A COMPLEX CASE OF DIAGNOSING BEREAVEMENT

Abstract

Introduction Diagnostic criteria regarding mood symptoms that develop after the loss of a loved one have changed significantly with the introduction of the DSM V. The DSM V provides additional guidance regarding the diagnosis of several disorders in the setting of a loss. These include normal grief, Major Depressive Disorder, Persistent Complex Bereavement Disorder with or without traumatic bereavement, and PTSD. However, accurate diagnosis may still pose a challenge, as the symptoms of these diagnoses have significant overlap especially when the loss is in the context of trauma. A case that highlights this diagnostic challenge will be presented. This case also illustrates the importance of gaining a thorough understanding of a patient's symptoms and associated thought content to distinguish between diagnoses. Methods Ms. A is a 70-year-old patient seen in the geriatric psychiatry clinic for depressive symptoms one year after the traumatic death of her longtime boyfriend. He had a cardiac arrest in their home, and she provided CPR until EMS arrived and took him to the hospital where he later passed. Despite the time that has lapsed, she still thinks of the circumstances surround his death quite often, and she feels significant guilt about his passing and about what more she could have done to save him. She also reports flashbacks to the event where she sees herself doing CPR on him, though she has no avoidance behaviors and goes on dates occasionally. Though she feels like she is slowly ‘getting over’ the loss, she has had worsening middle insomnia, lack of energy, and mild anhedonia for the past few months. Her mood is intermittently poor, feeling irritable and isolative for parts of the day and lasting for a few hours each time. She has had some weight gain, but no changes in concentration or appetite. She also denies thoughts of death and dying, and does not have thoughts of wanting to join her boyfriend in death. Results Testing included MOCA: 23/30, GAD-7: 2, DAST-10: 0, PHQ-9: 4. She did not meet diagnostic criteria for MDD or PTSD. As her symptoms have persisted more than 6 months after the stressor, Adjustment Disorder is not an appropriate diagnosis. Her final diagnosis was determined to be Persistent Complex Bereavement Disorder with Traumatic Bereavement. She was referred for psychotherapy, and an SSRI was deferred because of her wish to minimize medications. She was also started to trazadone 50mg at night for symptomatic relief of her sleep disturbance. Conclusions Understanding the subtleties of these symptoms is paramount in establishing an accurate diagnosis and therefore referring patients to the most effective therapy. This case demonstrates some complexities of psychiatric diagnosis in the setting of grief in the context of trauma. As part of this case presentation, a chart comparing symptoms among the differential diagnoses will be outlined. This research was funded by None PDF: http://submissions.mirasmart.com/Verify/AAGP2019/Original/AAGP2019-000371/AAGP2019-000371_Fig1.pdf