that when trying to pay his bills, he needs to read the bill repeatedly because he ​cannot
concentrate​ on what he is reading. He also reported that he has​ trouble sleeping most nights​. Gary
stated that he “does not want to go on living this way” and said that he has ​considered consuming
the bottle of sleeping pills that are in his medicine cabinet.​ He reported that he would not do this
since he does not want to upset his family, however. Gary ​denied ever experiencing a period of time
where he experienced an abnormally elevated mood that persisted for several days​. He​ denied
using substances and reported an insignificant medical history.

Diagnosis: Major Depressive Disorder

Treatment: Beck's cognitive therapy and/or drug therapy (Tricyclics, SSRIs, or MAO inhibitors)

Justification for Diagnosis:

Diagnostic requirements for major depression
a) Presence of five of the following symptoms for at least two weeks
i) Sad and depressed mood, most of the day, nearly everyday
(1) yes, past month, he has felt sad “all the time.”
(2) started to feel “down”
(3) these feeling have been getting worse.
ii) Loss of interest and pleasure in all, or almost all activities
(1) yes, less interested in seeing friends/family and caring for his garden
(2) has not seen any of his friends over the past month, and his father’s
garden is now overgrown with weeds
(3) Does not feel like eating
iii) Difficulties in sleeping (insomnia); not falling asleep initially, not returning to
sleep after waking up in the middle of the night, and early morning
awakenings; or, in some individuals, the desire to sleep a great length of time
(1) yes, trouble sleeping most nights
iv) Shift in activity level, becoming either lethargic (psychomotor retardation) or
agitated (no)
v) Poor appetite and weight loss, or increase appetite and weight gain
(1) yes, does not feel like eating
vi) Loss of energy and great fatigue nearly everyday
 (1) yes, does not have the energy to do things he used to do
vii) Negative self-concept, self-reproach, and self-blame, feelings of
worthlessness and guilt. (no)
viii) Complaints or evidence of difficulty in concentration, such as slowed thinking
and indecisiveness
(1) yes, cannot concentrate
(2) he stated that when trying to pay his bills, he needs to read the bill
repeatedly because he cannot concentrate on what he is reading
ix) Recurrent thoughts of death or suicide
(1) yes, considered consuming the bottle of sleeping pills that are in his
medicine cabinet
2) Denial of substance abuse
a) denied using substances, therefore condition not due to drugs
3) Violation of social norms
a)
4) Abnormality causes personal distress
a) started to feel “down” and was less interested in seeing friends/family and caring for
his garden.
5) Abnormality causes disability and dysfunction
a) His son stated that Gary has not seen any of his friends over the past month, and his
father’s garden is now overgrown with weeds.
b) Not shaven in a couple of weeks, he had several stains on his shirt, and had loose
fitting clothes.
c) His son stated that he has recently been checking in on his father, cleaning his
house, and bringing meals so his father does not lose any more weight.
6) Abnormality is unexpected
a) Does not seem to have a degenerative brain disease b/c he is able to articulate what
he is feeling

Justification for Treatment:

Diagnosis: Gary has Major Depressive Disorder (MDD)

Treatment: Cognitive Behavioural therapy and/or drug therapy

Justification for diagnosis:

For Gary to be diagnosed with MDD, he must have five of the following symptoms and they
must have lasted for at least two weeks.
1. Sad and depressed mood, most of the day, nearly everyday.
2. Loss of interest and pleasure in all, or almost all activities
3. Difficulties in sleeping (insomnia); not falling asleep initially, not returning to sleep
after waking up in the middle of the night, and early morning awakenings; or, in some
individuals, the desire to sleep a great length of time
4. Shift in activity level, becoming either lethargic (psychomotor retardation) or agitated
5. Loss of appetite and weight loss
6. Loss of energy and great fatigue nearly everyday
7. Negative self-concept, self-reproach, self-blame, feelings of worthlessness, and guilt
8. Difficulty concentrating
9. Recurrent thoughts of suicide
The first symptom is a sad and depressed mood, most of the day, nearly everyday. Gary
demonstrates this as he claims that he felt sad “all the time” during the past month, and these
feelings are getting worse. Another symptom is the loss of interest and pleasure in all, or almost all
activities. This is also seen in Gary as he is “less interested in seeing friends/family and caring for his
garden”, so much so that he “has not seen any of his friends over the past month, and his garden is
now overgrown with weeds”. Furthermore, difficulties in sleeping (insomnia); not falling asleep
initially, not returning to sleep after waking up in the middle of the night, and early morning
awakenings; or, in some individuals, the desire to sleep a great length of time is another criteria for
diagnosis. Gary claims to have trouble sleeping on most nights. However, a sign that Gary does not
demonstrate is a shift in activity level, becoming either lethargic (psychomotor retardation) or
agitated. Yet, Gary does show a loss of appetite and weight loss as he does not feel like eating and
his son has to bring him meals “so his father does not lose any more weight”. Moreover, Gary has a
loss of energy and great fatigue nearly everyday, as he “does not have the energy to do things he
used to do”, such as tend to his garden. Gary does not however show symptoms of a negative
self-concept, self-reproach, or self-blame, feelings of worthlessness and guilt. However, Gary does
show difficulty concentrating, as “he stated that when trying to pay his bills, he needs to read the bill
repeatedly because he cannot concentrate on what he is reading”. And finally, Gary shows signs of
recurrent thoughts of suicide as he “considered consuming the bottle of sleeping pills that are in his
medicine cabinet” in order to kill himself.
As per his claims, Gary seems to have seven of the nine symptoms that are required for a
diagnosis of Major Depressive Disorder, which qualifies him to be diagnosed. SInce he denies the
use of drugs, it can be maintained that the symptoms are not caused by external factors.
However, he also displays symptoms and behaviours that cause distress and dysfunction.
To begin, by avoiding his friends, Gary is causing further distress, which decreases his ability to
function in society, as he will also begin to avoid other social situations as well. Moreover, he is now
dependent on his son to clean his house and bring his meals. It seems that he's so depressed that
he cannot do simple tasks for himself, which was further emphasized as he showed up to the
appointment in loose fitting clothes with several stains and he seemed like he hadn't shaved in
weeks.

