Psychiatry [MOOD– LIFE AND DEATH]

Introduction
DSM-IV had Grief / Bereavement and Depression. DSM-V has Grief Depression
added persistent complicated bereavement disorder. This makes
things harder. See these as two concretely different diseases -
grief and depression - and PCBD being “in between.” Grief has
a shorter duration, with a mild depressed mood, but all the
attention and sadness is focused on the dead. Depression is Normal Abnormal
hopelessness, the loss of happiness, and sadness that’s pervasive Focus on deceased Focus on self
in all life. It’s actually easier than you think. Future is possible, No future is possible,
full of hope hopeless
Grief
After the loss of a loved one (a major stressor) there are two
reactions. Grief is a normal reaction that doesn’t impair normal Things that say “grief only”
functioning and will improve spontaneously - though it may
progress to depression. Onset can be anything, and, especially on - Ability to have fun / be happy with family
the test, duration must be < 12 months. It is important to let the - NO psychotic features, or if they sound psychotic, then
griever grieve, but also always be cognizant of the potential for there IS insight
suicide. Grief is hopeful and usually waxes and wanes. The - Any depressed mood revolves around the deceased or
patient CAN be happy with family and friends and CAN see the things that involved the deceased
future. Any depressive symptoms are focused at the deceased – - Happiness is possible
anhedonia, depressed mood, spontaneous crying. Even psychotic-
like features – talking TO the deceased, maintaining rituals as if
the deceased is present – if there IS INSIGHT (there isn’t
psychosis), even that is normal. Do not TREAT guilt – but you
can offer therapy sessions to get them through it.

Depression Things that say “this is depression”

Conversely, depression is pathologic - often impairing function
- and won’t resolve on its own. Using duration of symptoms - Depressed mood all the time
doesn’t work anymore (PCBD makes it less useful). In - YES psychotic features or NO insight
depression, the mood symptoms are there, but there has been a - Depressed mood is pervasive in elements of life beyond
transition away from the deceased, and the symptoms have those that included the deceased
become pervasive in the patient’s life. Depression is hopeless, - Happiness is impossible
is PERVASIVE in multiple elements of life, and does NOT wax - Hopelessness, despondent
and wane. The patient CANNOT be happy with family and
friends, and CANNOT see the future. If there’s any evidence of
psychotic features (lacking insight), then the diagnosis
immediately becomes depression with psychotic features; it
can’t be Grief or PCBD. Treat depression with SSRI or SnRIs,
ensure to contract for safety, and screen for suicide.

Persistent Complicated Bereavement Disorder

If there’s mostly depression but the emphasis remains focused
on the deceased (it’s NOT pervasive in all their life), or the
duration has exceeded 12 months but they don’t meet depression
criteria, call it PCBD. Treat PCBD with SSRI or SnRI just like
depression. PCBD is either persistent (>12 months) or complex
(hopelessness, persistent depressed mood) but it’s NOT pervasive
into all elements of a patient’s life. PCBD is almost never the right
answer on the test because it’s fairly ambiguous.

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 Psychiatry [MOOD– LIFE AND DEATH]

Adjustment Disorder after loved one dying

By definition, AD can’t be in the setting of bereavement.

Post-Traumatic Stress Disorder after loved one dying

PTSD can occur if the death of the loved one is violent or tragic.
PTSD will focus on flashbacks, avoidance, and fear rather than
on depressed mood. On the test, it will either be “obviously PTSD
in a violent death” or “obviously depression with a non-violent
death.” Baby Blues Post-Partum Post-Partum
Depression Psychosis
Baby #1 > #1 >#1
Post-Partum Differential
Cares about Doesn’t care Fears the baby,
The birth of a child can be a fairly stressful event. So stressful that baby about baby, may likely to kill it
is can produce mood symptoms, or more often reveal hurt baby
underlying psychiatric predisposition. To form a differential Timing Onset and Onset within 1 Onset within 1
and therefore know how to intervene, look at the timing, severity Duration month month
of symptoms, and mom’s feeling about baby. It’s especially within 2 weeks duration ongoing Duration
important to keep a close eye on a patient who has a history of ongoing
post-partum psychiatric illness or those beginning to exhibit Depression Dysthymic MDE None
symptoms. Bring a patient back for close follow-up. The goal’s Psychosis None None
to prevent mom from hurting herself or baby. Because there’s a Treatment Nothing Anti-depressants Mood stabilizers
or
gradual descent into disease (there’s no “switch”) it may be
Antipsychotics
possible to detect and prevent potential tragedy.

Kubler-Ross Stages of Death and Dying

Everyone deals with death of a loved one or even their own dying Denial
process in a different way. There are five stages typically Depression
encountered that may progress in any order, skip around, or go
Bargaining
back and forth between them. It’s not just an academic exercise
Anger
to decide which stage a patient is in; it’s useful to anticipate
Acceptance
reactions and decide what tone or stance to take with the patients.
On the test, it’s pretty easy to spot which stage someone is in. In
DDBAA (repeating) or DABAD (palindrome)
life, it takes a significant amount of emotional intelligence to get
it right.

Grief PCBD Depression

Onset Any > 6 months Any
Duration < 12 months > 12 months > 12 months
------------------------------------------------------------------------------------------------------------------------
Focus
- Dysphoria Deceased à Pervasive
- Guilt Global
- Anhedonia

When mood Waxes and wanes ß Persistent

Imagine Happy Cannot Imagine Happy

Behaviors Talking TO ß Hallucinations

Praying AT Auditory – WITH
Rituals As if there Visual – SEE
“Glimpse in crowd” Psychotic Features
+ insight No Insight

Why Deceased à Negative Self,

considering Despondent, Hopeless
Suicide

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