Case Studies

Mrs Jyotsna, aged 35 years, mother of two children, a computer operator, married to a company executive, began getting attacks of palpitations four months prior to psychiatric consultation. During each attack she had a throbbing sensation in the chest with complete awareness of the dubb-dubb sounds of heart action. The first couple of attacks she ignored, as they passed off by themselves in a few minutes, though they left her feeling uncomfortable. Subsequent attacks found her becoming restless, agitated, indulging in needless activity like drinking water or trying to phone up her husband at office till all of a sudden the attack subsided. The unpredictability of the onset of the attack left her nervous and apprehensive. About a month after the first attack, one attack occurred in the presence of her husband and later she had to tell him all about the illness and her fear of heart attack which she had been concealing from her husband till then. Her husband took her to their family physician who after a thorough physical examination and a brief history found nothing physically wrong, diagnosed anxiety neurosis, advised her to relax and regulate her diet and daily routine since digestive disturbances and gaseous distension could cause attacks of palpitations. The reassurance and support had a temporary alleviating effect but over the next few weeks the random occurrence of the panic-attack continued. Jyotsna became apprehensive and nervous once again started dreading the onset of another panic-attack.

On being requested by Jyotsna and her husband the family physician recommended a cardiology consultation. Once again the physical examination, ECG and routine blood and urine biochemistry revealed no abnormalities. The cardiologist counselled the couple about the physical manifestations of anxiety and prescribed a benzodiazepine and propranolol for palpitations and a multi-vitamin capsule. After a few weeks of this treatment Jyotsna’s palpitations and panic-attack had subsided but her negative thinking, fearfulness about several things other than the heart attack, general restlessness and agitation, irritability, minor physical discomforts at all times, interrupted sleep and lack of interest in daily household routine and work became apparent. The symptoms had till then remained unnoticed to a certain extent by Jyotsna herself due to the overwhelming nature of the panic-attack. Her husband had observed the changes but thought that they were secondary to her fear of impending death. This time the family physician rightly referred her to a psychiatrist and the couple had no resistance towards such a consultation since they were now aware of the psychological origins of the physical manifestation. A detailed history by the psychiatrist revealed that the double role of working and house-keeping were taking their toll on Jyotsna. The previous year had been a trying one with a change of boss at the workplace, change in nature of work, children’s ill-health, herself having to go through the school books so as to be able to guide the children and rapid changes of maidservants at home. Though she had bourne all this with apparent equanimity then, the hurry and the worry had started manifesting as panic-attacks and other symptoms of dysthymic disorder.(Reactive depression).

The treatment was modified by adding a tricyclic antidepressant with anxiolytic properties and changing over to a thioridazine with anti-depressant effect. Deep-muscle relaxation, modified Jacobson’s technique, was taught to Jyotsna and she was asked to practice it for 15/20 minutes two or three times daily. Thought-stopping was suggested for her negative and fearful thoughts. Supportive psychotherapy was directed towards better handling of issues at work and at home. Over a period of 4 weeks excellent improvement was seen. Maintenance doses of antidepressant and anti-anxiety medication was continued for a further period of four months, after good clinical improvement was achieved.

The lessons to be learnt from this are

• In depression, sometimes the mood is not one of sadness or the ‘blues’ but one of anxiety.
• Even in cases with predominant anxiety and physical symptoms, anti-depressant drugs are the ones which will give the desired results earlier.
• While suggesting investigations, where one is sure of the psychological origin of the physical symptoms one must be careful not to increase the apprehension and fear of both patients and relatives. This can be done by properly briefing them and indicating that the doctor expects the reports to be normal.
• Since anxiety and depression are so closely linked, many psychiatrists prefer the term mixed anxious depressive state and the drugs of choice are anti-depressants.

Tricyclic anti-depressants with known anxiolytic properties e.g. dothiepin, and other drugs like thioridazine with combined antidepressant and antipsychotic action would be used in such cases, the dosage being adjusted to the individual patient’s requirements. Behaviour modification techniques, auto-hypnosis, self-suggestion and meditation to tone down the hyperactive autonomic nervous system and brief psychotherapy are of course a must for improvement.