clinical presentation definition psychology

The Clinical Presentation

• First Online: 01 January 2013

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• Sergio V. Delgado 3 &
• Jeffrey R. Strawn 4  

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Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

Make everything as simple as possible, but not simpler —Albert Einstein (1879–1955)

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Sergio V. Delgado

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Delgado, S.V., Strawn, J.R. (2014). The Clinical Presentation. In: Difficult Psychiatric Consultations. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-39552-9_8

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8.1 Clinical Presentation

Section learning objectives.

• Identify and describe the five symptoms of schizophrenia spectrum disorders.
• Describe how schizophrenia presents itself.
• Describe how schizophreniform disorder presents itself.
• Describe how brief psychotic disorder presents itself.
• Describe how schizoaffective disorder presents itself.
• Describe how delusional disorder presents itself.
• Be able to distinguish the five disorders from one another.

8.1.1 Symptoms of Schizophrenia Spectrum and Other Psychotic Disorders

Individuals diagnosed with a schizophrenia spectrum or other psychotic disorder experience  psychosis,  which is defined as a loss of contact with reality and is manifested by delusions and/or hallucinations. These episodes of psychosis can make it difficult for individuals to perceive and respond to environmental stimuli, which can cause significant disturbances in everyday functioning. While there are a number of symptoms displayed in schizophrenia spectrum and other psychotic disorders, the presentation of symptoms varies greatly among individuals, as there are rarely two cases similar in presentation, triggers, course, or responsiveness to treatment (APA, 2013). We will now turn our attention to the five major symptoms associated with these disorders: delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms.

8.1.1.1 Delusions

Delusions are defined as “fixed beliefs that are not amenable to change in light of conflicting evidence” (APA, 2022, pp. 101). This means that despite evidence contradicting one’s thoughts, the individual continues to fixate on a false (i.e., erroneous) belief. There are a variety of delusions that can present in many different ways:

• Grandiose delusions –  beliefs they have exceptional abilities, wealth, or fame; the belief they are God or other religious saviors
• Persecutory delusions –  beliefs they are going to be harmed, harassed, plotted, or discriminated against by either an individual or an institution
• Referential delusions –  beliefs that specific gestures, comments, or even larger environmental cues (e.g., an ad in the newspaper, a terrorist attack) are directed at them
• Delusions of control –  beliefs that their thoughts/feelings/actions are controlled by others
• Delusions of thought broadcasting –  beliefs that one’s thoughts are transparent and everyone knows what they are thinking
• Delusions of thought withdrawal –  belief that one’s thoughts have been removed by another (e.g., alien) source

The most common delusion is persecutory (APA, 2022). It is believed that the presentation of the delusion is largely related to the social, emotional, educational, and cultural background of the individual (Arango & Carpenter, 2010). For example, an individual with schizophrenia who comes from a highly religious family is more likely to experience religious delusions.

8.1.1.2 Hallucinations 

Hallucinations are defined as “perception-like experiences that occur without an external stimulus” (APA, 2022; pp. 102). Hallucinations can occur in any of the five senses including hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), touching (tactile hallucinations), or tasting (gustatory hallucinations). Additionally, they can occur in a single modality or present across a combination of modalities (i.e. experiencing both auditory and visual hallucinations). For the most part, individuals recognize that their hallucinations are not real and attempt to engage in normal behavior while simultaneously combating ongoing hallucinations.

According to various research studies, nearly half of all people with schizophrenia report auditory hallucinations, 15% report visual hallucinations, and 5% report tactile hallucinations (DeLeon, Cuesta, & Peralta, 1993). Among the most common types of auditory hallucinations are voices talking to the individual or various voices talking to one another. Generally, these hallucinations are not attributable to any one person that the individual knows. However, they are usually clear, objective, and definite (Arango & Carpenter, 2010) and occur with the same impact as normal perception (APA, 2022). Additionally, the auditory hallucinations can be pleasurable, providing comfort to the individuals; however, in other individuals, the auditory hallucinations can be unsettling as they produce commands or have malicious intent.

8.1.1.3 Disorganized Speech

Among the most common cognitive impairments displayed in individuals with schizophrenia spectrum and other psychotic disorders are disorganized speech and thoughts. More specifically, thoughts and speech patterns may appear to be  circumstantial  or  tangential . For example, individuals with circumstantial speech  may give unnecessary details in response to a question before they finally produce the desired response. While the question is eventually answered by individuals with circumstantial speech, those with tangential speech  never reach the point or answer the question, but rather jump from topic to topic. Derailment , or the illogical connection in a chain of thoughts, is another common type of disorganized thinking. The most severe form of disorganized speech is  incoherence  or word salad which is where speech is completely incomprehensible and meaningful sentences are not produced.

These types of distorted thought patterns are often related to concrete thinking. That is, the individual is focused on one aspect of a concept or thing, and neglects all other aspects. This type of thinking makes treatment difficult as individuals lack insight into their illness and symptoms (APA, 2013).

8.1.1.4 Disorganized Behavior

Psychomotor symptoms can also be observed in individuals with schizophrenia spectrum and other psychotic disorders. These behaviors may manifest as awkward movements or even ritualistic/repetitive behaviors. They are often unpredictable and overwhelming, severely impacting the ability to perform daily activities (APA, 2013). Catatonic behavior , or the decrease or even lack of reactivity to the environment, is among the most commonly seen disorganized motor behavior in schizophrenia spectrum disorders. These catatonic behaviors include:

• Negativism  –  resistance to instruction
• Mutism  –   complete lack of verbal responses
• Stupor  –  complete lack of motor responses
• Rigidity  – maintaining a rigid or upright posture while resisting efforts to be moved
• Posturing  –  holding odd, awkward postures for long periods of time

On the opposite side of the spectrum is catatonic excitement,  where the individual experiences hyperactivity of motor behavior. This can include  echolalia  (mimicking the speech of others) and  echopraxia  (mimicking the movement of others) but may also simply be manifested through excessive and/or purposeless motor behaviors.

8.1.1.5 Negative Symptoms

All symptoms discussed up until this point can be categorized as  positive symptoms or symptoms that involve the presence of something that should not be there (e.g., hallucinations and delusions) or disorganized symptoms (disorganized speech and behavior). The final set of symptoms included in the diagnostic criteria of several of the schizophrenia spectrum and other psychotic disorders is negative symptoms , which are defined as the inability, or decreased ability, to initiate actions, speech, express emotion, or feel pleasure (Barch, 2013). Negative symptoms are typically present before positive symptoms and often remain once positive symptoms remit. They account for much of the morbidity in schizophrenia but are not as prominent in the other psychotic disorders (indeed, as you will see, they are not included as a symptom in some of these other disorders). Because of their prevalence through the course of schizophrenia, they are also more indicative of prognosis, with more negative symptoms suggestive of a poorer prognosis. The poorer prognosis may be explained by the lack of effect that traditional antipsychotic medications have in addressing negative symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006) as well as from avolition impacting daily functioning.

There are five main types of negative symptoms seen in individuals with schizophrenia:

• Affective flattening –  reduction in emotional expression (i.e., a reduced display of emotional expression)
• Alogia  –  poverty of speech or speech content
• Anhedonia  –  decreased ability to experience pleasure
• Asociality – lack of interest in social relationships
• Avolition –  lack of motivation for goal-directed behavior

8.1.2 Types of Schizophrenia Spectrum and Other Psychotic Disorders

8.1.2.1 schizophrenia.

As stated above, the hallmark symptoms of schizophrenia include the presence of at least two of the following symptoms for at least one month: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) disorganized/abnormal behavior, (5) negative symptoms. At least one of these must be (1), (2), or (3). These symptoms must create significant impairment in the individual’s ability to engage in normal daily functioning such as work, school, relationships with others, or self-care. It should be noted that the presentation of schizophrenia varies greatly among individuals, as it is a heterogeneous clinical syndrome (APA, 2022).

