Thea is a 60-year-old woman. She has 15 years of education and has worked in the past as an RN. She is not working currently by choice. She stated burn-out as a reason and although she was considered punctual, reliable, and organized, she was somewhat insufficient in her work and had worked many hours overtime.
Reports upon Referral
Thea initially presented with symptoms of depression and anxiety, discussing her conflict between and among herself, her husband, her adult daughter, and her mother who was visiting at the time as a cause. Her depression has been treatment resistant and there has been minimal impact by anti-depressants. She is currently taking Effexor (150 mg).
Thea’s situation has been complicated by medical challenges. She has received medical attention to address diverticulitis, gastreosophageal relflux disease, menopause, chronic insomnia, and pituitary adenoma. Thea has been on a variety of medications to assist with sleep without success.
It is unclear at this time how much her memory is impacted by depression, medical/organic concerns, chronic insomnia, or a combination of factors.
History of the Problem
During a neuropsychological workup onj 10/052012, the patient reported an 18-month history of memory and naming difficulties that had been highly variable from day to day. At that time, she reported occasional anomia and paraphasic errors, forgetfulness for routine conversations, repeating herself, and poor working memory (for example, entering a room and forgetting her goal).
She reported a remote history of depression in her 20s, treated by an outpatient psychiatrist, and not requiring hospitalization. She had been bothered by sleep disturbance, hot flashes, depressed mood, and headaches since menopause at age 55. She reported chronic insomnia. He primary care physician’s progress notes documented that her insomnia had not responded to treatment with Lunesta or melatonin.
At this time, she denied movement disorder or visual hallucinations, but did endorse daily fluctuations in cognition, vivid dreaming, crying out in her sleep, and acting out of dreams (i.e. possible REM sleep behavior). She reported the onset of unpleasant olfactory hallucinations in 12/ 2011, which she stated were diagnosed as migraine symptoms. However, she reported that these hallucinations were occurring daily at first, but now occurred 2 to 5 times per week in a fleeting manner. She has no other unusual perceptual, motor, or emotional episodes. She denied ever undergoing an EEG.
The neuropsychological evaluation in 10/2012 found her to be fully oriented with normal attention throughout testing. She performed normally on tests of processing speed, executive functions, language, and spatial abilities. She displayed some borderline inefficiencies in learning and free recall, but recognition of previously learned information was normal. The patient reported mild depressive symptoms on the BDI...