Mood Disorder
Case Report
Written by Group 6
1. Case History
Introduction
Alana is a young woman who suffers from mental health issues starting from childhood.
She went through early signs of anxiety at age nine and experienced depression by age twelve.
Her mental health issues can be traced back to some traumatic event that had so profoundly
affected her emotional well-being; hence, she has suffered from long-term feelings of emptiness
and hopelessness. Diagnosed with major depressive disorder and generalized anxiety disorder,
Alana has started consistent therapy recently. For years, she has faced all of this alone; now, she
goes twice a week. Although on medication, she was actually discouraged from treatment by her
family, which had prevented her from seeking help earlier. Currently, she is looking for a way to
get better by attending therapy sessions, as well as finding more about her life and purpose in it.
History of Presenting Complaint
Alana reports feeling severely depressed since age 12 with episodes of persistent
emptiness, feeling worthless, and having an inability to find joy in things that should otherwise
bring joy. She experiences anxiety beginning at age nine, resulting in a constant unease that is
always felt. In terms of her depressive times, she will go months without feeling the pleasure she
should feel regarding things in life. Despite going to a psychiatrist and receiving medication, she
was discouraged by family from taking the medication and did not continue any treatment until
much later.
Psychiatric History
The first psychiatric diagnosis Alana received was a diagnosis of major depressive
disorder. She was evaluated by a psychiatrist and diagnosed following a single session. She
reports generalized anxiety disorder, an on-going problem since childhood. She began regular
therapy only three months ago and comes to see psychiatrist twice a week. The depression and
anxiety symptoms she is currently experiencing have been ongoing for more than a decade. She
has never had consistent treatment for the symptoms.
Medical History
There is no mention of major physical health problems. Alana reports that a doctor once
told her that she had Premenstrual Dysphoric Disorder (PMDD), but she monitored her
symptoms and realized that her depressive episodes were not necessarily tied to her menstrual
cycle. She does not report any chronic physical illnesses or substance abuse.
Family History
Alana does not mention the mental history of her family in detail. She does say that her
family was against her seeking psychiatric treatment when she first sought help and made her not
take prescribed medication. She has later found support from a friend outside her family who
now checks in on her mental well-being.
Personal History
Alana had a traumatic experience at age nine that really changed her mental health. She
described a long history of emotional repression and isolation, feeling like no one in her life saw
her, even when she tried to express her struggles. Alana has learned to mask her depression,
pretending to be happy in social and professional settings. She finds moments of real happiness
fleeting, and her work in creating online content often exacerbates her feelings of emptiness.
2. Mental Status Exam (MSE)
The appearance and motor activity of Alana were not noticed as being agitated, lethargic,
or impulsive, indicating that she remains calm and has steady movement. The speech of Alana
was clear, which means that she is able to verbalize her thoughts in a coherent manner, though
emotionally she is mess inside.
In terms of cognition, Alana exhibited signs of being distracted and slowed; this is
consistent with the cognitive impairments that are so commonly observed in major depressive
disorder and generalized anxiety disorder. She will likely have difficulties focusing or sustaining
attention during conversation or tasks. Her insight and judgment were noted as being limited,
indicating while she may have some ability to recognize her state of affairs, she does not
understand just how her thoughts and feelings are affecting her, the hallmark of people with
chronic depression and anxiety.
3. Physical Examination
Although Alana's record does not detail a formal physical examination, she seems to be
maintaining her physical health. She states that she does self-care such as doing makeup or going
out, but these usually do not make her happy. There is no history of neglect or apparent physical
suffering, but her emotional numbness and the weight of "masking" her real emotions indicate a
need for continued emotional support.
4. Summary and Diagnosis
Alana comes with an obvious diagnosis of Major Depressive Disorder and Generalized
Anxiety Disorder. Her symptoms include sadness, emotional worthlessness, and significant
anxiety. She finds herself being unable to enjoy anything at times and feels that she has done
nothing worthwhile. Such a condition is compounded by the years of emotional alienation and
the pressure to carry a mask of happiness both at home and at work. Alana also exhibits
emotional exhaustion symptoms, contributing to her worsening depressive symptom.
5. Formulation
Alana's mental health issues arise from early traumatic experiences and prolonged
emotional neglect. Her depressive and anxious symptoms began in childhood and worsened due
to the lack of early intervention. The rejection she experienced when she tried to seek help has
probably added to her feelings of isolation. In spite of the suicide attempts, she shows herself
capable of improvement and hope for good mental health, since she continues to go to therapy
and tries to reach out the people through her work.
6. Management
A comprehensive treatment plan for Alana would include continuation of therapy, with
Cognitive Behavioral Therapy to combat the negative thought patterns and Dialectical Behavior
Therapy to teach the emotional regulation. Reconsideration of continuing on her medication
management must be taken to alleviate the symptoms of depression and anxiety and include a
focus on collaborative decision-making to help Alana feel supported in her use of medication.
Moreover, she would also require support groups to alleviate the sense of loneliness and bring a
community in her life. She might even practice mindfulness like meditation or journaling that
can keep intruding thoughts at bay. Regular sessions with a respected mental health professional
would keep her in check on progress and assure her of hearing her out for the rest of the healing
journey that she may undertake.