While the presence of active phase symptoms must persist for a minimum of one month to meet the criteria for a diagnosis of schizophrenia, the total duration of symptoms must persist for at least six months before a diagnosis of schizophrenia can be made. This six-month period can comprise a combination of active, prodromal, and residual phase symptoms. Active phase symptoms represent the “full-blown” symptoms previously described. Prodromal  symptoms are “subthreshold” symptoms that precede the active phase of the disorder and  residual  symptoms are subthreshold symptoms that follow the active phase. These prodromal and residual symptoms are milder forms of symptoms that may not cause significant impairment in functioning, with the exception of negative symptoms (Lieberman et al., 2001). Due to the severity of psychotic symptoms, mood disorder symptoms are also common among individuals with schizophrenia; however, to diagnose schizophrenia there must either be no mood symptoms or if mood symptoms have occurred they must be present for only a minority of the total duration of the illness. The latter helps to distinguish schizophrenia from a mood disorder with psychotic features for which psychotic symptoms are limited to the context of the mood episodes and are never experienced outside a mood episode.

8.1.2.2 Schizophreniform Disorder

Schizophreniform disorder is similar to schizophrenia with the exception of the length of presentation of symptoms and the requirement for impairment in functioning. As described above, a diagnosis of schizophrenia requires impairment in functioning and a six-month minimum duration of symptoms. In contrast, impairment in functioning is not required to diagnose schizophreniform disorder. While many individuals with schizophreniform disorder do display impaired functioning, it is not essential for diagnosis. Moreover, symptoms must last at least one month but less than six-months to diagnose schizophreniform disorder. In this way, the duration of schizophreniform disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder (which we will consider next).

Approximately two-thirds of individuals who are initially diagnosed with schizophreniform disorder will have symptoms that last longer than six months, at which time their diagnosis is changed to schizophrenia (APA, 2013). The other one-third will recover within the six-month time period and schizophreniform disorder will be their final diagnosis.

Finally, as with schizophrenia, psychotic symptoms must be experienced outside of the context of mood episodes (if mood episodes are present). Further, any major mood episodes that are present concurrently with the psychotic features must only be present for a small period of time, otherwise, a diagnosis of schizoaffective disorder may be more appropriate.

8.1.2.3. Brief Psychotic   Disorder

A diagnosis of brief psychotic disorder requires one or more of the following symptoms: (1) delusions, (2)  hallucinations, (3) disorganized speech, and (4) disorganized behavior. Moreover at least one of these symptoms must be (1), (2), or (3). Notice that negative symptoms are not included in this list. Also notice that while schizophrenia and schizophreniform disorder require a minimum of two symptoms, only one is required for a diagnosis of brief psychotic disorder. To diagnose brief psychotic disorder symptom(s) must be present for at least one day but less than one month (recall: one month is the minimum duration of symptoms required to diagnose schizophreniform disorder). After one-month individuals return to their full premorbid level of functioning. Also, while there is typically very severe impairment in functioning associated with brief psychotic disorder, it is not required for a diagnosis.

8.1.2.4. Schizoaffective Disorder

Schizoaffective disorder is characterized by two or more of the symptoms of schizophrenia (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) and  a concurrent uninterrupted period of a major mood episode—either a depressive or manic episode. Those who experience only depressive episodes are diagnosed with the depressive type  of schizoaffective disorder while those who experience manic episodes (with or without depressive episodes) are diagnosed with the bipolar type  of schizoaffective disorder. It should be noted that because a loss of interest in pleasurable activities is a common symptom of schizophrenia, to meet the criteria for a depressive episode within schizoaffective disorder, the individual must present with a pervasive depressed mood (not just anhedonia). While schizophrenia and schizophreniform disorder do  not  have a significant mood component, schizoaffective disorder requires the presence of a depressive or manic episode for the majority, if not the total duration of the disorder. While psychotic symptoms are sometimes present in depressive episodes, they remit once the depressive episode is resolved. For individuals with schizoaffective disorder, psychotic symptoms must be present for at least two weeks in the absence of a major mood episode (APA, 2022). This is the key distinguishing feature between schizoaffective disorder and major mood disorders with psychotic features.

8.1.2.5. Delusional Disorder

As suggestive of its title, delusional disorder requires the presence of at least one delusion that lasts for at least one month. It is important to note that any other symptom of schizophrenia (i.e., hallucinations, disorganized behavior, disorganized speech, negative symptoms) rules out a diagnosis of delusional disorder. Therefore the only symptom that can be present is delusions. Unlike most other schizophrenia spectrum and other psychotic disorders, daily functioning is not overtly impacted in individuals with delusional disorder. Additionally, if symptoms of depressive or manic episodes present during delusions, they are typically brief and represent a minority of the total duration of the disorder.

The DSM 5-TR (APA, 2022) has identified several subtypes of delusional disorder in an effort to better categorize the individual’s specific presentation of the disorder. When making a diagnosis of delusional disorder, one of the following specifiers is included.

• Erotomanic type –  the individual reports a delusion of another person being in love with them. Generally speaking, the individual whom the convictions are about are of higher status such as a celebrity.
• Grandiose type –  involves the conviction of having a great talent or insight. Occasionally, individuals will report they have made an important discovery that benefits the general public. Grandiose delusions may also take on a religious affiliation, as some people believe they are prophets or a God.
• Jealous type –  revolves around the conviction that one’s spouse or partner is/has been unfaithful. While many individuals may have this suspicion at some point in their relationship, a jealous delusion is much more extensive and generally based on incorrect inferences that lack evidence.
• Persecutory type –  involves beliefs that they are being conspired against, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of their long-term goals (APA, 2022). Of all subtypes of delusional disorder, those experiencing persecutory delusions are the most at risk of becoming aggressive or hostile, likely due to the persecutory nature of their beliefs.
• Somatic type –  involves delusions regarding bodily functions or sensations. While these delusions can vary significantly, the most common beliefs are that the individual emits a foul odor, that there is an infestation of insects on the skin, or that they have an internal parasite (APA, 2022).
• Mixed type  – there are several themes of delusions (e.g., jealousy and persecutory)
• Unspecified type  – these are delusions that don’t fit into one of the categories above (e.g., referential delusions without a persecutory or grandiose nature to them).
• Bizarre content –  delusions that are clearly not plausible (in one’s culture) and do not stem from ordinary experience (e.g., the delusion that one is an alien or vampire).

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Case conceptualization: Key to highly effective counseling

By Jon Sperry and Len Sperry

December 2020

I n their first session, the counseling intern learned that Jane’s son had been diagnosed with brain cancer. The therapist then elicited the client’s thoughts and feelings about her son’s diagnosis. Jane expressed feelings of guilt and the thought that if she had done more about the early symptoms, this never would have happened to her son. Hearing this guilt producing thought, the intern spent much of the remaining session disputing it. As the session ended, the client was more despondent.  

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.

Presentation

Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.

Predisposition

Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.

Precipitants

Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.

Perpetuants

Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm

Predisposition:

• Biological: Paternal history of anxiety
• Psychological: Views herself as inadequate and others as critical; deficits in assertiveness skills, self-soothing skills and relational skills
• Social: Few friends, a history of social anxiety, and parents who were highly successful and critical
• Cultural: No acculturative stress or cultural stressors but from upper-middle-class socioeconomic status, so from privileged background — access to services and resources

Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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• v.23(1); 2020 May 20

Clinical presentation and need for treatment of a cohort of subjects accessing to a mental illness prevention service

Marco solmi.

1 Neurosciences Department, University of Padua

2 Neuroscience Center, University of Padua

3 Padua University Hospital, Psychiatry Unit, Padua, Italy

Mara Campeol

Federica gentili, angela favaro, carla cremonese.

