Case 2, Episode 3: Diagnostic Deep Dive – Beyond “Major Depression”

“They said I have depression. I guess that fits. But sometimes I wonder if that’s just the word we use when we don’t really know what else to call it.” — Marcus, 48

 Marcus has been diagnosed with Major Depressive Disorder[1], recurrent, moderate to severe, for over two decades. He’s been prescribed antidepressants, tried therapy, and practiced mindfulness.

Each effort left behind traces of hope—and then, disappointment.

But what if the issue isn’t that nothing works, but rather that we’ve been treating the wrong thing?

In this episode, we dive into the diagnostic possibilities that often hide beneath the surface of chronic suffering—and what it means to diagnose with humility and depth.

The Problem with One-Size-Fits-All Diagnosis

The DSM gives us categories.

But our patients give us complexity.

And in that space between the checklist and the person, we must learn to listen differently.[2]

Let’s explore the four major diagnostic considerations we should revisit in Marcus’s case.

1. Persistent Depressive Disorder (Dysthymia)

“It’s always been there—just less bad at times.”

Why This Fits:

• Symptoms have lasted more than 2 years without full remission[3]

• Marcus describes chronic low mood, poor self-esteem, and fatigue

• He functions, but without joy, motivation, or hope

Why It Matters:

• Chronic depression responds differently than episodic MDD[4]

• Patients often develop low expectations for themselves and treatment

• Therapy must address maladaptive identity structures, not just mood 

Clinical Tip:
Ask: “When was the last time you felt well for more than a few weeks?”

If they can’t remember, think dysthymia. 

2. Complex PTSD (C-PTSD)[5]

“I just learned to not feel anything. It was safer that way.” 

Why This Fits:

• Marcus describes early abandonment and emotional neglect

• He avoids intimacy, has difficulty expressing needs, and often feels detached

• His affect is flattened, but not purely depressive—more like protective numbness

Why It Matters:

• Many patients with attachment trauma are misdiagnosed with only depression

• Standard CBT or medication may fall flat without relational healing

• Treatment may require trauma-informed, emotionally corrective experiences

Clinical Tip:
Look for trauma without capital “T”—not one event, but prolonged emotional absence.

3. Existential or Identity-Based Depression

“I don’t know why I’m here. I don’t think I ever really did.”

Why This Fits:

• Marcus has no clear narrative of purpose or future[6]

• His despair isn’t always sad—it’s hollow

• He speaks in philosophical, spiritual tones: “Maybe life just isn’t for me.”

Why It Matters:

• Existential distress is not a DSM category, but it’s clinically real

• Often linked to meaninglessness, not mood

• May benefit from existential therapy, spiritual dialogue, or purpose-driven work 

Clinical Tip:
Ask: “What does suffering mean to you? Do you believe there’s a reason behind this?”

4. Personality Structure Considerations

“I don’t like relying on people. They usually let you down.”

Why This Fits:

• Marcus shows traits of avoidant or obsessive patterns

• He’s high-functioning but rigid, emotionally distant, and self-critical

• There’s a lifelong pattern of emotional suppression and interpersonal avoidance

Why It Matters:

• Personality traits shape treatment response

• Schema[7] work, psychodynamic therapy, or mentalization-based therapy may help

• Without addressing the personality architecture, treatment will feel superficial

Clinical Tip:
Personality isn’t pathology. It’s a blueprint.

Treating personality traits doesn’t mean blaming the patient—it means helping them see and shape their internal world.

So, What’s the Diagnosis?

Perhaps all of the above.

Diagnosis in psychiatry is not about labeling. It’s about orientation.

What’s the most useful way of understanding Marcus’s suffering so we can begin to address it, hold it, and heal it together?

Coming Up Next: Episode 4 – Medication Strategy Reimagined
Next time, we’ll explore:

• Why “treatment-resistant depression” is often a misnomer

• How to design a medication plan using decision trees and logic, not guesswork

• The role of augmentation, rotation, and reassessment

• When to consider novel interventions (like ketamine or TMS)—and how to talk about them with empathy, not hype

Because Marcus doesn’t need another prescription.

He needs a new relationship with treatment itself. 

Reflective Prompt for You
Have you ever worked with someone labeled “treatment-resistant”—but later realized the treatment wasn’t wrong, just incomplete?

What helped you see the fuller picture?

You don’t treat a diagnosis. You treat a person.

References:

[1] Otte, Christian, et al. "Major depressive disorder." Nature reviews Disease primers 2.1 (2016): 1-20.

[2] Papakostas, George I., et al. "Overcoming challenges to treat inadequate response in major depressive disorder." The Journal of clinical psychiatry 81.3 (2020): 26406.

[3] Kennedy, Sidney H. "Core symptoms of major depressive disorder: relevance to diagnosis and treatment." Dialogues in clinical neuroscience 10.3 (2008): 271-277.

[4] Köhler, Stephan, et al. "Characteristics and differences in treatment outcome of inpatients with chronic vs. episodic major depressive disorders." Journal of affective disorders 173 (2015): 126-133.

[5] Franco, Fabiana. "Understanding and treating C-PTSD." Journal of Health Service Psychology 47.2 (2021): 85-93.

[6] Cruwys, Tegan, et al. "Depression and social identity: An integrative review." Personality and Social Psychology Review 18.3 (2014): 215-238.

[7] Renner, Fritz, et al. "Treatment for chronic depression using schema therapy." Clinical Psychology: Science and Practice 20.2 (2013): 166.