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           Crystal Smith, a 33-year-old African American homemaker, came to an outpatient clinic seeking “someone to talk to” about feelings of despair that had intensified over the previous 8-10 months. She was particularly upset about marital conflict and an uncharacteristic mistrust of her in-laws.

           Ms. Smith said she had begun to wake before dawn, feeling down and tearful. She had difficulty getting out of bed and completing her usual activities. At times, she felt guilty for not being her “usual self.” At other times, she became easily irritated with her husband and her in-laws for minor transgressions. She had previously relied on her mother in law to assist with the children, but she no longer entirely trusted her with that responsibility. That worry, in combination with her insomnia and fatigue, made it very difficult for Ms. Smith to get her children to school on time. In the past few months, she had lost 13 pounds without dieting. She denied current suicidal ideation, saying she “would never do something like that,” but acknowledged having that that she “should just give up” and that she “would be better off dead.”

           Two months previously, Ms. Smith had seen a psychiatrist for several weeks and received fluoxetine. She reluctantly gave it a try, discontinuing it quickly because it made her feel tired. She had also dropped out of therapy, indicating that the psychiatrist did not seem to understand her.

           Ms. Smith lived with her husband of 13 years and two school age children. Her husband’s parents lived next door. She said her marriage was good, although her husband suggested she “go see someone” so that she would not be “yelling at everyone all the time.” While historically sociable, she rarely talked to her own mother and sisters, much less her friends. A regular churchgoer, she had quit attending because she felt her faith was “weak.” Her pastor had always been supportive, but she had not contacted him with her problems because “he wouldn’t want to hear about these kinds of issues.”

           Ms. Smith described herself as having been an outgoing, friendly child. She grew up with her parents and three siblings. She recalled feeling quite upset at age 10-11 when her parents divorced and her mom remarried. Because of fights with other kids at school, she met with a school counselor with whom she felt a bond. Unlike the psychiatrist she had recently consulted, Ms. Smith felt the counselor did not “get into my business” and helped her recovery. She said she became quieter as she entered junior high school, with fewer friends and little interest in studying. She married her husband at age 20 and worked in retail sales until the birth of their first child when she was 23 years old.

           Ms. Smith had not used alcohol since her first pregnancy and denied any use of illicit substances. She denied past and current use of prescribed medications, other than the brief trail of the antidepressant medication. She reported generally good health.

           On mental status examination, Ms. Smith was a casually groomed young woman who was coherent and goal directed. She had difficulty making eye contact with the white middle aged therapist. She was cooperative but mildly guarded and slow to respond. She needed encouragement to elaborate her thinking. She was periodically tearful and generally appeared sad. She denied psychosis, although she reported occasion ally feeling mistrustful of her family. She denied confusion, hallucinations, suicidality, and homicidality. Cognition, insight, and judgement were all considered normal. 

What is the Differential Diagnosis with rationale, medication management, and appropriate follow-up?

Please describes the symptoms, assessment, differential diagnosis with rationale, and treatment recommendations.

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