Persistent Depressive Disorder Case Studies & Practical Application 5 — Questions and Answers
Question 1: A patient with PDD reports that despite treatment, she still feels 'not quite right' and functions below her premorbid level. This residual impairment is best described as which PDD treatment challenge?
- Treatment resistance requiring ECT
- Partial remission with residual symptoms, common in PDD (Correct answer)
- Medication noncompliance needing a different drug class
- Secondary gain preventing full recovery
Correct answer: Partial remission with residual symptoms, common in PDD
Partial remission with lingering residual symptoms is a common and clinically significant challenge in PDD, often requiring augmentation or combined treatment strategies.
Question 2: A therapist is using CBASP (Cognitive Behavioral Analysis System of Psychotherapy) with a PDD patient. What is the core mechanism that CBASP targets?
- Unconscious conflicts from early childhood
- Learned helplessness and disconnection between behavior and interpersonal outcomes (Correct answer)
- Dysfunctional automatic thoughts about future catastrophes
- Emotional dysregulation and impulsivity
Correct answer: Learned helplessness and disconnection between behavior and interpersonal outcomes
CBASP targets the perceived functional disconnection between a patient's behavior and its real-world interpersonal consequences, which is central to chronic depression.
Question 3: A 60-year-old man has had PDD for 20 years and has tried three different SSRIs without adequate response. What augmentation strategy has the most evidence in treatment-resistant chronic depression?
- Adding a benzodiazepine to his current SSRI
- Augmenting with an atypical antipsychotic such as aripiprazole (Correct answer)
- Switching to an herbal supplement (St. John's Wort)
- Adding a stimulant as monotherapy
Correct answer: Augmenting with an atypical antipsychotic such as aripiprazole
Augmentation with atypical antipsychotics (e.g., aripiprazole, quetiapine) has evidence supporting their use in antidepressant-refractory chronic depression.
Question 4: A patient meeting PDD criteria reports her symptoms began 3 months after losing her job and have persisted ever since (now 2.5 years). The clinician must differentiate PDD from prolonged grief or adjustment disorder. What feature most supports PDD?
- A clear psychosocial stressor at onset rules out PDD
- Duration beyond 6 months satisfies adjustment disorder criteria
- Persistence beyond 2 years with required symptom criteria supports PDD regardless of initial stressor (Correct answer)
- The stressor-linked onset means MDD is the correct diagnosis
Correct answer: Persistence beyond 2 years with required symptom criteria supports PDD regardless of initial stressor
PDD can be precipitated by a stressor; once symptoms persist beyond 2 years with required criteria met, PDD is the appropriate diagnosis regardless of the initial trigger.
Question 5: A clinician reviews a patient's PHQ-9 scores over 18 months and finds consistently mild scores (8–10) with no score-free intervals. Which finding on structured interview would best confirm a PDD diagnosis?
- One or more prior manic episodes
- Persistent depressed mood plus at least 2 of: poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, or hopelessness (Correct answer)
- Psychotic features during periods of lowest mood
- At least 5 MDD criteria met continuously for 2 years
Correct answer: Persistent depressed mood plus at least 2 of: poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, or hopelessness
DSM-5 PDD requires chronically depressed mood plus at least two of the six specified associated symptoms for at least 2 years.
Question 6: A school counselor observes a 12-year-old student who has been persistently irritable (not sad) with low energy and poor concentration for 14 months. Can this presentation qualify for a PDD diagnosis?
- No; PDD requires sad mood, not irritability, in all age groups
- No; PDD cannot be diagnosed before age 18
- Yes; irritable mood can substitute for depressed mood in children and adolescents (Correct answer)
- Yes; but only if a prior MDD episode has occurred
Correct answer: Yes; irritable mood can substitute for depressed mood in children and adolescents
In children and adolescents, DSM-5 allows irritable mood to satisfy the depressed mood criterion for PDD.
Question 7: A patient with PDD completes 16 weeks of combined SSRI and CBT therapy and achieves remission. What does research suggest about the risk of recurrence after treatment ends?
- Remission after combined treatment essentially eliminates future recurrence risk
- Patients with PDD have significantly elevated recurrence risk and often require maintenance treatment (Correct answer)
- Once remission is achieved, PDD rarely recurs because the underlying pathology resolves
- Recurrence risk in PDD is the same as for a single MDD episode
Correct answer: Patients with PDD have significantly elevated recurrence risk and often require maintenance treatment
PDD carries a high lifetime recurrence risk, and maintenance pharmacotherapy and/or continued psychotherapy are often recommended to sustain remission.
Persistent Depressive Disorder Case Studies & Practical Application 5
A patient with PDD reports that despite treatment, she still feels 'not quite right' and functions below her premorbid level.
This residual impairment is best described as which PDD treatment challenge?