Persistent Depressive Disorder Case Studies & Practical Application 3 — Questions and Answers
Question 1: A social worker notices a client has had chronic low mood for 3 years but continues to work and maintain relationships, though with significant effort. This level of functioning is most consistent with which feature of PDD?
- Ruling out PDD because functioning is preserved
- The chronic but subthreshold nature of PDD that impairs but does not incapacitate (Correct answer)
- Cyclothymic Disorder with predominant depressive cycling
- Malingering due to intact occupational function
Correct answer: The chronic but subthreshold nature of PDD that impairs but does not incapacitate
PDD is characterized by persistent but often subthreshold symptoms that impair quality of life and functioning without necessarily causing complete incapacitation.
Question 2: A patient reports that her depressive symptoms began before age 21. According to DSM-5, how should this be documented?
- As a separate specifier: 'with early onset' (Correct answer)
- As a specifier: 'with late onset'
- Early onset does not change the diagnosis or documentation
- Reclassify as childhood-onset MDD rather than PDD
Correct answer: As a separate specifier: 'with early onset'
DSM-5 includes the specifier 'with early onset' for PDD when onset is before age 21, which has prognostic and treatment implications.
Question 3: During a clinical interview for PDD, a patient says she feels 'empty and hopeless most of the time but not crying or obviously sad.' How should the clinician interpret this?
- Depressed mood requires visible sadness, so PDD is less likely
- Emptiness and hopelessness can qualify as depressed mood for PDD (Correct answer)
- This presentation suggests Bipolar II hypomanic baseline
- These symptoms indicate alexithymia, not depression
Correct answer: Emptiness and hopelessness can qualify as depressed mood for PDD
In PDD, the persistent depressed mood can present as emptiness or hopelessness rather than overt sadness or tearfulness.
Question 4: A 50-year-old man with a 10-year history of PDD discontinues his SSRI after feeling 'fine' for 6 months. Within 3 months he relapses. What does this pattern illustrate?
- The SSRI caused a dependency syndrome requiring tapering
- Long-term maintenance treatment is often necessary for PDD (Correct answer)
- Six months of remission is sufficient for safe discontinuation
- He likely has undiagnosed bipolar spectrum disorder
Correct answer: Long-term maintenance treatment is often necessary for PDD
PDD has a high relapse rate after medication discontinuation, indicating that many patients require long-term or indefinite maintenance pharmacotherapy.
Question 5: Which psychotherapy has the strongest evidence base specifically adapted for the chronic nature of PDD?
- Interpersonal Therapy (IPT) only
- Cognitive Behavioral Analysis System of Psychotherapy (CBASP) (Correct answer)
- Motivational Interviewing (MI)
- Dialectical Behavior Therapy (DBT)
Correct answer: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
CBASP was specifically developed to treat chronic depression/PDD and has the strongest evidence base for this population.
Question 6: A patient with PDD also misuses alcohol regularly. Which clinical principle should guide the treatment approach?
- Achieve full sobriety before initiating antidepressant treatment
- Alcohol use disorder is likely the cause of PDD and will resolve with sobriety
- Address both PDD and alcohol use disorder concurrently with integrated treatment (Correct answer)
- Prioritize PDD treatment, as alcohol use is a coping mechanism that will self-resolve
Correct answer: Address both PDD and alcohol use disorder concurrently with integrated treatment
Integrated treatment addressing both PDD and substance use simultaneously produces better outcomes than sequential treatment of either disorder alone.
Question 7: A patient's PDD questionnaire reveals low self-esteem, poor concentration, and hypersomnia but no anhedonia or suicidal ideation. What does the absence of anhedonia indicate in this context?
- PDD diagnosis is invalid without anhedonia
- PDD requires anhedonia only if symptoms last less than 2 years
- Anhedonia is not a required symptom of PDD; only depressed mood is mandatory (Correct answer)
- The clinician should diagnose MDD instead, as PDD always includes anhedonia
Correct answer: Anhedonia is not a required symptom of PDD; only depressed mood is mandatory
PDD requires persistent depressed mood plus two or more associated symptoms; anhedonia is not listed as a core required symptom in DSM-5's PDD criteria.
Persistent Depressive Disorder Case Studies & Practical Application 3
A social worker notices a client has had chronic low mood for 3 years but continues to work and maintain relationships, though with significant effort.
This level of functioning is most consistent with which feature of PDD?