Case Studies

Real Life Cases In Clinical Practice

CASE REPORT II
-Dr Nilesh Shah
-Dr (Miss) Roop Majli

Mrs.Chatterji is a 58 year old housewife. She was brought to the psychiatric OPD of our hospital by her husband who is a businessman.

Mrs.Chatterji was apparently fine till 8 months ago when her younger son moved to another city. According to the patient's husband, initially she would tell him how much she was missing her son. He noticed that after a while she began to speak less and became withdrawn from the rest of the family members. She would reply to their questions in monosyllables and never initiated conversations. Occasionally she would complain of severe headaches and back pain and later on began to complain of constant fatigue with weakness.

Her relatives noticed that she would neglect her household chores, often not cleaning the house for days, not cooking or gardening (which was an activity she enjoyed). Her movements appeared slow and laborious.

Frequently the patient had to be reminded / urged to have a bath and comb her hair. Mrs.Chatterji had to be coaxed to eat and then too, would say that she had no appetite.

On few occasions, her husband noticed her crying in their bedroom. On questioning she told him that she was feeling very sad and felt that there was nothing left to live for and she would rather be dead. She often contemplated committing suicide by taking an overdose of sleeping tablets.

It was after hearing this that her husband had taken her to a general practitioner who in turn referred her to a psychiatrist.

SIGNS & SYMPTOMS PROFILE FOR PATIENTS INFORMATION

Most human beings feel depressed at some point of time.
But, normal depressive state is not the same thing as a pathological depressive illness.

A pathological depression is a profound, persuasive disturbance in the feeling state or mood which can secondarily affect the individual’s thinking with behaviour. It is prolonged with many stretch over a long period of time, may or may not be precipitated by some event (adverse or otherwise) with can be / very severe in intensity.

Signs and Symptoms of Depression

There are different categories of signs and symptoms of depression

Mood changes
Changes in thought process
Changes in behaviour
Physical symptoms
Biological symptoms
Psychotic features

a)	Mood changes
	Sadness is one of the classical symptoms of depression. The person feels dejected and sad for a length of time and finds it virtually impossible to snap out of this mood. No amount of indulging in one’s hobbies or other pleasurable activities seem to help. In fact the person finds it impossible to enjoy or derive pleasure from usual activities which gave pleasure earlier. There is disinterest in dally activities like watching TV, listening to music etc. Social withdrawal is seen in a large group of patients who slowly loose all contacts with family, friends and neighbours. The patient often describes him / herself as sad, gloomy and miserable. Crying spells may also be present.
b)	Changes in thought process
	The patient thinks of him / herself as useless incapable of doing any good constructive work and feels worthless. They blame themselves for all mistakes made (whether or not the case actually). This self blame often translates into a tremendous amount of guilt. The patients feel that they are ruining others lives along with their own. Commonly seen in depressives is the pessimistic thought process that everything had has occurred in their lives / is occurring in their lives or that whatever will happen to them will be for the worse. They feel extremely hopeless and helpless. Depressed people often find it very hard to take decisions and keep procrastinating. Occasionally they get fed up of life, all convinced that their life will never get better and therefore is not worth living. These thoughts might be replaced by suicidal ideas and a death wish
c)	Behavioural Changes
	Depressed patients have some classical symptoms that must be looked out for. For the most part they have psychomotor retardation They appear to move slower than N, take a longer time to finish tasks than earlier. There is also lack of self care that is apparent unconcern about their personal hygiene and grooming. A depressed patient may not even get out of bed to take a shower or comb his / her hair. On the other hand, some depressed persons are very restless and agitated. They feel very anxious and nervous
d)	Physical complaints
	A huge number of patients of depression usually present with physical complaints and are therefore likely to consult their general physicians first. Unlike psychiatric symptoms, physical symptoms find ready acceptance naturally. Multiple, non specific aches and pains are very common. These persons complain of feeling very weak and constantly tired and fatigued. Often fatigue is coupled with lethargy and numbness
e)	Biological symptoms
	There are a variety of biological symptoms associated with depression. The commonest feature is sleep disturbances. Often, there is a reduction in total sleep time. Depressed patients find it difficult to fall asleep, tend to have an interrupted sleep and wake up much earlier than was previous for them. Another group of depressed patients have just the opposite symptoms, i.e. they sleep excessively, wake up much later than usual. Appetite is often commonly affected in depressed people who have loss of appetite, only pick at their food and tend to loose weight as a result. In others, depression manifests in an increase in appetite. They eat voraciously and tend to put on a sudden spur of weight during the illness. Loss of libido is also reported. The depressed person has decreased interest in matters of sex and sexual activity. This may result from a general loss of interest in all surroundings and in members of the opposite sex. Also seen is a feeling of dryness of the mouth, person finds it necessary to sip water throughout the day. Constipation may also be seen in depressed patients.
f)	Psychotic symptoms
	Certain psychotic symptoms/features can also be present in depressive patients Delusions i.e. false, firm ideas that a person may develop. Delusions can be of many types and contents can vary eg. persecutory ideas feeling and hopelessness, worthlessness and helplessness a feeling that nothing good will ever happen in their lives, the world is a terrible place and so are all the other people the patient knows. Depressives may get fixated on the idea that they have no money and are paupers inspite of evidence to the contrary. Severely depressed persons may have auditory hallucinations and are generally of a derogatory or jeering nature. They are not persistent however. Not every patient is likely to manifest all these symptoms and signs of depression and virtually any symptom of which patients commonly complain can be associated with depression. It is imperative however, to be able to pick up and read these signs and symptoms and bring the patient as soon as possible to a psychiatrist to ensure return to pre morbid functioning as soon as possible.

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