Justification for treatment:

When it comes to treatment through medication Tricyclics, SSRIs, or MAO inhibitors have
been proven to help lift the mood of depressed people. Tricyclics inhibit the reuptake of
norepinephrine and serotonin. Serotonin reuptake inhibitors, as the name suggests, inhibits the
reuptake of serotonin. Finally, Monoamine Oxidase Inhibitors prevent the enzyme Monoamine
Oxidase from removing further norepinephrine, serotonin, and dopamine from the brain. SInce low
levels of norepinephrine, serotonin, and dopamine are linked to depression, these drugs effectively
enhance mood for a short period of time.
However, Cognitive-Behavioural therapy is recommended for long-term improvement. CBT
will also help modify any of Gary’s dysfunctional attitudes by also tackling his behaviour that
reinforces these attitudes. For example, the cognitive portion will correct Gary’s negative perception
and high attention to negative events. By doing so, Gary will progressively begin to focus more on
positive life event than negative ones. Moreover, by behaving in such ways that increases his natural
norepinephrine, serotonin, and dopamine, such as taking walks and doing things he enjoys, Gary will
feel happier. Therefore, by modifying his behaviour and ways of thinking, Gary will be able to see his
surroundings in a less threatening perspective, and learn to live a more functional life.
As a result, I would recommend a combination of Drug therapy and Cognitive-Behavioural
therapy.

References
Davidson, G., Blankenstein, K., Flett, G., Neale, J., (2014) Abnormal Psychology, Fifth
Canadian Edition

What someone else wrote

Major Depressive Disorder.

Treatment: The recommended course of treatment includes the following

(1) Beck’s Cognitive Behavioral Therapy (CBT)

(2) Medication (Specifically Selective Serotonin Reuptake Inhibitors (SSRIs))

Justification for Diagnosis: According to the DSM-5, a diagnosis of major depressive disorder is
appropriate if the client meets (A) five or more of its diagnostic criteria, (B) the symptoms cause
distress / social and occupational impairment and (C) the condition is not attributable to physiological
effects of a substance/ medical condition.
(A) Gary meets five or more of DSM’s diagnostic criteria.

(1) Firstly, Gary shows depressed mood most of the day. Gary himself acknowledges that he started
to feel “down” and feels sad most of the time. Additionally, upon entering the clinic Gary did not smile
and was looked at the ground. This is circumstantial evidence but suggests that Gary is not content.

(2) Secondly, Gary shows diminished interest and pleasure from activities which he would engage
in. This is made evident by Gary who states he is no longer interested in seeing his friends/family or
taking care of his garden. Gary’s lack of interest in these activities is also confirmed by his son.

(3) Additionally, Gary’s appetite has decreased and he has lost weight. Gary is brought food to his
home by his son but Gary says that he does not feel like eating. The son also mentions how he tries
to bring food because he is concerned about his father’s weight loss.

(4) Gary also mentions that he has trouble sleeping most nights.

(5) Gary also mentions that he no longer has the energy to do things like he used. This lack of
energy is a symptom of depressed mood.

(6) Gary also shows feelings of worthlessness and inappropriate guilt. For instance, Gary mentions
that he no longer wants to continue living the way that he is and does not want to upset his family by
consuming a bottle of sleeping pills. This is also a sign of suicidal thoughts but at the same time
shows that he is inappropriately worried more about his family rather than his own well-being.

