Here is the rationale for the DSM diagnosis:
Axis I: The diagnosis of Major Depressive Disorder was made because Lauren’s primary symptoms revolve around her feelings of emptiness and hopelessness. She talks about having a “hole in [her] soul” (p. 8) and being invisible. She relates a time when she was so invisible she could not even set off the motion detectors set-up by her apparently ill mother to protect the family from the ‘return of the Nazis.’ Lauren describes her adolescence and young adulthood as if she has having never been free of these mood symptoms.
Lauren reports major depressive symptoms since childhood. The presence of major depressive episode is supported by the following symptoms as reported by Lauren:
1) Lauren suffers from a depressed mood most of the day, nearly every day by her own subjective report in her memoir. She has feelings of emptiness and describes on-going depression that is stifling and comforting – “like a blanket” (p. 51).
2) Lauren shows a markedly diminished interest or pleasure in all or almost all activities. She states that she knew nothing of pleasure before taking Prozac.
3) Weight loss: Lauren says that she had a diagnosis of anorexia as an adolescent and states that “in years [she] had not eaten a meal … without anxiety” (p. 37) indicating that weight maintenance is a chronic problem.
4) Worthlessness: Lauren feels invisible. She uses the words ‘emptiness’ and ‘dwindling’ to describe depression.
5) Lauren has recurrent suicidal ideation and has made at least one suicide attempt.
Lauren’s symptoms have been present over many years more or less constantly; therefore it appears that Lauren suffers from chronic major depression.
She has mood-congruent psychotic features associated with her mood disorder. She has delusions that eight people live inside of her and that these individuals talk to her (auditory hallucinations) and help her define herself. Lauren’s delusions are of a bizarre nature but they are congruent with her depressive mood. An example of congruence is this stanza about loss from a poem that Lauren reports was written by the ‘Blue Baby’ that lives inside her:
“Mother of many
Watch your children play
Hightailing across a field, leaving you
With nothing but a spray of snow.
So cup your hands and try to catch all that’s left
Of your children” (p. 45-46).
Lauren does not seem to meet the criteria for Schizophrenia because Major Depressive Episodes have occurred concurrently and for a long time relative to the duration of the active and residual periods of delusions and hallucinations. However, it is not clear that the psychotic symptoms occur exclusively during periods of mood disturbance. If this were found to be true with additional information from the client, the diagnosis of Major Depressive Disorder could be confirmed.
Lauren’s symptoms seem to meet Criterion A for Schizophrenia but are better described by Major Depressive Disorder with Psychotic Features than Schizoaffective Disorder because the emptiness and other depressive symptoms appear to be primary. Her depressive symptoms are not superimposed on Schizophrenia, or Schizophreniform Disorder.
Delusional Disorder was considered and ruled out. Lauren’s hallucinations can be considered bizarre. In addition, Lauren’s mood episodes are long and appear to be of the same duration as the delusions.
Psychotic Disorder, Not Otherwise Specified was also ruled out because her psychotic symptoms (delusions and hallucinations) appear to be secondary to her feelings of emptiness.
Laura has not reported any Manic or Hypomanic Episodes.
Lauren also has a diagnosis of Obsessive-Compulsive Disorder (OCD) and it is the recent sudden presentation of these symptoms that prompted her to seek additional help and new medication. Lauren reports that she is endlessly counting, touching, checking, and tapping. She also reports repetitively checking the stove to make sure that she has turned it off. These behaviors meet the criterion for compulsion and the compulsions are considered excessive. The content of the compulsions are not restricted to the Major Depressive Disorder.
The current compulsions are causing significant interference with her normal routine causing her to be referred help for this specific condition. There is no evidence that the compulsions are due to substance abuse or any general medical condition.
Axis II: The social worker might also consider the diagnosis of Borderline Personality Disorder and, in fact, Borderline Personality Disorder is listed in the memoir as a diagnosis given to Lauren at age 19. With the information in the case study, Lauren does not seem to meet five of the criteria as required. Although she may meet some of the symptoms (chronic feelings of emptiness, unstable identity as indicated by the people living inside her), there is no evidence in PROZAC DIARY of the defining feature of borderline personality disorder: a pattern of unstable and intense relationships.
Axis III: Lauren provided little medical information but appears to be without problematic medical conditions at this time.
Axis IV: Lauren appears to be estranged from her parents and her sisters. She only mentions them in the past tense. She does not appear to have a social network that she can rely on for support. She does not discuss having any friends and does not date. The client is currently unemployed. She has had menial jobs for short periods of time and been fired or quit. She reports living in a small, dank apartment with bugs and very little furniture.
Axis V: Lauren’s current global assessment of functioning was determined to be at 35. Lauren is not able to maintain a job or personal relationships. She is socially isolated and living in sub-standard housing conditions. She considers her delusions and hallucinations to be a defining factor in her life and the spark for her creativity. While she continues to have thoughts of suicide, she has not made an attempted suicide since she was in high school.