Outreaching activities decrease prognostic accuracy of at-risk mental state defining tools, over-attracting subjects who are not at increased risk of mental illness. The setting was a mental illness primary indicated prevention outpatients service embedded within the Psychiatry Unit of Padua University Hospital, Italy. Help-seeking patients accessing the service between January 2018 and December 2018 were evaluated with validated tools assessing functioning, at-risk mental state, schizotypal personality features, depressive and anxious symptoms, together with medical and family history collection. The primary outcome was the prevalence of drop in functioning at presentation according to the Social and Occupational Functioning Assessment Scale (SOFAS). Secondary outcomes were diagnoses according to DSM-5 criteria and meeting criteria for at-risk mental state. Fifty-nine patients accessed the service, mean age was 18.8 (2.12) years old, 54.2% were females. Virtually all subjects (97.7%) had a drop in functioning. Baseline primary diagnoses were depressive episode in 33%, anxiety disorder in 21%, personality disorder in 17%, adjustment disorder 9%, conduct disorder 7%, schizophrenia spectrum disorder 5%, bipolar disorder 5%, eating disorder in 1.7%, dissociative disorder 1.7%. Overall, 59.1% met at-risk mental state criteria. Lower functioning was associated with anxious symptoms (p=0.031), a family history of mental illness (p=0.045) and of suicide (p=0.042), and schizotypal personality traits (p=0.036). Subjects accessing a prevention service embedded within the mental health department already present a trans-diagnostic drop in functioning, mainly due to a non-psychotic mental disorder, with at-risk mental state in one patient out of two, and schizophrenia or bipolar disorder already present in only 10% of subjects. Prevention service within mental health facility setting appears to properly detect subjects in need of treatment with a drop in functioning, at risk of developing severe mental illness, without any outreaching activity in the general population.

Introduction

Age of onset of mental illness is in adolescence or young adulthood the latest, (Birrell, Newton, Teesson, Tonks, & Slade, 2015 ; Goodwin & Hamilton, 2002 ; Hudson, Hiripi, Pope, & Kessler, 2007 ; Thorup et al., 2007 ) if not in childhood (neurodevelopmental disorders).(Atladottir et al., 2014 ) Duration of untreated illness is one of the main determinants of long-term outcome in subjects suffering from mental illness, (Compton, et al., 2011 ; Compton, Gordon, Weiss, & Walker, 2011 ; Ghio, Gotelli, Marcenaro, Amore, & Natta, 2014 ; Hung, Liu, & Yang, 2017 ; Medeiros, Senço, Lafer, & Almeida, 2016 ; Penttilä, Jaäske l ̈ ainen, Hirvonen, Isohanni, & Miettunen, 2014 ) yet it remains, for the vast majority of mental disorders, too long and generally far from meeting clinical recommendations. A provocative editorial has stated that psychogeriatrics starts right after adolescence, suggesting that the current worldwide mental health services organization splitting adult (age ≥ 18) from childhood/adolescence psychiatry fails to prevent or to intervene early in subjects with mental illness.(Parellada, 2013 ) Hence, mental illness prevention services have been and are being set up in several contexts, (Fusar-Poli et al., 2018; Fusar-Poli, Davies et al., 2019 ; Fusar-Poli, Estradé et al., 2019 ; Fusar-Poli, Oliver et al., 2019 ; McGorry, Hartmann, Spooner, & Nelson, 2018 ) with age intake threshold often below age 18.

However, it has also been shown that detection rates of subjects later developing psychosis is as low as 5%.(van Os & Guloksuz, 2017 ) Moreover, the transition rates (from at-risk state to psychosis) depend on several factors, with lower functioning and referrals from clinical contexts increasing the risk of transition to psychosis when meeting Ultra-High Risk (UHR+) criteria. Any attempt in improving detection rates through outreaching activities in the general population ultimately results in a dramatic loss of prognostic accuracy of the state-of-theart UHR definition tools(Fusar-Poli et al., 2016 ) (such as Comprehensive Assessment of At-Risk Mental State), (Yung et al., 2005 ) as opposed to referrals from medical or psychiatric clinical contexts, as well as low functioning which confer a pre-test risk enrichment, optimizing tools’ prognostic accuracy.

Hence, setting a mental illness prevention service within the context of a larger hospital, and specifically of a psychiatry department, without any outreaching activity, and solely relying on referrals from clinical contexts, might be expected to select subjects with adequate pre-test risk enrichment. Also, not limiting the target population to those subjects meeting UHR criteria might allow those individuals with different from UHR clinical profiles (which equally results in a drop in functioning) to receive an early assessment and eventual needs-based treatment.

The present work aims to describe the functioning level and eventual psychiatric disorders in subjects referring to a mental illness prevention service within a hospital, and specifically within a mental health department which did not engage in any outreaching activity.

The setting was a mental illness primary indicated prevention outpatients service embedded within the Psychiatry Unit of Padua University Hospital. The age intake threshold was 14. No outreaching activity in the general population was made, and all patients were referred by mental health specialists, emergency department, or general practitioners. Help-seeking patients accessing the service between January 2018 and December 2018 were evaluated with validated tools measuring functioning, atrisk mental state, schizotypal personality features, depressive and anxious symptoms, together with medical and family history collection.

Clinical assessment

More specifically, the Social and Occupational Functioning Assessment Scale (SOFAS)(Goldman, Skodol, & Lave, 1992 ) was used to measure functioning. SOFAS evaluates four areas of functioning, namely social relevant activities, including work and academic performance, social and personal relationships, self-care, disturbing and aggressive behaviors. Functioning is scored on a continuum from 0 (lowest) to 100 (highest), where range 90-100 and 80-90 identify people with greater functioning than the general population, 70 as a threshold for mild difficulties, 70 to 30 indicating moderate difficulties and score lower than 30 identifying subjects in need for support or supervision. Functioning was also assessed with the Health of the Nation Outcome Scale (HoNOS) e- Health of the Nation Outcome Scale for Children and Adolescents (HONOSCA). These multidimensional scales focus on daily functioning impairment due to symptoms. The adult version (HoNOS) consists of 12 items, while the adolescent one (HoNOS-CA) consists of 13 items. (Gowers et al., 1999 ; Pirkis et al., 2005 ; Wing et al., 1998 ) each item score goes from 0 (no problems at all), 1 (mild problem without the need of any specific action), 2 (issue of mild intensity but still relevant to the person functioning), 3 (moderate issue with the need for treatment) to 4 (serious to very severe problem). HoNOS and HoNOS-CA were the only instruments differing between adults and adolescents.

Global score can be split up into four subscales evaluating functioning impairment related to psychiatric symptoms, such as depression, anxiety, hallucinations, and concerns, related to impairment in global basic functions, as psychomotor, cognitive or physical limitations, related to behavior including violence both against self and the others, and finally related to social and environmental issues (housing problem, unemployment or financial difficulties, interpersonal troubles, and lack of social support). Schizotypal features were assessed with the Schizotypal Personality Questionnaire Brief Version (SPQ-B), already widely applied both in general and clinical population (Fonseca-Pedrero, Lemos-Giráldez, Paino, Sierra-Baigrie, & Muñiz, 2012 ; Fonseca-Pedrero, Paíno- Piñeiro, Lemos-Giráldez, Villazón-García, & Muñiz, 2009 ) with a cut-off score of 17 indicating the presence of schizotypal personality traits. Patients underwent the Comprehensive Assessment of At-Risk Mental States (CAARMS) (Yung et al., 2005 ) to assess whether they met the criteria for ultra-high risk (UHR) state. CAARMS is a semi-structured interview investigating seven psychopathological areas through dedicated domains: positive symptoms, cognitive functioning, affectivity, negative symptoms, behavioral changing, motility and experience of body, and general psychopathology. Positive symptoms are investigated with a specific focus on unusual thought content, not bizarre ideas, perceptive anomalies, and disorganized speech. Positive symptoms intensity and frequency, together with a drop in functioning defines whether a subject meets or does not meet UHR criteria. UHR criteria and the wider framework of the staging of schizophrenia we refer to in this work are reported in Table 1 . Depressive symptoms were assessed with the Hamilton Rating Scale for Depression (HAM-D), (Hamilton, 1960 ) and anxious symptoms with the Hamilton Rating Scale for Anxiety (HAM-A).(Hamilton, 1959 ) Diagnoses were formulated according to DSM-5 criteria, utilizing a clinical interview performed by a psychiatrist.

