Scenario for Analysis

Cara M. is a sixteen year-old, single female who comes from a very wealthy family. Cara is in high school and has successfully maintained high grades and has many friends, and has had a successful career as an elite soccer player. Until recently, she has seemed to have strong moral values and make healthy decisions for herself. Her parents have been very proud of her and her mature decision-making.

Cara’s parents bring her to the pediatrician's office stating that things have recently changed for Cara. She has dropped her long-term friends and begun having more sporadic friendships. Her parents suspect that she has started using drugs and drinking alcohol. They also recently found a used pregnancy test in her room. When confronted by her parents, Cara stated that she is not using drugs or having sex. Rather, she claimed these items belong to a friend, and she became angry, stating that they were invading her privacy.

Since then, Cara has been acting very angry in the house and yelling at her parents and brothers. Her parents are aware that, in the past, she seemed to have a slight problem with depression, which they thought was due to stress at school. She was never treated for depression, however, and they thought she was having “normal” teenage “ups and downs.” Her parents state that she has never acted angry and impulsive as she has lately. Her mother states that other family members have some mental illness, but she does not want to discuss those issues in the therapy session.

Cara comes into her appointment without her parents and states that she has been feeling somewhat out of control lately. She states that her emotions have been very intense and that she does not know how to deal with them. Cara finally admits that she has even cut herself on her arms twice because it seems to “help with her pain.” The cutting scared her, and she wants to learn how to handle her emotions in healthier ways. She also relays that she has recently experienced times when she cannot sleep for a few days. During this time, she was tempted to use drugs and be promiscuous. She reports that she cannot control her “racing thoughts.” She reported feeling emotionally out of control and like she was going to have a “breakdown.” She reports strained relationships, especially at home, and she just wants things to feel more manageable again.

What are other important assessment questions for Cara and her family from a biological, psychological and social perspective?
What possible medical conditions or concerns would you need to rule out?

Co-morbid Conditions

Depression occurs with other mental disorders. As discussed previously, the biochemical mechanisms are intricate and overlapping with physical and mental illnesses. This same situation occurs along the pathways are involved in mental illness. As with medical/mental co-morbidity, it is important to treat the primary illness where there is co-morbidity of more than one mental illness.

Mental illnesses co-morbid with depression and anxiety can be separated into five main categories as follows:

- Anxiety
- Eating disorders
- Personality Disorders
- Psychosis
- Substance Abuse

Anxiety

Anxiety in a person with a major depression often leads to poor treatment response, reduced social and work function, increased chronicity and increased risk of suicidal behavior.

Among those with mild-to-moderate depression, 11% also suffer from panic disorder, 3% from bipolar disorder and 46% from concurrent anxiety disorders. (30) 80-90% with Major Depressive Disorder also have anxiety symptoms such as anxiety, obsessive preoccupations, panic attacks, phobias, excessive health concerns. (30)

About one third of individuals with Major Depressive Disorder also have a full-blown anxiety disorder; either Panic Disorder, Obsessive-Compulsive Disorder or Social Phobia. (30) Panic disorder leads to a risk of suicide in as many as 15% of cases. (11)

Separation anxiety is prominent in children. (9, 16) Also present is sadness, hopelessness, anger and depression from security needs felt when parents leave or are absent. This is often seen in hospitalized children.

Anxiety may manifest as panic disorder after pregnancy in conjunction with postpartum depression. There are psycho/biophysical factors contributing to PPD but the anxiety often limits lifestyle choices and lowers self-esteem contributing to the hopelessness inherent in the depression itself.

Of all the psychiatric illnesses treated by healthcare professionals, anxiety disorders are the most common. They affect all ages including children and adolescents. Adding to the risk factors are such demographics as age under 45 years, smokers, low socioeconomics, separation or divorce and abuse survivors. A single patient may have more than one anxiety disorder or other psychiatric illnesses. Left untreated the anxiety worsens and can lead to suicide. (11)


Eating Disorders (ED)

Individuals with Anorexia and Bulimia often develop Major Depressive Disorder. (30) Depression is the result of the chemical imbalances caused by these diseases from malnutrition, excessive exercising or purging.

Other factors contributing to the depressive symptoms are the unresolved feelings that are suppressed by their ED patterns which have become maladaptive coping mechanisms for feelings and life situations.

The drive to be thin is an intense physical and emotional process that overrides all of the body’s cues to nourish itself. (28) Depression can be the result of the chemical imbalances caused by these diseases from malnutrition, excessive exercising or purging.

Other factors contributing to depressive symptoms are the unresolved feelings that are suppressed by their ED patterns that have become their maladaptive coping mechanisms for feelings and life situations. Many clinicians will see a destabilization of mood when their ED clients are in treatment because this “coping mechanism” is no longer in place and seeming to keep them “stable.” This usually subsides with treatment that includes the learning of effective, healthy coping mechanisms.

Many of the body’s physical systems are compromised when a client/patient has an eating disorder. This can lead to severe and sometimes irreversible medical complications, even death.

Personality Disorders

Personality disorders often limit the functioning of the individual cutting him/her off from job, support and other resources. Depression may be the first symptom to bring the client to therapy.

