Differential Diagnosis

The patient's presentation of lack of motivation, difficulty accomplishing tasks, concentration problems, and significant changes in sleep patterns and energy levels suggests a complex clinical picture. The following differential diagnoses are considered:

• Single Most Likely Diagnosis
  • Major Depressive Disorder (MDD): The patient's history of a previous diagnosis of depression, current symptoms of lack of motivation, energy, and interest in activities, along with significant changes in sleep patterns, strongly support this diagnosis. The recent life changes (moving and unemployment) could be contributing factors to a depressive episode.
• Other Likely Diagnoses
  • Attention Deficit Hyperactivity Disorder (ADHD): Although the patient has no formal ADHD diagnosis, the suggestion of it in a prior evaluation, combined with her symptoms of difficulty concentrating, procrastination, and feeling overwhelmed by tasks, make ADHD a plausible diagnosis. The patient's symptoms could be indicative of an inattentive type.
  • Adjustment Disorder: Given the patient's recent significant life changes (moving to a new city and becoming unemployed), an adjustment disorder could be considered, especially if the symptoms are primarily in response to these stressors and do not meet the full criteria for another disorder.
• Do Not Miss Diagnoses
  • Bipolar Disorder: It is crucial to rule out bipolar disorder, especially given the patient's history of trying various medications with significant side effects (e.g., feeling "wired" on Lexapro), which could indicate a bipolar spectrum disorder. The patient's symptoms of increased sleep and fatigue could also be part of a depressive phase of bipolar disorder.
  • Thyroid Disorders: Hypothyroidism can cause symptoms of depression, fatigue, and lack of motivation, making it essential to consider and rule out through laboratory tests.
  • Sleep Disorders: The patient's significant changes in sleep patterns (sleeping until 1 PM, frequent napping) could indicate an underlying sleep disorder, such as hypersomnia or sleep apnea, which needs to be evaluated.
• Rare Diagnoses
  • Neurodegenerative Disorders: Although less likely, certain neurodegenerative disorders (e.g., early stages of frontotemporal dementia) can present with significant changes in motivation and personality. However, these would be considered only after more common diagnoses have been thoroughly evaluated and ruled out.
  • Chronic Fatigue Syndrome: Now more commonly referred to as Myalgic Encephalomyelitis (ME), this condition is characterized by profound fatigue that is not improved by rest and lasts for more than 6 months. While the patient's symptoms of extreme tiredness and frequent napping could suggest this, the diagnosis would require a more detailed evaluation of the patient's history and symptoms.