History collection

Clinical and family history were collected including family history for mental illness and suicide, perinatal complications, previous contacts with public mental health services, and ongoing psychopharmacological therapy. Substance use was also investigated, with special regards to cannabis. Some self-reported information was also collected, namely non-specific physical symptoms, as headache, asthenia, and gastrointestinal distress, along with stressful life events.

Primary and secondary outcomes

The primary outcome was a drop in functioning defined as SOFAS below 70, or a loss of more than 30% in SOFAS score in the last 12 months. Secondary outcomes were prevalence of primary diagnoses according to DSM- 5 criteria, and meeting UHR criteria.

Staging model of severe mental illness, and specific criteria for ultra-high risk for psychosis.

The staging model adapted from McGorry et al. 2006. UHR risk criteria adapted from Yung et al. ( 2005 ); APS: Attenuated Psychotic Symptoms; BLIPS: Brief Limited Intermittent Psychotic Symptoms; GRFD: Combination of Genetic Risk and Functional Decline.

Statistical Analysis

Frequency and mean values of primary and secondary outcomes were simply calculated with descriptive statistics. The normality of variables distribution was assessed with the Shapiro-Wilk test. Associations between clinical factors and primary outcome (codified as continuous scores) were assessed with Student’s t-test (categorical factors) or Pearson correlation (continuous factors) in case of normal distribution, or with Mann-Whitney’s U or ANOVA (categorical factors) or Spearman’s rho (continuous factors) in case of non-normal distribution. A chisquared test was used to compare the distribution of primary and secondary outcomes (codified as categorical values) across categorical factors. Statistical analysis has been performed with Jamovi open software for Windows.

Characteristics of the included sample, primary and secondary outcomes

Demographic characteristics and frequency of primary and secondary outcomes are reported in Table 2 . Fiftynine adolescents and young adults aged 15-24 accessed the prevention service embedded within Padua University Hospital, Psychiatry Unit. Overall mean age was 18.8 (2.12) years old, 54.2% were females.

A drop in functioning as measured with SOFAS below 50 was present in 32.6%, and below 70 in 97.7%, and mean SOFAS score was 56.5 (SD 11.3). The mean HONOS(-CA) score was 15.7 (SD 6.3). Patients were affected by a depressive episode (n=19; 32.7%), anxiety disorder (n=19; 32.7%), personality disorder (n=10; 17.3%,), conduct disorder (n=4; 6.9%), schizophrenia (n=3; 5.2%), bipolar disorder (n=3; 5.2%). Overall, 59.1% met UHR criteria. Specifically, subjects at UHR had Attenuated Psychotic Symptoms (77%), Genetic Risk and Deterioration syndrome plus Attenuated Psychotic Symptoms (19%), and Brief Limited Intermittent Psychotic Symptoms plus Attenuated Psychotic Symptoms (4%). UHR criteria were met most frequently in “not bizarre ideas” (61%) and unusual thought content (41.5%). Virtually all patients had at least mild anxious symptoms (96.9%), and 85.3% had at least mild depressive symptoms. SPQ-B was positive for schizotypal personality traits in 13.6%.

Characteristics associated with primary and secondary outcomes

Considering SOFAS, no correlation showed up with family history of psychiatric illness and family history of suicide, nor perinatal complications. Age, first degree relatives with psychiatric illness, previous contacts with public mental health services, ongoing psychopharmacological therapy, and substance misuse (cannabis) were not statistically significantly associated with functioning neither. Notably, considering SOFAS, functioning did not differ between UHR+ and UHR – subjects, across diagnoses, nor it correlated with depressive and anxious symptoms.

Considering HONOS and HONOS-CA, a family history of psychiatric illness and family history of suicide showed to be associated with a drop in functioning, when considering specific subscales ( Table 4 , Table 5 ). More in detail, second-degree family history of psychiatric illness was associated with the HoNOS subscale (p=0.045), family history of suicide with Symptoms HoNOS subscales (p=0.042), and schizotypal personality with social HoNOS subscale (p=0.036). Also, anxiety symptoms correlated with symptoms of HoNOS-CA (r=0.576, p=0.031). On the other hand, age, first degree relatives with psychiatric illness, previous contacts with public mental health services, ongoing psychopharmacological therapy, and substance misuse (cannabis) were not statistically significantly associated with functioning. HONOS and HONOS-CA did not differ between UHR+ and UHR- subjects even when specific subscales were considered. HONOS and HONOS-CA differed/did not differ across diagnoses neither and did not correlate with depressive or anxiety symptoms.

Associations among clinical factors and functioning are reported in Table 3 and Table 4 .

No association emerged between functioning and C-section ( Table 6 ).

This study shows that a primary indicated prevention service embedded in a mental health unit within a wider clinical context (general hospital) properly detects young help-seeking subjects who do have a drop in functioning, but who have not developed schizophrenia spectrum disorder nor bipolar disorder yet.

Prevention is still in its infancy in psychiatry. Duration of untreated illness has shown to be far from meeting duration criteria in several mental disorders, including depressive disorder, (Hung, Yu, Liu, Wu, & Yang, 2015 ) bipolar disorder, (Dagani et al., 2017 ; van Meter, Burke, Youngstrom, Faedda, & Correll, 2016 ) schizophrenia, (Compton et al., 2011 ) obsessive-compulsive disorder, (Albert et al., 2019 ) anxiety disorders, (Benatti et al., 2016 ) among others.(Kisely, Scott, Denney, & Simon, 2006 ) Such delay in detecting subjects with mental illness onset can be also due to the artificial splitting of mental health services between age under and greater than 18. As already suggested, psychogeriatrics start right after adolescence, (Parellada, 2013 ) and early intervention, hence prevention services (even more) should not set any age intake threshold. As shown by the present data, subjects start suffering from early symptoms of non-psychotic mental illness well before age 18, and all of them already have a drop in functioning when accessing prevention service. Also, the present data support the appropriateness across prevention services of a soft entry point(McGorry et al., 2018 ) rather than a stricter inclusion criteria focusing on UHR status only, (Yung et al., 2005 ) given that functioning is compromised across all diagnoses, and across both UHR+ and UHR- subjects, and given that no significant difference in terms of functioning emerged across such groups. Such a trans-diagnostic drop in functioning may be because among all subjects with anxiety disorders, reasonably only a small portion makes it to the clinical attention, leaving out subjects with the subclinical symptom, possibly seeking help outside of the clinical network of public health services. Indeed, the clinical setting and the absence of any outreaching activity of the service has both advantages and disadvantages. The advantages are related to the (mental health) clinical environment acting as a filter including only help-seeking and more severe cases who do have an increased risk of developing psychosis or bipolar disorder, for instance, (Fusar-Poli et al., 2016; Fusar-Poli, Sullivan, Shah, & Uhlhaas, 2019 ; Fusar-Poli, Werbeloff et al., 2019 ; van Meter et al., 2016 ) hence minimizing the risk to treat subjects whose symptoms might have self-remitted later without any intervention, thus minimizing the risk of any harm potentially related to psychotherapeutic or psychopharmacologic agents. The disadvantages are however that setting the prevention services within a clinical context might act as a barrier to those subjects with less committed help-seeking attitude, allowing also stigma(Green, Hunt, & Stain, 2012 ; Kamaradova et al., 2016 ) to delay referral to professional mental health context, ultimately prolonging the duration of untreated illness. Further studies should assess whether keeping prevention services within the clinical context in the local context where the present study is set is an effective approach in detecting only subjects actually at increased risk of developing schizophrenia or bipolar disorder or recurrent major depressive disorder, and at the same time in detecting a substantial proportion of those who later develop the conditions, also thanks to a softer entry point which might be a considerable difference from the criticized UHR paradigm- based services.(van Os & Guloksuz, 2017 ).

Demographic and clinical characteristics of the included sample.

