Case Studies

A 42 years old male married businessman, Vasant, had developed weakness, headache, chest pain, tingling sensation in extremities. He had trouble sleeping and was waking up early in the morning. In the last two months he had lost 7kg weight.

He had consulted several physicians for the above complaints. The physical examination was normal except for hypertension which was controlled well with medication. The various blood investigations and those for thyroid function, diabetes as well as cardiogram were normal.

On the advice of a relative, the patient reluctantly consulted a psychiatrist. On detailed psychiatric history taking it was discovered that the patient was lethargic and had lost interest in his hobbies. He was always lost in thoughts especially negative ones. He was very irritable and the slightest noise of television or even music would make him angry. He would sleep through entire Sundays. Inspite of being very regular at work earlier, he had been absent from office thrice in a week. He also expressed suicidal ideations.

Regarding his premorbid personality, the patient was excessively devoted to work and was very meticulous. He was emotional but would suppress any negative feelings. He was over conscientious about morality and ethics. He was reluctant to delegate tasks to others.

His wife also informed that there was a similar episode about 5 years back. Also the father and the elder brother were under psychiatric treatment for depressive disorder.

On further inquiry it was found that his business was not doing well since a year. Also though his brother had promised earlier, he later refused him financial help for buying a house. As a result he was unable to fulfill his financial commitment which he had promised. This came as a severe blow to him.

DISCUSSION

The diagnosis of Major Depressive Disorder is clear (Axis I). Initially the diagnosis was missed by physicians probably because of actual weight loss of 7 kg and other somatic symptoms. Once psychological symptoms are evaluated (depressed mood,loss of interest, significant weight loss, insomnia, psychomotor retardation, fatigue, thought of death – DSM IV criteria) the diagnosis is obvious. Also previous episode of depressive disorder and family history make the diagnosis very clear.

The diagnosis of somatization disorder is not made, as there is other psychiatric disorder namely major depressive disorder. The somatic symptoms have started only recently and not before the age of 30 years. In Indian subcontinent it is well accepted fact that psychological disorders present with somatic symptoms. On follow-up with antidepressants, all the somatic symptoms subsided.

The poor business is a continuous stress. However the breach of trust by significant person (the elder brother) led to loss of prestige and acted as an acute stress (Axis IV).

Suicidal ideation and impairment in occupational work gives rating of 40 on Global Assessment of Functioning (GAF) current. In past year, the patient has been active in all functioning areas including occupational, familial and social functioning give GAF rating of 90.

Axis I Major Depressive Disorder Recurrent.
Axis II Obsessive Compulsive Personality
Axis III Hypertension.
Axis IV Loss of prestige Acute Stress Occupational worries:Chronic stress.
Axis V GAF Current 40
GAF Past Year 90.

FOLLOW UP:

With antidepressant medication, the patient improved well. Within six weeks of treatment he was attending work regularly and was going out socially on Sundays. On therapist’s advise, he discussed his financial commitment and difficulties with the landlord who was sympathetic towards him. This reduced his worries.