This enduring pattern of inner experience and behavior often starts in adolescence or early adulthood and leads to extremes of distress and impairment. Personality disorders often limit the functioning of the individual cutting him/her off from job, support and other resources. Depression may be the first symptom to bring the client to therapy.

The exact etiology of these disorders is unclear but many of them seem to share underlying limbic system and sympathetic nervous system reactivity with mood disorders, as well as problems in cortical functioning and processing, that account for their shared symptoms.

For instance, Borderline Personality Disorder (BPD) is associated with mood disorders, substance abuse, anxiety disorders, dissociative identity disorder and eating disorders. There are correlations of biologic abnormalities with the affective instability, psychotic episodes, and impulsivity of BPD clients. These include limbic system and frontal lobe dysfunction, decreased serotonin activity and increased receptor site reactivity for stress responses. (11)

Histrionic Personality Disorder affects 2-3% of the population. In males it may manifest with substance abuse problems while women usually present with depression, suicidal attempts and medical symptoms that seem unexplained. (11) When this individual enters the medical system his or her symptoms may be treated appropriately or passed off as a mental illness manifestation. This way some actual illnesses, even cancers, are missed; or patients receive medication where none is required.

There are too many personality disorders to elaborate on each one in this module. The most important fact to retain is that there is a co-morbidity with depression. The impulsivity and other behaviors associated with many of these disorders predispose individuals to acts of suicide, inaccurate treatment by medical personnel or other lethal situations.

Psychosis

Mood congruent delusions and hallucinations may accompany severe Major Depressive Disorder. (19) This could complicate the diagnosis of the primary mental disorder and render treatment ineffective. Additionally, the life changes and limitations from the onset of psychosis may lead to the hopelessness and helplessness of depression.

This enduring pattern of inner experience and behavior often starts in adolescence or early adulthood and leads to extremes of distress and impairment. Personality disorders often limit the functioning of the individual cutting him/her off from job, support and other resources. Depression may be the first symptom to bring the client to therapy.

The exact etiology of these disorders is unclear but many of them seem to share underlying limbic system and sympathetic nervous system reactivity with mood disorders, as well as, problems in cortical functioning and processing, which accounts for their shared symptoms.

Depressions among clients/patients with psychosis are important to recognize and to treat appropriately. The suicide rate among schizophrenics is 10% which is higher than that of the general population. (11) Those with schizoaffective disorder have more mood responses than those with schizophrenia and are very susceptible to suicide. (11)

Mood congruent delusions and hallucinations may accompany severe Major Depressive Disorder. (30) This could complicate the diagnosis of the primary mental disorder and render treatment ineffective. Also, the life changes and limitations from the onset of psychosis may lead to the hopelessness and helplessness of depression.

Individuals who have been diagnosed with Schizophrenia and other thought disorders are at high risk, not only from their disease, but from the medications used to treat them. As well as leading to diabetes in many cases, some psychotropic medications in use can lead to Neuroleptic Malignant Syndrome (NMS). This occurs in about 1% of those taking such medications as Haldol or other dopamine blockers.

NMS can be a fatal situation and 33% of patients with this complication do die as a result. (11) NMS is characterized by severe muscle rigidity with an elevated temperature greater than 99.5 and usually between 101 and 103F. This is accompanied by two or more of the following:

- Tachycardia (rapid heart rate)
- Hypoxia (decreased oxygen)
- Hypertension or hypotension (elevated or low blood pressure)
- Excessive diaphoresis (sweating)
- Incontinence (loss of bowel and bladder control)
- Tremor
- Change in mental status ranging from confusion to coma
- Mutism (inability to speak)
- Lab tests showing elevated leukocytes, creatinine phosphokinase and metabolic acidosis. (10)

The psychotic illnesses are life altering. The clients/patients face many losses as a result of their onset, from their basic ability to feel control in their lives to the loss of job, family and most of their support systems. Diagnosis and treatment are often complicated by their co-morbidity with depression. With the high incidence of suicide among this population it is important to make thorough and ongoing assessment of these individuals.

An awareness of the potential for NMS is necessary for the clinician who may encounter this phenomenon in their practice, in the emergency room or in other medical settings. Melanie, the client discussed in the previous section was likely experiencing signs of this syndrome.

Substance Abuse

Many individuals with depression self medicate with alcohol which adds to their problem making diagnosis and treatment difficult. Conversely, people with alcohol or drug addictions have a high rate of depression.

There is a co-morbidity rate of 21% for mild-to–moderate depression and substance abuse and one of 19% with drug abuse apart from alcohol. (10)
Depression may also be a consequence of drug or alcohol withdrawal and is commonly seen after cocaine and amphetamine use. (11)

Alcohol or street drugs are often mistakenly used as a remedy for depression, but actually worsen a Major Depressive Disorder. (19) Many individuals with depression self medicate with alcohol which adds to their problem making diagnosis and treatment difficult. Conversely, people with alcohol or drug addictions have a high rate of depression.