SOFAS: Social and Occupational Functioning Assessment Scale. HONOS: Health of the Nation Outcome Scale; HONOS-CA: Health of the Nation Outcome Scale for Children and Adolescents; HAM-D: Hamilton Rating Scale for Depression; HAM-A: Hamilton Rating Scale for Anxiety; SPQ-B: Schizotypal Personality Questionnaire Brief Version; UHR: Ultra-High-Risk; APS: Attenuated Psychotic Symptoms; BLIPS: Brief Limited Intermittent Psychotic Symptoms; GRFD: Combination of Genetic Risk and Functional Decline.

Global functioning is homogenously compromised in help-seeking subjects aged 15 to 24.

SOFAS: Social and Occupational Functioning Assessment Scale; HONOS: Health of the Nation Outcome Scale; HONOS-CA: Health of the Nation Outcome Scale for Children and Adolescents; HAM-D: Hamilton Rating Scale for Depression; HAM-A: Hamilton Rating Scale for Anxiety; SPQ-B: Schizotypal Personality Questionnaire Brief Version; UHR: Ultra-High-Risk. U= Mann- Whitney’U; t=Student’s t.

The presence of only a few positive correlations suggests a homogenous distribution of functioning impairment across young help-seeking subjects included in the present study. There is the need for a comprehensive diagnostic assessment that has to go beyond the drop in functioning in young help-seeking subjects, to detect diagnosis- or spectrum-specific clinical features to administer the proper treatment. Also, the lack of significant differences in functioning across different clinical features might be due to the non-specific nature of SOFAS or similar instrument, which calls for new instruments measuring functioning with a finer-grained approach compared with those available to date.

Mean comparison between HONOS and HONOS-CA, global score and subscales with regards to the family history of psychiatric illness.

HONOS: Health of the Nation Outcome Scale; HONOS-CA: Health of the Nation Outcome Scale for Children and Adolescents; Sym: symptoms subscale; Soc: social subscale; Beh: Behavior subscale; Imp: Impairment subscale. U= Mann-Whitney’U; t=Student’s t.

Mean comparison between HONOS and HONOS-CA, global score and subscales with regards to the family history of suicide.

HONOS: Health of the Nation Outcome Scale; HONOS-CA: Health of the Nation Outcome Scale for Children and Adolescents; Sym: symptoms subscale; Soc: social subscale; Beh: Behavior subscale; Imp: Impairment subscale.

Mean comparison between HONOS and HONOS-CA, global score and subscales, with regards to C-section at birth.

HONOS: Health of the Nation Outcome Scale; HONOS-CA: Health of the Nation Outcome Scale for Children and Adolescents; Sym: symptoms subscale; Soc: social subscale; Beh: Behavior subscale; Imp: Impairment subscale.U= Mann-Whitney’U; t=Student’s t.

The present study has some strengths. First, it reports on a real-world setting where however validated scales have been applied, providing valid clinical measures Second, it shows that a prevention service embedded in a psychiatry unit within a University Hospital detects young subjects who have severe clinical pictures and who might have waited months or even years before accessing to adult mental health services. In this sense, the results of this study support the clinical appropriateness of such prevention service which fills a gap in the current mental health organization in Italy.

The study has several limitations. First, it has a crosssectional design and an estimate of the proportion of and factors associated with the transition to psychosis remains unstudied. Second, the sample size is relatively small and analyses may have been underpowered to detect significant associations between functioning and other clinical factors. Third, results are valid only for the local context, and any inference in different settings would require external replication.

In conclusion, prevention service within mental health facility setting appears to properly detect subjects in need of treatment with a drop in functioning, without outreaching activity in the general population. Padua prevention service detects help-seeking subjects with frequent age below 18, in need of treatment for comorbid early depressive episodes, anxiety or personality disorders, who in around one case out of two also meet UHR criteria, who all have poor functioning.

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6.1: Dissociative Disorders - Clinical Presentation

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• Page ID 161377

• Alexis Bridley and Lee W. Daffin Jr.
• Washington State University

Learning Objectives

• Describe dissociative disorders.
• Describe how dissociative identity disorder presents.
• Describe how dissociative amnesia presents.
• Describe how depersonalization/derealization presents.

Dissociative disorders are a group of disorders characterized by symptoms of disruption and/or discontinuity in consciousness, memory, identity, emotion, body representation, perception, motor control, and behavior (APA, 2022). These symptoms are likely to appear following a significant stressor or years of ongoing stress (i.e., abuse; Maldonadao & Spiegel, 2014). Occasionally, one may experience temporary dissociative symptoms due to lack of sleep or ingestion of a substance; however, these would not qualify as a dissociative disorder due to the lack of impairment in functioning. Furthermore, individuals who suffer from acute stress disorder and PTSD often experience dissociative symptoms, such as amnesia, numbing, flashbacks, and depersonalization/derealization. However, because of the identifiable stressor (and lack of additional symptoms listed below), they meet diagnostic criteria for a stress disorder as opposed to a dissociative disorder.

There are three main types of dissociative disorders: dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder .

Dissociative Identity Disorder (DID)

The key diagnostic criteria for dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession (Criteria A). How overt or covert the personality states are depends on psychological motivation, stress level, cultural context, emotional resilience, and internal conflicts and dynamics (APA, 2022), and severe or prolonged stress may result in sustained periods of identify confusion/alteration. Those presenting as being possessed by spirits or demons and for a small proportion of non-possession-form cases, the alternate identifies are readily observable. Generally, though, the identities in non-possession-form dissociative identity disorder are not overtly displayed or only subtly displayed and when they are, it is just in a minority of individuals and manifests as different names, hairstyles, handwritings, wardrobes, accents, etc. If the alternate identities are not observable, their presence is identified through sudden alterations or discontinuities in the individual’s sense of self and sense of agency, as well as recurrent dissociative amnesias (see the second criteria below; APA, 2022).

The second main diagnostic criteria (Criteria B) for dissociative identity disorder is that there must be a gap in the recall of events, information, or trauma due to the switching of personalities. These gaps are more excessive than typical forgetting one may experience due to a lack of attention. The dissociative amnesia presents as gaps in autobiographical memory, lapses in memory of well-learned skills or recent events, and discovering possessions for which there is no recollection of ever owning, and can involve everyday events and not just events that are stressful or traumatic.

It should be noted that most possession states occurring around the world are part of broadly accepted cultural or religious practice and should not be diagnosed as dissociative identity disorder (Criteria D). The possession-form identities in dissociative identity disorder manifest most often as a spirit or supernatural being taking control and the individual speaking or acting in a distinctly different way. These identities present recurrently, are involuntary and unwanted, and cause significant distress or impairment (Criteria C). Impairment varies in adults from minimal (i.e., high functioning professionals) to profound. For those minimally affected, marital, family, relational, and parenting functions are more likely to be impaired by symptoms of dissociative identity disorder rather than their occupational and professional life.

While personalities can present at any time, there is generally a dominant or primary personality that is present most of the time. From there, an individual may have several subpersonalities . Although it is hard to identify how many subpersonalities an individual may have at one time, it is believed that there are on average 15 subpersonalities for women and 8 for men (APA, 2000).

The switching or shifting between personalities varies among individuals and can range from merely appearing to fall asleep, to very dramatic, involving excessive bodily movements, though for most, the change is subtle and may occur with only subtle changes in overt presentation. When sudden and unexpected, switching is generally precipitated by a significant stressor, as the subpersonality best equipped to handle the current stressor will present. The relationship between subpersonalities varies between individuals, with some individuals reporting knowledge of other subpersonalities while others have a one-way amnesic relationship with subpersonalities, meaning they are not aware of other personalities (Barlow & Chu, 2014). These individuals will experience episodes of “amnesia” when the primary personality is not present.

