ATYPICAL PSYCHIATRIC

PRESENTATION
Updated: July 05, 2021

DR WAHEEDULLAH

HISTORY
Patients with major depressive disorder will not present with a complaint of low mood,
anhedonia, or other typical symptoms every time. Almost patients will present with
complaints of (e.g., fatigue, headache, abdominal distress, or change in weight).
Patients may complain more of irritability or difficulty concentrating than of sadness or
low mood, but children with major depressive disorder may also present with initially
misleading symptoms such as irritability, decline in school performance.

Familial, social, and environmental factors

Depression is must attached with family history, and very important to ask the family
members of Depression history, social and environmental factors, even in preschool
children, hospitalized children whose parents were not allowed to visit them.

Dysphoric mood
A dysphoric mood may show from the patient face, setting, speaking as sadness,
heaviness, numbness, sometimes irritability and mood swings, sometime with a loss
of interest or pleasure in their usual activities, difficulty concentrating, or loss of
energy and motivation. Some patients will complain of feelings worthlessness,
hopelessness, or helplessness.

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ATYPICAL PSYCHIATRIC PRESENTATION

Psychosis
Psychosis is a condition that affects the way your brain processes information. It
causes you to lose touch with reality. You might see, hear, or believe things that
aren't real. Psychosis is a symptom, not an illness. 26-Jul-2021
Patients with major depressive disorder commonly show deep thinking. Nevertheless,
it is important to evaluate each patient for evidence of psychotic symptoms, because
this affects initial management.
Symptoms of psychosis should prompt a careful history evaluation to rule out any of
the following:
 Bipolar affective disorder  Schizoaffective disorder
 Organic brain syndrome  Schizophrenia
 Substance abuse

PHYSICAL EXAMINATION
No physical findings are specific to major depressive disorder; the diagnosis is stand
on history and the mental status examination. Nevertheless, a complete mental
health evaluation should always include a medical evaluation to rule out organic
conditions that might imitate a depressive disorder. Most of these fall into the
following major general categories:
 Infection  Endocrine disorder  Medication
 Tumor  Neurologic disorder

Appearance and affect

Most patients with major depressive disorder present with a normal appearance. In
patients with more severe symptoms, a decline in grooming and hygiene can be
observed, as well as a change in weight. Patients may show psychomotor
retardation, as well as demonstrate a flattening or loss of reactivity in the patient's
affect (i.e., emotional expression). Psychomotor agitation or restlessness can also be
observed in some patients with major depressive disorder.

Speech
Speech may be normal, slow, monotonic, or lacking in spontaneity and content.
Pressured speech should suggest anxiety or mania.

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ATYPICAL PSYCHIATRIC PRESENTATION

Major Depressive Disorder

The specific DSM-5 criteria for major depressive disorder are outlined below.
At least 5 of the following symptoms have to have been present during the same 2-
week period.
 Depressed mood: For children and adolescents, this can also be an
irritable mood
 Lose interest or loss of pleasure in almost all activities (anhedonia)
 Weight change or appetite disturbance
 Sleep disturbance (insomnia or hypersomnia)
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness
 Less ability to think or concentrate;
 Recurrent thoughts of death, recurrent suicidal ideation without a specific
plan, or a suicide attempt or specific plan for committing suicide
The symptoms cause significant distress or impairment in social, occupational or
other important areas of functioning.
The disturbance is not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorders
Depressive disorders can be rated as mild, moderate, or severe.

DEPRESSION WITH ANXIOUS DISTRESS

Anxious distress is defined as the presence of at least 2 of the following symptoms;
 Feeling keyed up or tense
 Feeling unusually restless
 Difficulty concentrating because of worry
 Fear that something awful may happen
 Feeling of potential loss of control
Severity is further specified as:
 Mild: Two symptoms
 Moderate: Three symptoms
 Moderate-severe: Four or five symptoms
 Severe: Four or five symptoms with motor agitation
High levels of anxiety are associated with higher suicide risk, longer duration of
illness.

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ATYPICAL PSYCHIATRIC PRESENTATION

DEPRESSION WITH MELANCHOLIC FEATURES

In depression with melancholic features, either a loss of pleasure in almost all
activities or a lack of reactivity to usually pleasurable stimuli is present. Additionally,
at least 3 of the following are required:
 Depressed mood.  Depression that is worse
in the morning
 Waking up 2 hours earlier  Observable psychomotor
than usual retardation or agitation
 Weight loss or anorexia  Excessive or unsuitable
guilt
A depressed mood that is described as more severe, longer lasting or present without
a reason is not considered. Melancholic features are more frequent in inpatients and
are less likely to occur in milder major depressive episodes. They are also more likely
to be comorbid with psychotic features.

