Case Vignette Assignment 2 (10 points)

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Rachel
Rachel sits sullen, head down, tearful and conveys her persistent worry; If I dont get this under control I am afraid he will leave me.
For the past two weeks Rachel has felt despondent and sad. She cant seem to shake it, as if there were a dark cloud hovering over her throughout
the day. Im worthless as a spouse, as a daughter, as a human being. Who would want me in their life? If I were dead and gone perhaps I
wouldnt be a burden on them anymore, but if I were dead I know it would hurt them all, so I cant win either way. At work recently she has not
been able to keep her mind on her work. She has just felt that her gas tank is on E. Trying to keep up at work and home feels like she is
climbing up a hill in slow motion. Nothing right now is appealing to her, not food, not her hobbies, not catching up with friends.
Rachel still feels significant guilt for a recent period of time where her husband said that she just lost it. Rachel spent several
hundreds of dollars on craft supplies because she was planning to make projects and earn extra money. While she enjoys crafts this was surprising
to her husband because it was so impulsive and she has never made crafts on this level or in this number. She just seems to be running all the
time. She hasnt been coming to bed, and I dont think she is sleeping very much. During these few days she seemed more elated and fun, but
she couldnt seem to keep her body or mind still and at times was more impatient and irritable than usual.
The past year has been a roller coaster, he reports. This is not the first time we have had issues with her bouncing off the walls and
spending money on pointless stuff. This also happened at the beginning of the year, and after that she had several weeks where she got like this
again, so down she could barely keep going. Things then seemed better and back to normal for some time, but then she had another month or so
where she was back down, and then another. It just seems in this past year that there have only been a few periods of a couple of months straight
at any given time where she has not gone back and forth from either being off in a hole or soaring through the sky.
1. Based upon this vignette identify the likely diagnosis/diagnoses, including any applicable rule out (R/O) diagnoses (if any). List ICD code
number, diagnosis, and any applicable specifiers

Diagnosis: F31.32 Bipolar I Disorder, Major Depressive Episode, Moderate, with rapid cycling

2. How would you support or justify your diagnosis? What details support what criteria? Explain
these in narrative form, meaning that each answer needs to be at least a paragraph or more (one
to two sentences will not suffice) with attention to writing using complete sentences, appropriate
grammar (spelling, punctuation) and clear organization and expression of content.
I would justify my diagnosis based on the provided symptoms of mania she has
previously experienced. I would also say that rapid cycling is justified by the number of mood
shifts in the previous year and that only a few periods of a couple of months straight at any
given time where she was not experiencing mood shifts. She is definitely in a major depressive
episode as shown by the last 2 weeks being despondent, worthlessness, diminished ability to
think or concentrate at work or home, recurrent thoughts of death (if I were dead and gone
perhaps I wouldnt burden them), loss of interest in hobbies, friends, eating food.
3. What conditions would you look to rule out?
Major Depressive Disorder because of a reported history of Mania, Bipolar II because it
appears as she has had manic episodes not hypomanic based on the length of time it was
reported she was soaring through the sky, Anxiety disorders because of the excessive money
spent on crafts which was reported as impulsive, her lack of sleeping much in that time period,
report of her being more elated and fun but could not keep her body or mind still.

4. What are three pieces of information you would like to know that would help you to either
better support the diagnosis or to better understand this individual?
When did the symptoms of mania and depression first appear?
Has the mood changes always been the same as the past year?
Has anyone in your family had mood swings similar to you?

Angie
Angie, 28, shows up wearing a sweater with the Character Eeyore on it from Disneys Winnie the Pooh. Thats the nickname my
family gave me, so if the sweater fits, wear it. Angies childhood and family were chaotic. She lost her father, the family experienced recurrent
episodes of homelessness, and Angie and her older sister were even once removed from the home by CPS for a time due to their mother being
neglectful. The family has always struggled financially and has limited resources.
Angie reports that she has felt depressed for as long as I can remember. She more generally identifies her high school years as the
general start for her feeling down. Since then she cannot recall any significant period of time when she did not feel depressed. She can enjoy
some activities at times and loves her family and friends, but she persistently feels down. She tends to overeat, complains of low energy, and
often feels hopeless about her future. She describes herself in very demeaning and self-deprecating ways, minimizing her intelligence, appearance
and capabilities.
She says sometimes she drinks too much when she sets out to try and feel better. She becomes much attached to men very quickly and
begins to feel dependent on them, the relationship and their treatment of her for her well-being. Sadly this pattern of dependence and meeting
men in settings while drinking has led to a series of abusive partners. Right now she is working and living with a friend, but in the past she says
her depression has not only interfered with her romantic relationships but states it has also led to budgeting and financial problems where she has
ended up in debt and behind on bills.
1. Based upon this vignette identify the likely diagnosis/diagnoses, including any applicable rule out (R/O) diagnoses (if any). List ICD code
number, diagnosis, and any applicable specifiers

Diagnosis: F34.1 Persistent Depressive Disorder with atypical features, early onset, moderate

2. How would you support or justify your diagnosis? What details support what criteria? Explain
these in narrative form, meaning that each answer needs to be at least a paragraph or more (one
to two sentences will not suffice) with attention to writing using complete sentences, appropriate
grammar (spelling, punctuation) and clear organization and expression of content.
I would justify my diagnosis by the length of time she has been experiencing depressed
mood (over 2 years) most of the day more days than not. The symptoms of overeating, low
energy, hopelessness she reports feeling. The atypical features are justified because of her mood
reactivity (she can enjoy some activities at times) as well as interpersonal rejection sensitivity
(having many relationships and being dependent on them) and weight gain (admitted over
eating). Early onset is justified because of her reporting to feeling this way since at least high
school (she is 28 now and was feeling this way before age 21).
3. What conditions would you look to rule out?
I would rule out major depressive disorder because of the length of time she has stated
she consistently felt depressed mood (since at least high school and she is 28 now). There has

been no psychosis reported or observed. Not substance related because the depressed mood was
present before she was using substances (alcohol). I would rule out Bipolar I & II because no
evidence of mania or hypomania has been reported.
4. What are three pieces of information you would like to know that would help you to either
better support the diagnosis or to better understand this individual?
Have you ever met the full criteria for a major depressive episode?
Have you ever used any other substances besides alcohol?
Have you ever met men when you were sober of all substances?