Dissociative Amnesia

Dissociative amnesia is identified by the inability to recall important autobiographical information, usually of a traumatic or stressful nature. It often consists of selective amnesia for a specific event or events or generalized amnesia for identity and life history. This type of amnesia is different from what one would consider permanent amnesia in that the information was successfully stored in memory but cannot be freely recollected. It is conceptualized as possibly being a reversible memory retrieval deficit. Additionally, individuals experiencing permanent amnesia often have a neurobiological cause, whereas dissociative amnesia does not (APA, 2022).

There are a few types of amnesia within dissociative amnesia. Localized amnesia , the most common type, is the inability to recall events during a specific period. The length of time within a localized amnesia episode can vary—it can be as short as the time immediately surrounding a traumatic event, to months or years, should the traumatic event occur that long (as commonly seen in abuse and combat situations). Selective amnesia is, in a sense, a component of localized amnesia in that the individual can recall some, but not all, of the details during a specific period. For example, a soldier may experience dissociative amnesia during the time they were deployed, yet still have some memories of positive experiences such as celebrating Thanksgiving or Christmas dinner with the members of their unit. Systematized amnesia occurs when an individual fails to recall a specific category of information such as not recalling a specific room in their childhood home.

Conversely, some individuals experience generalized dissociative amnesia in which they have a complete loss of memory for most or all of their life history, including their own identity, previous knowledge about the world, and/or well-learned skills. Individuals who experience this amnesia experience deficits in both semantic and procedural knowledge. This means that individuals have no common knowledge of (i.e., cannot identify letters, colors, numbers) nor can they engage in learned skills (i.e., typing shoes, driving car). While generalized dissociative amnesia is extremely rare, it is also extremely frightening. The onset is acute, and the individual is often found wandering in a state of disorientation. Many times, these individuals are brought into emergency rooms by law enforcement following a dangerous situation such as an individual wandering on a busy road.

The distress and impairment suffered by those with dissociative amnesia resulting from childhood/adolescent traumatization varies. Some are chronically impaired in their ability to form and sustain satisfactory attachments while others are highly successful in their occupation due to compulsive overwork. And finally, a substantial subgroup of those afflicted by generalized dissociative amnesia develop a highly impairing, chronic autobiographical memory deficit that is not ameliorated by relearning their life history, resulting in poor overall functioning in most life domains (APA, 2022).

Depersonalization/Derealization Disorder

Depersonalization/derealization disorder is categorized by recurrent episodes of depersonalization and/or derealization. Depersonalization can be defined as a feeling of unreality or detachment from oneself . Individuals describe this feeling as an out-of-body experience where you are an observer of your thoughts, feelings, and physical being. Furthermore, some patients report feeling as though they lack speech or motor control, thus feeling at times like a robot. Distortions of one’s physical body have also been reported, with various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from their feelings, lacking the ability to feel emotions despite knowing they have them.

Symptoms of derealization include feelings of unreality or detachment from the world —whether it be individuals, objects, or their surroundings. For example, an individual may feel as though they are unfamiliar with their surroundings, even though they are in a place they have been to many times before. Feeling emotionally disconnected from close friends or family members whom they have strong feelings for is another common symptom experienced during derealization episodes. Sensory changes have also been reported, such as feeling as though your environment is distorted, blurry, or even artificial. Distortions of time, distance, and size/shape of objects may also occur.

These episodes can last anywhere from a few hours to days, weeks, or even months. The onset is generally sudden, and like the other dissociative disorders, is often triggered by intense stress or trauma. Many individuals describe feeling like they are “crazy” or “going crazy” and fear they have irreversible brain damage. They experience an altered sense of time and may be obsessed about whether they really exist.

As one can imagine, depersonalization/derealization disorder can cause significant emotional distress, as well as impairment in one’s daily functioning. The disorder is associated with major morbidity and impairment occurs in both interpersonal and occupational spheres due to “…the hypoemotionality with others, subjective difficulty in focusing and retaining information, and a general sense of disconnectedness form life” (APA, 2022).

Key Takeaways

You should have learned the following in this section:

• Dissociative disorders are characterized by disruption in consciousness, memory, identity, emotion, perception, motor control, or behavior. They include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.
• Dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession.
• Dissociative amnesia is characterized by the inability to recall important autobiographical information, whether during a specific period (localized) or one’s entire life (generalized).
• Depersonalization/derealization disorder includes a feeling of unreality or detachment from oneself (depersonalization) and feelings of unreality or detachment from the world (derealization).

Review Questions

• Identify the diagnostic criteria for each of the three dissociative disorders. How are they similar? How are they different?
• What are the types of amnesia within dissociative amnesia?
• What is the difference between depersonalization and derealization?

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What Is Clinical Depression?

Symptoms of clinical depression include feelings of sadness and a lack of energy

Nancy Schimelpfening, MS is the administrator for the non-profit depression support group Depression Sanctuary. Nancy has a lifetime of experience with depression, experiencing firsthand how devastating this illness can be.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Catherine Song

Depression is one of the most common mental health disorders. In fact, it's estimated that 1 in 5 adults in the United States have received a depression diagnosis in their lifetime.

Depression exists on a continuum of severity, ranging from relatively mild, transient states of low mood to severe, long-term symptoms that have a major impact on a person’s quality of life. Depression is often described as being mild , moderate , or severe. When a person’s symptoms have reached the chronic end of the spectrum and require professional treatment, it's typically referred to as clinical depression.

Although depression can take on many forms and may be categorized in several different ways, there are two primary types of clinical depression as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM–5): major depressive disorder (unipolar depression) and the depressive phase of bipolar disorder.

Symptoms of Clinical Depression

People experience depression in different ways. Some people only have a few symptoms, while others have many. Some symptoms might get better over time while others may get worse.

It’s important to work with your mental health care team to identify which depression symptoms you experience and determine the best approach to treating them. For each type of clinical depression, as well as the various subtypes, there are some symptoms or features that are common in those who experience it. 

Major Depression

Also known as major depressive disorder or unipolar depression, this form is what most people think of when they hear “depression.” Major depression is typically characterized by the following symptoms:

• Sadness, feelings of emptiness
• Loss of enjoyment of hobbies, work, other activities
• Appetite changes, weight loss or gain
• Trouble sleeping (too much or too little)
• Feeling "slowed down" or being excessively agitated
• Tiredness, fatigue, lack of energy
• Physical symptoms and pain (such as body aches, stomach upset, headaches)
• Feelings of worthlessness or guilt
• Problems with concentration or focus
• Inability to make decisions or poor decision-making
• Thinking about death or dying ; planning or attempting suicide

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database .

Psychotic Depression

Psychotic depression is considered part of the unipolar depression spectrum at its most severe and not a separate form of depression. People who have mental health conditions that cause them to experience hallucinations or delusions may also have a form of depression.

Psychotic depression can manifest with hallucinations that are focused on death or being gravely ill. Delusions also might be related to other major life stressors, such as losing a job or being poverty stricken.

Depressive Phase of Bipolar Disorder

Clinical depression can also be a feature of another mental health condition called bipolar disorder . People with bipolar disorder tend to alternate between periods of depression and periods of greatly elevated mood called mania . 

In the depressive phase, symptoms can be very similar major depression. During the manic phase , symptoms at the opposite end of the spectrum are more likely, such as:

• Increased energy
• Sleeplessness
• Irritability
• Rapid speech
• Hypersexual behavior
• Racing thoughts
• Grandiose ideas
• Greatly increased activity
• Impulsivity
• Poor judgment

Other forms of depression are classified a bit differently, often because they occur in specific situations or require different treatment approaches. 

Postpartum Depression

Postpartum depression is depression that occurs after a person gives birth and can persist well into the first year postpartum. While it is common and treatable, it needs to be promptly and correctly diagnosed. While many new parents experience ups and downs when caring for a new baby (especially on little sleep) the typical stress and anxiety of the newborn stage usually last only a few weeks, whereas postpartum depression is more serious and can last long after the birth of a child. 

Premenstrual Dysphoric Disorder (PMDD)

With PMDD , people who have a menstrual cycle become depressed prior to the onset of their period. Hormonal changes can cause mild menstrual symptoms (PMS) in anyone who has periods, but it’s not the same as PMDD. In PMDD, symptoms are more intense, persistent, and require treatment. 