DEPRESSION WITH CATATONIA

The DSM-5 criteria for diagnosis of depressive episodes with catatonia requires the
presence of 3 or more of 12 psychomotor features during most of the episode:
 Stupor  Catalepsy
 Waxy flexibility  Mutism
 Negativism  Posturing
 Mannerism  Stereotypy
 Agitation  Grimacing
 Echolalia  Echopraxia

ATYPICAL DEPRESSION
An episode of depression may be identified as having atypical features.
Characteristics of this subtype are mood reactivity and exclusion of melancholic and
catatonic subtypes in addition to 2 or more of the following for a period of at least 2
weeks:
 Increased appetite or weight gain
 Increased sleep
 Feelings of heaviness in arms or sensitivities of the legs.

POSTPARTUM DEPRESSION
Depression in the postpartum period is a common and potentially very serious
problem; up to 85% of women can develop mood disturbances (ie, “postpartum
blues”); however, 10-15% of women experience of depression, and 0.1-0.2% of
women experience postpartum psychosis.

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ATYPICAL PSYCHIATRIC PRESENTATION

Postpartum psychiatric illness was initially conceptualized as a group of disorders

specifically linked to pregnancy and childbirth.
Postpartum mood disorder (major depressive or manic) episodes with psychotic
features appear to occur in from 1 in 500 to 1 in 1000 deliveries. The risk is
particularly increased for women with prior postpartum mood episodes but is also
elevated for those with a prior history of a depressive or bipolar disorder or a family
history of bipolar disorder. Women who have had a postpartum episode with
psychotic features have a risk of recurrence between 30-50% for subsequent
deliveries.
Signs and symptoms of postpartum depression are clinically indistinguishable from
major depression that occurs in women at other times. These symptoms interfere
with the mother’s ability to function, with risk of self-harm or harm to the infant.
The American Academy of Pediatrics (AAP) states that more than 400,000 infants
are born each year to mothers who are depressed.
Treatment of depression is essential for both maternal and infant well-being and can
improve outcomes.

SEASONAL AFFECTIVE DISORDER

About 70% of depressed people feel worse during the winter and better during the
summer. Patients with seasonal affective disorder are more likely to report atypical
symptoms, such as hypersomnia, increased appetite, and a craving for
carbohydrates.
Diagnosing seasonal affective disorder in children is difficult because they experience
the recurrent universal stressor of beginning school every autumn. Also, a young
child might present with apparent seasonal affective disorder but not yet have had
previous episodes.

MAJOR DEPRESSIVE DISORDER WITH PSYCHOTIC

FEXATURES
The presentation of severe major depressive disorder may include psychotic
features. Psychotic features include delusions and hallucination. Major depressive
disorder with psychotic features is considered a psychiatric emergency. Patients may
require psychiatric hospitalization.

OTHER SPECIFICED DEPRESSIVE DISORDERS

The DSM-5 includes a category of disorders with features of depression that do not
meet criteria for a specific depressive disorder. Examples include the following: [2]
 Recurrent brief depression
 Short duration depressive episode

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ATYPICAL PSYCHIATRIC PRESENTATION

 Depressive episode with insufficient symptoms

METABOLIC DEPRESSION
Several studies report an association between metabolic syndrome and depression.
However, longitudinal studies have also shown that depression predicts subsequent
obesity and centripetal obesity, likely because of poor diet, lack of exercise, and
psychobiologic changes such as increased cortisol levels.
On the other hand, individuals with depression who have metabolic syndrome may
simply be more likely to have persistent or recurrent depression. Thus, depression
with metabolic abnormalities could be labeled metabolic depression, a possible
chronic subtype of depression.

CULTURAL INFLUENCES ON EXPRESSION OF DEPRESSION

Cultural influences on the presentation of depression can be significant, culturally
distinctive experiences (e.g., fear of being hexed or bewitched; experience of
visitations from the dead) should be distinguished from actual hallucinations or
delusions that may be part of a major depressive episode with psychotic features.

SUICIDAL IDEATION
Patients with depression should be assessed for suicidal ideation, especially if
agitation is present. When a patient has contemplated or attempted suicide, the
burden is on the health care provider to directly explore the situation with the patient
in as much detail as possible to determine the current presence of suicidal ideation
as well as accessible means and plans. Discussing these is the most important step
clinicians can take in an attempt to prevent suicide in an at-risk patient.

The end

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