Michelle Adams, a 51-year-old former hairdresser, came to a psychiatric

Michelle Adams, a 51-year-old former hairdresser, came to a psychiatric clinic at the urging of her primary care doctor. A note sent ahead revealed that she had been tearful and frustrated at her last medical appointment, and her doctor, who had been struggling to control her persistent back pain, felt that an evaluation by a psychiatrist might be helpful. Greeting Ms. Adams in the waiting room, the psychiatrist was struck by both her appearance and her manner: here was a woman with shaggy silver hair and dark sunglasses, seated in a wheelchair, who offered a limp handshake and a plaintive sigh before asking the psychiatrist if he would mind pushing her wheelchair into his office. She was tired from a long commute, and, she explained, “Nobody on the street offered to help me out. Can you believe that?” Once settled, Ms. Adams stated that she had been suffering from unbearable back pain for the last 13 months. On the night “that changed everything,” she had locked herself out of her apartment and, while trying to climb in through a fire escape, had fallen and fractured her pelvis, coccyx, right elbow, and three ribs. Although she did not require surgery, she was bed-bound for 6 weeks and then underwent several months of physical therapy. Daily narcotic medication was only moderately helpful. She had seen “a dozen” doctors in various specialties and tried multiple treatments, including anesthetic injections and bioelectric stimulation therapy, but her pain was unrelenting. Throughout this ordeal and for years prior, Ms. Adams smoked marijuana daily, explaining that a joint enjoyed in hourly puffs softened her pain and helped her to relax. She did not drink alcohol or use other illicit drugs. Prior to the accident, Ms. Adams had worked at a neighborhood salon for more than 20 years. She was proud to have a number of devoted clients, and she relished the camaraderie with her colleagues, whom she referred to as “my real family.” She had been unable to return to work since her accident on account of the pain. “These doctors keep telling me I’m good to go back to work,” she said with visible anger, “but they don’t know what I’m going through.” Her voice broke. “They don’t believe me. They think I’m lying.” She added that although friends reached out after the accident, lately they had seemed less sympathetic. She let the calls go to voice mail most of the time because she just did not feel up to socializing on account of the pain. In the last month, she had stopped bathing daily and gotten slack about cleaning her apartment. Without the structure of work, she often found herself up until 5:00 a.m., and pain woke her several times before she finally got out of bed in the afternoon. As for her mood, she said, “I’m so depressed it’s ridiculous.” She often felt hopeless of any possibility of living without pain but denied ever thinking of suicide. She explained that her Catholic faith prevented her from considering taking her own life. Ms. Adams had never seen a psychiatrist before and did not recall ever having felt depressed prior to her accident, although she described a “hot temper” as a family trait. She spoke of only one meaningful romantic relationship, years ago, with a woman who was emotionally abusive. When asked about any legal difficulties, she revealed several arrests for theft in her 20s. She was “in the wrong place at the wrong time,” she said, and was never convicted of a crime. A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. Evidence: B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms. 2. Persistently high level of anxiety about health or symptoms. 3. Evidence: Excessive time and energy devoted to these symptoms or health concerns. C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Evidence: BONUS 3 POINTS: Code based on the nature and severity of the symptoms. Select ALL that apply. Bonus points only granted if you select only the correct answers, not if you select additional incorrect ones. Getting this question incorrect does not count against you. With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Mild: Only one of the symptoms specified in Criterion B is fulfilled. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom). MAJOR DEPRESSIVE DISORDER Yvonne Perez was a 23-year-old woman who presented for an outpatient psychiatric evaluation 2 weeks after giving birth to her second child. She was referred by her breast-feeding nurse, who was concerned about the patient’s depressed mood, flat affect, and fatigue. Ms. Perez said she had been worried and unenthusiastic since finding out she was pregnant. She and her husband had planned to wait a few years before having another child, and her husband had made it clear that he would have preferred that she terminate the pregnancy, an option she would not consider because of her religion. He had also been upset that she was “too tired” to do paid work outside of the home during her pregnancy. She had then become increasingly dysphoric, hopeless, and overwhelmed after the delivery. Breast-feeding was not going well, and she had begun to believe her baby was “rejecting me” by refusing her breast, spitting up her milk, and crying. Her baby had become very colicky, so she felt forced to hold him most of the day. She wondered whether she deserved this difficulty because she had not wanted the pregnancy. Her husband was gone much of the time for work, and she found it very difficult to take care of the new baby and her lively and demanding 16-month-old daughter. She slept little, felt constantly tired, cried often, and worried about how she was going to get through the day. Her mother-in-law had just arrived to help her care for the children. Ms. Perez was an English-speaking Hispanic woman who had worked in a coffee shop until midway through her first pregnancy, almost 2 years earlier. She had been raised in a supportive home by her parents and a large extended family. She had moved to a different region of the country when her husband had been transferred for work, and she had no relatives nearby. Although no one in her family had seen a psychiatrist, several family members appeared to have been depressed. She had no prior psychiatric history or treatment. She denied illicit drug or alcohol use. She had smoked for several years but stopped when she was pregnant with her first child. Ms. Perez had a history of asthma. Aside from a multivitamin with iron, she took no medications. On mental status examination, Ms. Perez was a casually dressed, cooperative young woman. She made some eye contact, but her eyes tended to drop to the floor when she spoke. Her speech was fluent but slow, with increased latency when answering questions. The tone of her speech was flat. She endorsed low mood, and her affect was constricted. She denied thoughts of suicide and homicide. She also denied any hallucinations and delusions, although she had considered whether the current situation was punishment for not wanting the child. She was fully oriented and could register three objects but only recalled one after 5 minutes. Her intelligence was average. Her insight and judgment were fair to good. A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. • Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or slowing nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Evidence: B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Evidence: C. The episode is not attributable to the physiological effects of a substance or another medical condition. Evidence: D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. Evidence: E. There has never been a manic episode or a hypomanic episode. Evidence: Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. BONUS 5 POINTS: Code based on the nature and severity of the symptoms. Select ALL that apply. Bonus points only granted if you select only the correct answers, not if you select additional incorrect ones. Getting this question incorrect does not count against you. Single Episode Recurrent Episodes Mild Moderate Severe With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern (recurrent episode only)

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