Seasonal Affective Disorder (SAD)

Some people experience bouts of depression at certain times of the year, most often in the dark winter months (though it can occur at any time of year). It's referred to as seasonal affective disorder.

The lack of sunlight has been associated with low mood for a number of reasons, including vitamin D deficiency and an increased likelihood that someone will be spending more time alone or at home (potentially due to colder weather and shorter days). Several holidays and celebrations also occur during this time of the year, which can contribute to depression and anxiety in some people.

Dysthymia (Persistent Depressive Disorder)

If you have an episode of depression that lasts two years or more, you may be diagnosed with dysthymia . Sometimes, major depression also develops or alternates with periods of persistent depression. 

Situational Depression

Many people will experience a period of depression in their lifetime in response to a specific event. Losing a job, caring for a parent or child who is ill, getting divorced, or experiencing a trauma such as a robbery, car accident, or a house fire are just a few examples of stressors that could lead to situational depression .

Unlike more persistent forms of depression, situational depression can usually be treated and improves in response to positive change in a person’s situation, such as getting a new job and having social support, counseling, and in some cases, medication. 

The DSM-5 also mentions other forms of depression classified as atypical . If you are having symptoms of depression, the doctors and mental health professionals you’re working with will evaluate your symptoms carefully.

You may experience more than one form of depression in your lifetime. If you are a parent or young person, newer entries in the DSM-5 also categorize forms of depression that are more specific to children and teens. 

Depression in Children and Teens

It used to be believed that children couldn’t be depressed, but we now know that’s not true. Children, teens, and young adults can experience depression, but it may not look the same as it does in adults. 

Children may not yet have the language skills and emotional awareness to express exactly what they are feeling. An adult who is depressed may feel profound sadness , whereas a depressed child may appear angry, frustrated, and irritable. 

Symptoms of depression in school-aged children and teens may interfere with school work, social activities, or friendships. For example, a child who is depressed may begin to make poor grades in school, lose interest in after school activities like sports, or no longer want to hang out with friends. 

As with teens and adults, children who are experiencing depression may also have trouble sleeping, lose their appetite, or have unexplained physical symptoms such as headaches and stomachaches. 

If you're concerned that your child or teen is depressed, talk to your pediatrician. There are some medical conditions that can cause depression which will need to be ruled out . If your child is diagnosed with depression, finding the appropriate treatment is critical to their well-being. 

You can help by putting together a network of mental health professionals, doctors, teams at school, as well as friends and people in the community, who can support your family as you learn about managing your child’s depression. 

Different types of clinical depression include major depressive disorder, psychotic depression, depressive phases of bipolar disorder, postpartum depression, premenstrual dysphoric disorder, and seasonal affective disorder. Depression can also occur in children, although symptoms may present somewhat differently than in adults.

Causes of Clinical Depression

The causes of depression are not completely understood, but it’s believed that there are several key factors, including genetics and environment, that make a person more likely to become depressed.

Some Common Causes of Depression

Researchers have particularly been interested in investigating whether depression is an inherited condition. A major theory is that certain genetic changes make neurotransmitters (mood-regulating chemicals in the brain) ineffective or scarce. 

The other major component is environmental triggers which may make a person who is genetically predisposed to depression more likely to develop it. Certain factors that make it more likely a person will experience clinical depression include:

• A family history of depression (especially a parent or sibling)
• Experiencing a traumatic event or major life change (such as loss of a job, death or serious illness of a spouse, divorce)
• Financial troubles (such as debt and worries about paying for big expenses)
• Being very ill or injured (such as from cancer or a car accident), needing to have surgery or undergo medical treatment, or having to manage a chronic and/or progressive health condition (such as multiple sclerosis)
• Caring for a loved one (spouse, child, parent) who has a major illness, injury, or disability
• Taking certain medications that can cause symptoms associated with depression (including medications used to treat depression)
• Using illegal drugs and/or misusing alcohol 

If you have experienced a form of depression before, you may be more likely to experience it again or develop another form in response to certain stressors or life changes (such as having a baby). 

Diagnosis of Clinical Depression

Your doctor may be the first health care professional to talk to you about depression. If you feel depressed, your doctor may want to start by ruling out medical conditions, such as thyroid disorders, that can cause depression symptoms. While your primary care doctor can diagnose clinical depression, they may want also you to be evaluated by someone with psychological expertise.

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If you will be taking medication to treat depression, your doctor may refer you to a psychiatrist . This type of doctor has special training for prescribing and monitoring medications used to treat mental health conditions. They can make sure that the medication you are taking for depression is the best fit for the form you have and that the dose is the safest and most effective for you.

Co-Occurring Conditions

In addition to physical medical conditions that can cause symptoms of depression or increase the likelihood someone will become depressed, there are also several other mental health conditions that people with depression may be diagnosed with.

When a person who has depression also has another mental health condition, it's referred to as a "co-occurring" condition. Common co-occurring conditions in people with clinical depression include:

• Anxiety disorders
• Obsessive-compulsive disorde r (OCD)
• Post-traumatic stress disorder (PTSD)
• Attention deficit and hyperactivity disorder (ADHD)
• Autism spectrum disorders
• Eating disorders and body dysmorphia
• Alcohol and drug use disorders

Sleep disorders, irritable bowel syndrome (IBS), headaches, chronic pain, and fibromyalgia are other conditions that may co-occur with depression.

Treatment for Clinical Depression

There are several different ways to treat depression . You may need to try different approaches or combine more than one method. What works well for one person with depression may not work for someone else. Your health care team will inform you of the options that are safe for you. 

If your symptoms are severe or your mental health team feels you are at risk of hurting yourself or someone else, you may need to start treating your depression in the hospital, an inpatient mental health care facility, and/or take part in outpatient treatment programs.

Keep in mind that the process can take time. You also may need to adjust the way you manage your depression symptoms in response to changes in your life.

One of the first-line treatments for clinical depression is medication. There are several different types of antidepressants , however, those belonging to a class called selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed. 

SSRIs such as Prozac (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), and Paxil (paroxetine) are generally preferred by both doctors and patients because they tend to have fewer and less bothersome side effects compared to older classes of antidepressants. Other major classes of antidepressants include:

• Serotonin and norepinephrine reuptake inhibitors ( SNRIs ) such as Effexor (venlafaxine), Cymbalta (duloxetine), and Pristiq (desvenlafaxine).
• Monoamine oxidase inhibitors ( MAOIs ) such as Marplan (isocarboxazid), Nardil (phenelzine), and Parnate (tranylcypromine). MAOIs are not safe to use with SSRIs.
• Atypical antidepressants such as Wellbutrin (bupropion).
• Tricyclic antidepressants such as Tofranil (imipramine) and Elavil (amitriptyline). Tricyclics are of an older class of antidepressant medications that are not prescribed as often due to their side effects.

Your doctor or psychiatrist may recommend you take more than one type of antidepressant or add another pharmaceutical treatment, such as anti-anxiety medications , to your routine.

Antidepressants can worsen some mental health conditions . For this reason, it’s very important to work closely with your doctor and therapist to ensure you have the most accurate diagnosis, and that the treatment you choose is a safe and effective way to manage your symptoms.

Before you start taking antidepressants, you should know that it can take some time for the medication to work. Your doctor or psychiatrist will likely have you try taking the medication for a certain period of time—usually several weeks or months—before adjusting the dose or trying a different medication. 

After starting an antidepressant it can take several weeks for you to feel a difference in your symptoms. It may also take weeks for side effects to resolve.

Even if you have side effects or don't feel your medication is working, do not stop taking it suddenly. This can cause withdrawal, which can be serious. Talk to your doctor if you want to stop taking your antidepressant.

If your doctor wants you to switch to a different medication, they will instruct you to gradually lower your dose over several weeks. Tapering off antidepressants can help prevent symptoms of withdrawal. 