(7) Gary also displays trouble concentrating. For instance, he has trouble reading his bills and is
required to read it several times since he cannot concentrate.

(8) Gary also has recurrent suicidal ideation. Gary illustrates these intentions based on his
consideration to consume an entire bottle of sleeping pills in his medicine cabinet following the
statement that “he does not want to go on living this way”.

(B) Gary’s symptoms have also caused significant distress and impaired social and other important
areas of functioning. For instance, Gary has difficulty being motivated to meet his friends or engage
in his hobbies such as gardening. Additionally, Gary shows poor hygiene and decorum given he has
not shaven in a couple of weeks, had stain on his shirt and wore loose fitting clothing at the clinic.
This suggests that his ability to take care of himself has diminished.

(C) Gary’s depressed mood cannot be attributed to drugs or a medical condition given that he has
denied those being significant factors.

A potential differential diagnosis could be bipolar disorder given that Gary could currently be in a
depressive episode. However, Gary has denied experiencing an abnormally elevated mood and thus
does not show signs of experiencing a manic episode. Therefore, Gary should not be diagnosed with
bipolar disorder.

Based on the evidence supported above, the best diagnosis for Gary’s symptoms is major
depressive disorder.
Justification for Treatment: Cognitive behavioral therapy and SSRIs are recommended to treat
Gary’s major depressive. Theories on major depressive disorder suggest that negative schemas and
maladaptive cognitive processes lead to feelings of worthlessness and depressed mood. Therefore,
CBT is recommended to correct Gary’s negative outlook so that he learns to be less attentive to
negative events and progressively focus more on positive events in his life. Additionally, this form of
therapy will also attempt to teach Gary about his negative beliefs and fix biases such as
overgeneralization. A behavioural component is also included so that Gary can experience
enjoyment and wellness. This includes assignments such as walking and getting up in the morning.
Overall CBT has been empirically shown to be effective and have its intended effects in a
six-session period. Selective serotonin reuptake inhibitors are also recommended alongside CBT
since antidepressants have been shown to improve patient outcome if combined with psychological
therapy. SSRIs inhibit reuptake of serotonin and it is shown to be effective since low serotonin levels
have been linked with depression. Antidepressants have side-effects but based on available options
SSRIs have the least while also being effective. Monoamine oxidase inhibitors, while effective, are
not recommended give they require a special diet to be followed. Nonetheless, if Gary finds the side
effects of SSRIs to be severe then an alternative antidepressant will be used or they their use will be
discontinued. Other therapies such as ECT and TMS are not recommended given they are
expensive and only recommended for severe cases of long term depression. Given Gary’s
depression is relatively recent CBT and medication is the recommended route.

Another person's composition

Diagnosis: Major Depressive Disorder

Treatment: Cognitive therapy coupled with behavioural components

Justification for Diagnosis:

According to the DSM-5, major depressive disorder is defined as meeting requirements from each of
the following 5 criterion:

A) having 5 symptoms of depressed mood or loss of interest

B) impairment in important areas of functioning

C) the depressive episode is not manic or hypomanic,

D) the depressive episode cannot be attributable to the use of a substance and

E) it cannot be explained better by another schizophrenia spectrum or psychotic disorder.

Gary can be diagnosed with major depressive disorder because he exhibits more than 5 symptoms
from criterion A, which include:

(i) subjective and observable depressed mood nearly everyday or most of the day; he states
that he feels “down” and “sad all the time”, and becomes tearful
(ii) he has trouble sleeping most nights

(iii) he experienced significant weight loss

(iv) loss of energy

(v) he shows suicidal intentions because he considers consuming a bottle of sleeping pills,

to name a few. Furthermore, Gary is functionally impaired by the symptoms of criterion A because
he lacks social interest and cannot productively complete important tasks. His lack of social interest
is apparent by the way he did not smile upon arriving at the clinic and he reports to have stopped
visiting his friends for the past month. Gary is also impaired occupationally because he cannot
complete his bills or perform daily tasks such as shaving or gardening. Gary’s major depressive
episode is not attributable to the side effects of any drugs, cannot be better explained by
schizophrenia, psychosis or another related disorder and the lack of a manic or hypomanic episode
suggests that his depression is unipolar.

Justification for Treatment:

Although antidepressants could be a treatment for depression, there are many side effects that must
be considered when consuming drugs. Evidence suggests that increased levels of social support are
more effective, which gears the treatment possibilities toward cognitive and behavioural therapies.
Cognitive therapy aims to monitor and restructure thought patterns that interfere with the client’s
functioning and sense of self. Some behavioural changes are also coupled with cognitive therapy
because occupations are encouraged by the therapist. These occupations include going out for a
walk or writing a diary to decrease stressful moods. Examples of behavioural changes that could
increase social support for Gary are if he expressed his gratitude towards his son for looking after
him, or if he started speaking with his friends over the phone.