Anxiety, Depression, and Psychosis in a 24-Year-Old Woman

Adrian Preda, MD

Disclosures

December 05, 2018

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a Case Challenge, please contact us.

Background

A 24-year-old woman with a past diagnosis of schizoaffective disorder presents with a chief complaint of severe anxiety. She reports that she has been experiencing gradually worsening anxiety and depression over the past 2 months, despite ongoing treatment with a selective serotonin reuptake inhibitor (fluoxetine) and a second-generation neuroleptic (quetiapine).

She experienced her first "mental breakdown" around age 17 in the context of extreme stress. She was preparing for admission to a competitive college and experiencing relationship stress, the breakup of her first significant romantic relationship. She was unable to sleep for almost a week. Because she was severely agitated, she saw a psychiatrist who recommended admission to a psychiatric facility. She readily accepted inpatient treatment because she felt too unwell to function.

She has a poor recollection of her 2-3 weeks in the psychiatric hospital. She remembers taking "a ton of medications," being asleep most of the time, and "tied to a bed" during the brief moments when she would wake up. She was discharged on a second-generation antipsychotic (quetiapine), which she has continued at doses ranging from 200 mg to 400 mg total daily dose.

Over the past 7 years since her initial episode, she experienced one additional episode, following another romantic disappointment. During that episode, she described her mood quality as "agitated and wired." She experienced psychomotor agitation ("feeling restless") and abundant energy despite an inability to sleep for about 3 weeks. Her symptoms culminated with paranoid and grandiose delusions and resulted in a second hospitalization. With treatment that involved antipsychotic medications, her symptoms remitted and she returned to baseline normal functioning, including doing well in her current graduate studies. She is now engaged to be married following a 2-year stable relationship.

Unlike prior episodes, during the current episode, her mood is colored by a "black and unbearable sadness." She reports low energy levels and lack of motivation and interest, to the point that she stopped seeing her friends and going to school. Although her past episodes followed significant stress, she says that prior to the current episode, things were "going well" and reports no significant stressors.

As for her treatment, her prior psychiatrist gradually increased the dose of quetiapine from 200 mg daily to 200 mg twice daily and added fluoxetine, which was gradually escalated over a 4-week span from an initial dose of 10 mg daily to a dose of 40 mg daily. Following the medication changes, the patient experienced some improvement in her sadness, with brief, hours-long, sporadic episodes (2-3 times a week) of suddenly feeling better. She also reported a change in her overall mood quality from "just feeling sad" to "being sick with worries about anything and everything." However, she denies any thoughts or plans regarding suicide. Her associated symptoms also changed from decreased motivation to ambivalence ("I can't start anything") and from decreased energy to negative energy ("I am tired but restless"). Her sleep remained poor. She denies experiencing abnormal perceptions, disorganized or delusional thinking, or any other psychotic symptoms, and no evidence suggests any such elements were present.

Her other past psychiatric and developmental history is noncontributory. Regarding substance use, she reports drinking 1-2 glasses of wine "almost every evening" as a "nightcap to fall asleep" for the past month. She has no other history of alcohol or other substance abuse. Her past medical and surgical history is essentially negative. Her family history is negative for formal diagnoses, but she acknowledges that mental illness was stigmatized in her environment and that her father was "moody" but would not seek help. She has no family history of other psychiatric hospitalizations.

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