In some cases, your doctor may start you on a new medication while you are still slowly reducing your dose of your old one. If you are changing antidepressants or adjusting to a new dose, it’s very important that you stay in touch with your mental health care team. 

The health care provider prescribing medication will discuss the risks and benefits with you. There may be some circumstances when taking a particular drug to treat depression would not be advised or you may need an adjusted dose.

For example, if you are pregnant or breastfeeding, your doctor will talk to you about any risks associated with the medications you take or are considering taking. They will help you evaluate the risks and benefits of each decision.

Children, teens, and young adults with depression may have serious side effects when taking certain antidepressants. People under the age of 25 taking these medications can be at an increased risk of worsening symptoms, including suicidal ideation.

Research has indicated that the risk of attempting suicide can also be markedly increased, which is why these medications get a black box warning from the FDA. 

Psychotherapy

Psychotherapy is another popular choice for treating depression, both on its own and combined with antidepressants. Psychotherapy involves working with a therapist, either by yourself or with a group, to talk through how you feel, your experiences, and how you view yourself and the world.

Together, you may be able to identify certain underlying causes or triggers that influence your depression. Once you are aware of them, you can begin to work on effective coping strategies. 

One example is cognitive-behavioral therapy , which research has found can be effective for treating depression.   Other studies indicate the combination of medication and psychotherapy may be the most effective treatment, as each method targets depression in a different way.

When both are used together, the underlying chemical imbalance and individual psychological factors can be addressed.  

If you have depression, therapy can help you better understand yourself and your depression symptoms. It’s also an essential component of your support system. If you are taking antidepressant medications, a psychiatrist can help by monitoring your dose to ensure it continues to work well and be safe.

There can be barriers to accessing therapy, such as a lack of providers where you live, not having reliable transportation, and cost. A relatively new option you may want to learn more about is using an internet connection or cellphone to communicate with a mental health provider. These options may also be more appealing to teens with depression.

Therapists can use email or text messaging, video chatting, or voice calls to connect with people who need help managing depression. You can also download mental health apps on your smartphone or tablet to help you track your symptoms or communicate with your provider. There are even some apps that offer interactive self-help resources and games to help you practice new coping skills, like mindfulness.

Treatment for clinical depression typically involves the use of medications, psychotherapy, or a combination of the two. 

Alternative and Complementary Treatment

You may choose to explore complementary or alternative therapies for depression. One of the most common is an herbal supplement called St. John’s wort . 

The FDA has not officially approved St. John’s wort to treat depression, but it is often suggested by alternative health practitioners. Research has indicated that St. John’s wort may be beneficial for some people who have symptoms of depression.   

The supplement comes in various doses and preparations and can be purchased over-the-counter and at most health food stores. There is no standard dose and you may want to work with a practitioner as you undertake some “trial and error” to determine the dose that feels right for you. 

Similar to how prescription medications affect neurotransmitter levels, St. John’s wort may influence the levels of a specific neurotransmitter called serotonin in the brain. When people have too little serotonin, they can feel depressed. Increasing the amount of serotonin can help improve symptoms. However, having too much serotonin can lead to a serious condition called serotonin syndrome . 

If you are taking a medication that carries a risk of increasing your serotonin levels too much, your doctor will teach you about the signs of serotonin syndrome to watch for. They will also want you to make sure that you never take more than one medication, herb, or supplement that can raise your serotonin levels at the same time (including St. John’s wort). 

While St. John’s wort may be helpful for some people with mild-to-moderate depression, it can also interact with a number of prescription medications. If you are already taking an antidepressant, do not start taking St. John’s wort until you’ve discussed it with your doctor.  

Coping With Clinical Depression

Clinical depression can be disabling and may make it difficult to function normally at work, school, and home. Medication and therapy can be valuable components of depression treatment, but each individual person with depression will need to find their own ways of coping with the condition. 

If you have depression, there are a variety of avenues you can explore to help you manage your symptoms. Depending on your lifestyle, physical health, and preferences, you can work with your mental health care team to develop the strategies that work best and feel like a good fit for you.

Physical Activity

Research has shown that the physical and mental symptoms of depression may benefit from getting your body moving. When you exercise, your body releases endorphins, which can boost your mood. Regular physical activity also helps keep your muscles and bones strong, improves cardiovascular health, and promotes a healthy weight.

Exercise not only helps keep your body and mind in working order, but it can give you the opportunity to connect with others.

Even if you prefer working out alone, going to the gym or taking your dog for a stroll through the park can help lessen feelings of isolation that come with depression. Other ideas include joining a community sports team or taking a group fitness, dance, or yoga class.

Hobbies and Creativity

A major symptom of depression is losing interest in hobbies or activities you used to enjoy. Motivation and focus can be challenged when you have depression. It's not easy, but finding ways to keep your mind engaged is an important part of learning to cope with depression.

You may find it helpful to start with a hobby or activity you already know you like and try to give yourself small milestones to work toward. While you may not feel up to teaching yourself an entirely new skill if you’re depressed, keeping your mind engaged without putting too much pressure on yourself can be a healthy strategy for coping . It can also help you reconnect with the parts of your life you might feel you have “lost” to depression or even find an entirely new interest or hobby.

If you enjoy being creative, you may find these activities help you deal with your depression symptoms. It can also be an opportunity for you to express how you are feeling in a new way. You may even be able to use your creativity as part of your therapy. 

Kids especially benefit from using creative expression to help them communicate and understand feelings of depression. Other creative outlets such as reading and making music can be coping strategies, though they may be difficult to stick with if you are having trouble focusing.

You can also use these activities as a way to encourage yourself if you are having a hard time leaving the house or have not had an interest in social activities.

For example, one day you may find a quiet afternoon alone at an art gallery or museum feels doable. On another day, you may feel up to seeing a movie or attending a concert or theatrical performance with a friend. 

Self-Care and Staying Connected

Depression can make it very hard to take care of yourself physically, emotionally, mentally, and spiritually. If you are struggling with self-care such as showering or cleaning your home , buying groceries, working, or other day-to-day pursuits, you may feel guilty and ashamed. 

It can feel impossible to ask for help, but even making small, healthy changes can make coping with depression symptoms more manageable. Having help tidying up your room, getting your trash taken out, stocking up your kitchen with easy-to-prepare meals, and making sure you can get to your doctor or therapy appointments are just a few ideas. 

It’s also important to stay connected to others . Depression can be incredibly isolating. In fact, you may feel like you need to stay far away from other people–even the people you love most. 

Sometimes, especially when you are first diagnosed, you may not feel ready to talk to your loved ones about your depression. At first, it might be easier to explore how you are feeling with other people who are going through the same process. 

Start by asking your doctor or therapist about support groups in your local community. If you don’t have a wide network of support or you do not feel ready to talk to people face-to-face, you may find it helpful to seek out online depression support groups .

Message boards, forums, and social media groups can be a place to share experiences that may feel less intense for you, as it provides a little distance and sense of anonymity. 

Online support networks may continue to be valuable to you even after you have opened up about your depression with your loved ones and have the support of your mental health team. Whether you are primarily connecting with others in-person or talk to them online, the most important thing is that you feel safe doing so.

A Word From Verywell

If you or a loved one has clinical depression, you may be overwhelmed by all the different aspects of living with mental illness there are to consider. While everyone's experience with depression will be unique, there are some commonalities when it comes to symptoms, causes, and treatment.

You will want to discuss your specific symptoms with your mental health care team. They will help you find the safest and most effective treatment for you, which may include medication, therapy, or both.

Your support network, whether in-person or online, can be there for you as you learn to cope with the symptoms of depression. When you're depressed, it can be hard to ask others for help. It's important to remember that you don't need to address all the different aspects of living with depression at the same time—and you don't have to face it alone.

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By Nancy Schimelpfening Nancy Schimelpfening, MS is the administrator for the non-profit depression support group Depression Sanctuary. Nancy has a lifetime of experience with depression, experiencing firsthand how devastating this illness can be.