The coexistence of a substance use disorder and a mental disorder is often diagnosed and treated under the heading of Dual Disorders. These manifest in four possible ways:

- The primary mental illness with subsequent substance abuse – this is the case of self-medication to cope with the symptoms of the primary mental illness. These individuals usually have poor coping skills, impaired judgment and poor impulse control.
- A primary substance use disorder with psychopathologic sequelae – in this case, the psychiatric symptoms manifest due to intoxication, withdrawal or chronic abuse of alcohol or drugs.
- Dual primary diagnosis – here the mental illnesses and the substance abuse exist together and exacerbate each other.
- A common etiology – this is the case of one factor causing both disorders such as genetics, dopamine dysfunction or cholinergic activity dysfunction (HPA axis). These problems predispose clients/patients to affective disorders and substance abuse through their own body chemistry. (10)


At highest risk for suicide are males with substance abuse that is chronic with frequent relapses, frequent short hospitalizations, impulsive behavior, negativity toward treatment, suicidal gestures, psychosis and depression. Periods of untreated psychosis and treatment with older antipsychotic drugs have also been associated with increased suicidal behavior and attempts. (10)

Alcohol and drug-dependent individuals are at high risk for other causes of death as well. Their behaviors while intoxicated often put them in harms way for homicide and infections such as HIV or hepatitis. They face an increased rate of diabetes, liver disease, gastrointestinal problems, high blood pressure and stroke.

Often these clients/patients enter the medical system for treatment of their medical symptoms. Their substance abuse goes untreated; their abuse interferes with medications and medical treatments; their general health complicates healing; their tendencies towards impulsivity or treatment resistance further impair medical outcomes.

For these reasons, treatment of the substance abuse as the primary disease being aware of the possibility for dual disorders is vital to the prevention of further complications and even death in these cases.


Summary

Differential diagnosis is critical to the development of an effective treatment plan - which may include a combination of therapies. The effectiveness of these interventions will depend on the ordering of interventions to treat the primary disease first. Therefore, it is necessary to be aware that a client’s symptoms may be due to medications, medical illness, trauma, alcoholism, mental illness or a combination of all of these. The order and timing of these interventions will be critical to their success.

Summary Page

Depression/Anxiety Accompanying other Mental Illnesses: Co-morbid

HOW THEY CAUSE SYMPTOMS:

There is an overlap in the psychodynamic as well as the neuro-chemical factors that predispose the individual to the above disorders as well as to depression.

Within each individual their mechanisms of physiological arousal, cognitive processing and coping responses are critical to the manifestation of symptoms. These mechanisms are unique to each individual and provide different symptom clusters that may indicate a primary depressive illness or some other psychiatric disorder.

Sometimes, as in the case of eating disorders and substance abuse, the side effects of the disease caused by malnutrition or biochemical dysfunction lead to symptoms of depression/anxiety.

The psychotropic medications used to treat certain mental illnesses can mask an underlying primary depression or the depression can be the result of the psychosocial impact of the mental illness on the individual.

CRITICAL ASPECTS OF ASSESSMENT:

In the case of co-morbid mental illnesses, it is important to determine which is the primary illness and to treat this first. In the case of substance abuse, this disorder must be stabilized first. If the client/patient presents with symptoms of over-medication this must be stabilized first before other therapies can begin.

Since substance use clouds cognitive processing as well as emotional vulnerability, a clearing through abstinence for a period is necessary before beginning cognitive therapies. Substances taken by the abuser can interfere with medications dispensed by medical professionals for their physiologic symptoms as well as altering the effects of medications given for their psychiatric illnesses.

The effect of eating disorders on the cognitive/perceptual functioning of the individual is much the same as the effect of abused substances. The person has come to rely on the feelings associated with their eating disorder to deal with life situations and emotions. Therefore, the eating disorder would require primary attention.

It is important to assess the individual’s pre-morbid as well as current responses to situations. A normal response consists of three parts: physiological arousal, cognitive processes and coping responses.

It is important to be aware of the risk factors for various psychiatric illnesses. For instance the risk factors for anxiety are such demographics as age under 45 years, smokers, low socioeconomics, separation or divorce and abuse survivors. A single patient may have more than one anxiety disorder or other psychiatric illnesses.

With some disorders such as Histrionic Personality Disorder there may be substance abuse problems in males while women usually present with depression, suicidal attempts and medical symptoms that seem unexplained. When this individual enters the medical system their symptoms may be treated appropriately or passed off as a mental illness manifestation. In this way some actual illnesses, even cancers, are missed; or patients receive medication where none is necessary.

RISKS AND DANGERS IF LEFT UNTREATED:

Many of the co-morbid mental illness conditions have a high risk of suicide especially among those clients/patients with psychosis or impulse control disorders. Left untreated the anxiety worsens and can lead to suicide.

As well as leading to diabetes in many cases, some psychotropic medications in use can lead to Neuroleptic Malignant Syndrome (NMS). This occurs in about 1% of those taking such medications as Haldol or other dopamine blockers. NMS can be a fatal situation and 33% of patients with this complication do die as a result.

Inaccurate diagnosis may miss underlying medical illnesses which left untreated can lead to death or impairment while focus remains on the co-morbid mental illnesses.

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