Educationals

CASE : A PANIC ATTACK

Sumant, a 25 year old male had sudden chest pain, palpitations, excessive perspiration and a feeling of impending death. The attack lasted for 10 to 15 minutes and then subsided. His pulse rate was 104 per minute at that time and the BP was normal. The E.C.G. (cardiogram) was normal except for a fast heart rate . Other investigations done at a later stage (stress test for heart functions , 2D Echo) were also normal. After about 10 days, the patient developed a similar episode while travelling by train. He was taken to a nearby hospital, where again all the investigations were normal. By now the patient was so afraid that he would not travel anywhere alone. His wife or any other relative would accompany him. In presence of them the attacks were very mild and could easily be controlled. The patient improved with antidepressants drugs and psychotherapy. Within three months the patients started going out alone, initially to nearby areas and by four months of treatment he could travel long distances all by himself.

This is just another way in which depressive illness can manifest itself

Physical symptoms -

• Big increase or loss in weight
• Excessive sleep or inability to sleep (insomnia)
• Low energy, fatigue, weakness
• Restlessness or slowed body movements

Somatization

In Indian society and culture, the chances of purely psychological/ behavioural symptoms being dismissed as inconsequential and not a part of medical illness is rather high. If a person complains of too many thoughts, confusion and indecisiveness about a few things, the reaction from the family members is usually, "forget the thoughts and you will be all right", moreover his chances of being taken to a doctor and getting treated are also very low. However, if the person reports that he has bodily symptoms such as headache or pain, he is sympathetically advised by the family members to consult a doctor. Thus, in Indian society, the psychological symptoms and associated disease, are not given the status of medical disease compared to physical symptoms. Hence, we are more likely to use the medium of the body (physical complaints) for expressing our inner tensions. The production of these symptoms is not intentional. i.e.the person has no control over the production of these symptoms.

The symptoms may pertain to any part of the body :-

• Abdominal: vomiting, abdominal pain, nausea, bloating, gases, constipation, diarrhoea
• Pain : limbs and extremities, backache, joint pains
• General body : weakness heaviness in limbs, tingling in extremities ( insect crawling), tremors, increased sweating
• Chest : shortness of breath when not exerting, palpitations, chest pain, choking sensation
• Head : forgetfulness, headache, giddiness, heaviness of head

Whenever these signs and symptoms do not correspond with any known physical illness or the tests and investigation done are normal, the underlying problem may be depression. In all such cases, symptoms related to thinking, feeling and behaviour need to be evaluated for proper diagnosis by the doctor. The doctor may then prescribe a drug which is not for the symptom but will take care of the underlying depressive illness.

Myths and realities of depressive illness

There are certain myths, misconceptions, erroneous beliefs and prejudices about depressive illness. These myths often prevent the patient from seeking proper treatment and hence need clarification.

Myth No. 1 : " He has become lazy, he does not want to work"
Fact : No
Loss of desire and the initiative to work is often a symptom of depressive illness. If a patient who earlier was very hard working, stops working and loses his desire and initiative to work, it is often wrongly interpreted by people around as "he has become lazy" or "he does not want to work". Most often advice given is "go to work and everything will be all right".

It is necessary to realize if people who have earlier been sincere and working regularly, suddenly become lazy and stop working, they are actually suffering depressive illness. They need proper treatment and need to consult a doctor at the earliest.

Myth No. 2: "Control your thoughts and you will be all right"
Fact : In depressive illness thoughts are beyond the control of the patient.
If a person complains of too many thoughts or says that he has no mood to work, the immediate reaction from family members is "control your thoughts and you will be all right"," be confident and nothing will happen to you". It is important to understand that unlike in the case of a normal person, a depressed person has no control over his thoughts and mood. Hence advising a depressed patient to control his thoughts is like advising a patient suffering from typhoid fever "control your fever and you will be all right". In both cases i.e. controlling fever in typhoid and controlling thoughts in depressive illness are not easy. The family members and relatives need to understand the futility of such advise and help him get treated for his condition.

Myth No. 3: "Antidepressant drugs are sedatives and habit forming"
Fact : No
Antidepressant drugs are neither sedatives nor habit forming. In a depressed patient these drugs bring back the mood to the normal level where as in a normal person these drugs have no effect. With the action of the antidepressant drugs the chemical changes in the brain come back to normal and the person feels better, more peaceful and is able to sleep well. A person taking antidepressant can do all the normal work as they do not feel sleepy or drowsy during day-time in fact the performance of a depressed patient on antidepressants will improve as the drugs take care of the underlying problem, releasing him from the dungeons of depressive illness and thus allowing him to come back to his normal self.

Myth No.4 "Somebody has done something -these are influences of witchcraft, bad omens etc."
Fact : No
Many people even today strongly believe that a depressed patient is under the bad influence of witchcraft, is possessed by a "devi" or a "shaitaan", and hence needs to be taken to those people who will free him from these influences and that doctors cannot do anything for patients.

Scientifically there is no proof for such an rationale. The validity of this rationale can be judged from the fact that previously even small pox was believed to have been caused by "devi". Today it is common knowledge that small pox is a viral infection and can be effectively controlled with vaccination and modern medicine. Similarly it has been proven that depressive illness is primarily due to chemical changes in the brain and can be cured with proper treatment. Rather than wasting time in going to the above people, starting scientific treatment early will yield much better results.

Myth No.5: "I have more tension and nothing happens to me where as he gets depressed at the slightest stress faced by him"
Fact : The comparison is wrong and does not help in proper treatment .
In a family, only one develops tuberculosis, while others remain healthy although all are having similar contacts with TB and breathing the same air. In this case family members do not say "Why have you developed tuberculosis, while I am healthy". In fact they sympathize with the patient and help him get treated.

When physical resistance to an infection is less, the patient is at a greater risk of catching that infection. Similarly in depressive illness, which is a combination of Hereditary-Social factors, when psychological resistance is reduced due to any of the factors, the patient is at a greater risk of falling prey to depressive illness. The family members need to help him get treated and help build up his psychological resistance both during and after the treatment.