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Author Gonzalo Romero (Reviewed by Will Gibson and Yazan Daaboul)
Exam Type USMLE Step 1
Main Category Behavioral Science/Psychiatry
Sub Category General Principles
Prompt A 47-year-old man presents to his primary care physician after being concerned about his current state of mind. He started developing extreme fatigue 3 weeks ago after his dog passed away, whom he considered his "best buddy" for 15 years. He never got married, but has had a girlfriend for 5 years. The patient reports being an avid swimmer in the past, but no longer has any interest in swimming these days. He has trouble falling asleep every night. The patient reports difficulty concentrating at work to the extent that his supervisors and colleagues are also concerned. He cries inconsolably several times during the day; and he cannot recall any time when he was not feeling down since his loss. When the physician asks about his overall status, he replies: "I feel worthless and think about ending my life”. The patient denies taking any medication or illicit drug use. His blood pressure is 122/84 mmHg, heart rate is 82/min, temperature is 37.1 °C (98.7 °F). On physical examination, he appears unkempt and has a flat affect. What is the most likely diagnosis?
Answer A Normal grief
Answer A Explanation [[AnswerAExp::Although individuals with normal grief may present with symptoms similar to major depression, normal grief becomes unlikely in the presence of extreme symptoms that are continuously present and associated with suicidal ideation. In contrast, normal grief is characterized by a depressed mood that lasts generally up to 6 months after one's loss. Unlike major depression, normal grief may improve when the patient is surrounded by support. Treatment for normal grief includes psychotherapy. Use of medication in normal grief is not recommended.]]
Answer B Major depression disorder
Answer B Explanation [[AnswerBExp::Major depression disorder (MDD) lasts for at least 2 weeks and is characterized by a depressive mood associated with at least 5 out of 9 symptoms (see SIG-E-CAPS below). Treatment usually includes psychotherapy and antidepressants (usually SSRIs).]]
Answer C Bipolar disorder
Answer C Explanation [[AnswerCExp::Bipolar disorder is characterized by symptoms of major depression that alternate with manic episodes. The episodes of mania consist of elevated mood, grandiose thoughts, low frustration tolerance, increased energy levels, decreased appetite, uninhibited behavior, increased libido, and "flight of ideas".]]
Answer D Dysthymia
Answer D Explanation [[AnswerDExp::Dysthymia is a mild, but chronic form of depression that often lasts more than 2 years. Patients typically display depressed mood and loss of interest in regular activities. Therapy consists of psychotherapy and antidepressants, most commonly SSRIs.]]
Answer E Cyclothymia
Answer E Explanation [[AnswerEExp::Cyclothymia is a type of chronic mood disorder widely considered to be a milder or subthreshold form of bipolar disorder. Cyclothymia is characterized by numerous mood disturbances, with periods of hypomanic symptoms alternating with periods of mild or moderate depression.]]
Right Answer B
Explanation [[Explanation::This middle-aged man experiences a constellation of symptoms after the recent death of his cherished dog. While the recent onset of his symptoms raises the suspicion that he is experiencing normal grief, the severity and persistence of his symptoms throughout the day, along with the alarming presence of suicidal contemplation out of context of his loss, makes major depression a more likely diagnosis. Recall the mnemonic for the diagnosis of major depression: SIG-E-CAPS
  • Sleep changes
  • Interest (loss - also referred to as anhedonia)
  • Guilt or feelings of worthlessness
  • Energy loss/fatigue
  • Cognition/concentration problems
  • Appetite/weight changes (usually decreased, sometimes increased)
  • Psychomotor retardation (lethargy) or agitation (anxiety)
  • Suicidal ideations

The diagnosis of major depression requires the presence of a depressed mood plus 5 of the 9 SIG-E-CAPS criteria with symptoms lasting greater than 2 weeks. This patient has sleep disturbances (S), anhedonia (I), feelings of worthlessness (G), loss of energy (E), decreased ability to concentrate at work (C), flat affect (P), and most importantly suicidal ideation (S). With 7 of the 9 criteria and symptoms lasting 3 weeks, this patient meets the criteria for major depression.
Educational Objective: Major depression is characterized by the presence of depressed mood plus 5 out of 9 SIG-E-CAPS symptoms lasting for at least 2 weeks. Although normal grief may have similar symptoms that usaully last up to 6 months after the loss of a loved one, patients with normal grief do not typically experience continuous depressed mood throughout the day and generally have no suicidal ideations.
References: First Aid 2014 page 507]]

Approved Yes
Keyword Psychiatry, Behavioral science, Depression, Grief, Suicide
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