2. DEPRESSION
INTRODUCTION
A person with severe depression has profound feelings of sadness,
worthlessness and guiltiness which usually are incapacitating. These depressive
feelings often are so marked that they cause a distortion of the person’s contact
with reality. The predominant feature of a severe depression is a profound
feeling of melancholy and despair. The majority of patients with severe
depressions have suicidal thoughts at sometime during their illness. Suicidal
attempts are common.
The production of a severe depression requires the occurrence of predisposing
interpersonal trauma in childhood precipitating emotional stress in adult life.
The childhood of the person who later develops a severe depression is
characterized by traumatic interpersonal relationships in which
1) He is emotionally rejected and his needs for affection are not met
2) His self esteem gets lost and
3) Strong hostility is mobilized within him toward the people who have
damaged him, but he feels much guilt about the rage he feels toward
them.
This emotional trauma usually begins in the patient’s early childhood and
continues in varying degrees throughout his formative years to his adolescence.
Occasionally a severe depression is precipitated by the death of an emotionally
close person, throwing the patient in to an emotional turmoil.
Depression and mania are the key emotions in mood disorders. Depression is a
low sad state in which life seems dark and its challenges overwhelming. Mania,
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the opposite of depression, is a state of breathless euphoria, or at least frenzied
energy, in which people may have an exaggerated belief that the world is theirs
for the taking. Most people with a mood disorder suffer only from depression,
a pattern called unipolar depression. They have no history of mania and return
to a normal or nearly normal mood when their depression lifts. Others
experience periods of mania that alternate with periods of depression, a pattern
called bipolar disorder.
International Classification of Disease 10 (ICD-10) Criteria for Depressive
Episode says at least two of the following three symptoms must be present, for
at least two weeks:
1. Depressed mood to a degree that is definitely abnormal for the individual,
present for most of the day and almost every day, largely uninfluenced by
circumstances and sustained for at least 2 weeks.
2. Loss of interest or pleasure in activities that are normally pleasurable.
3. Decreased energy or increased fatiguability.
In addition, at least two of the following seven symptoms should be present:
1. Loss of confidence and self-esteem
2. Unreasonable feelings of self-reproach or excessive and inappropriate
guilt.
3. Recurrent thoughts of death or suicide or any suicidal behaviour.
4. Complaints or evidence of diminished ability to think or concentrate,
such as indecisiveness or vacillation.
5. Change in psychomotor activity, with agitation or retardation (either
subjective or objective).
6. Sleep disturbance of any type.
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7. Change in appetite (decrease or increase) with corresponding weight
change.
Depending upon the number and severity of the symptoms, a depressive
episode may be specified as mild, moderate or severe. Somatic presentations
are very common, especially tiredness, sleep problems and aches and pains.
Anxiety symptoms often coexist with depressive symptoms, particularly in
community or primary care populations.
AFFECTIVE (MANIC – DEPRESSIVE) PSYCHOSIS OR BIPOLAR
DISORDER
Major mood disorders can be limited primarily to emotional extremes and quite
often they have psychotic symptoms. This combination of mood disorders and
a break with reality is called Affective Disorder or affective psychosis.
Kraeplin divides into 3 Manic-Depressive psychoses:
1.
Manic type,
2.
Depressed type and
3.
Circular reactions
Manic Type
Manic reactions are characterized by varying degrees of elation and
psychomotor over activity. Three degrees are commonly delineated, denoting
the progression of behavior from mild to extreme degrees of manic excitement.
They are:
1.
Hypo mania: It is the mildest form of mania by moderate elation,
flightiness and over activity. He is intolerant of criticism and denounce as a
stupid fool who dares to disagree with him or interfere with his plans.
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2.
Acute mania (Hyper mania): This is the more severe form of mania, the
individuals mood may change rapidly from gaiety to anger. There is a wild
flight of ideas, frequently leading to incoherent speech.
3.
Delirious (Hyperacute) mania: This is the most severe type of manic
reaction. The individual experience vivid auditory and visual hallucinations.
His behavior is obscene, entirely shameless and personal habits completely
deteriorate.
Depressed Types or Depressive Phase
The Symptoms of depressive reaction is in many ways the reverse of that in
manic reactions. They are divided in to three types:
(a)
Simple Depressions : The outstanding symptoms in simple depression
are a loss of enthusiasm and a general slowing down of mental and physical
activity. The individual feels dejected and discouraged. Feelings of
unworthiness, failure, sinfulness and guilt dominate his sluggish thought
process. Suicidal tendencies are common. There is a severe mental and motor
retardation.
(b)
Acute Depression : In acute depressive reactions the mental and physical
retardation is increased. The individual becomes increasingly inactive, tends to
isolate himself from others, does not speak of his own accord and extremely
slow in his responses. Feelings of guilt and worthlessness becomes more
pronounced and the individual becomes increasingly self accusatory.
Hypochondrical delusions are common.
(c)
Depressive Stupor : It is the most severe degree of psychomotor
retardation and depression. The individual becomes almost completely
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unresponsive and inactive. He is usually bedridden and utterly indifferent to all
that goes on around him. He refuses to speak or eat and has to be tube – fed,
confusion concerning time, place and person is marked and there are vivid
hallucinations and delusions.
The depressed state of the manic depressive psychosis differs from other
depressions in that (1) there is no apparent precipitating stress (2) the
depression usually lifts spontaneously after a period of time and (3) subsequent
periods of depression almost invariably occur.
Circular Type
The circular type of manic depressive psychosis is distinguished by at
least one episode of both mania and depression. Only some 15 to 25 per cent
of manic depression actually show an alternation between manic and
depressive episodes. In this manic depressive circular type, there are severe and
recurrent swings in mood. While most of the swings are in the direction of
depression, the pattern also include episodes of elation and excitement. These
fluctuations in emotional level are accompanied by psychotic symptoms.
UNI POLAR DEPRESSION
Types of Unipolar Depression:
1.
Psychotic depression: In this, the reality is distorted and delusions and
hallucinations are experienced
2.
Involutional depression: This is generally experienced at middle age,
without previous episodes of severe depression
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CAUSES
The cause of Manic-Depressive disorders can be
Biological Factors
The hereditary predisposition which Slater found in his study that
approximately 15% of the brothers, sisters, parents and children of manicdepressive were also manic depressives.
The Neuro-physiological factors express that imbalances in excitatory and
inhibitory process may predispose some people toward extreme mood swings.
The Biochemical factors suggests that catecholamine function may be
decreased in depression and increased in mania.
Psychological and Interpersonal Factors
This include Predisposing family and personality factors, severe stress, feelings
of helplessness and loss of hope, extreme defense, social roles and
communications
General Socio-Cultural Factors.
Carothers found manic reaction fairly common among African natives but
depressive reactions relatively rate – exact opposite of their incidence in the
United states. Jacob found that manic-depressive disorders were significantly
high among the divorced and 3 times higher in urban than in rural areas.
Psycho Social Factors
The causal mechanisms for depression, like all other mental disorders, are
likely to be related to an interplay between genetic vulnerability and
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precipitating factors in a person's psychosocial environment . Globally, there is
evidence to support both these pathways, as well as the potential interaction
between them. In South Asia, most of the evidence on determinants of
depression focus on psychosocial factors . Five major themes emerge from
these studies.
1) The relationship between female gender and depression. This increased risk
is both due to the harsher social environments for women (for example, their
exposure to interpersonal violence) as well as reproductive and maternal
factors .
2) The relationship between economic impoverishment and depression. For
example, a primary care study reported a strong association between indicators
of poverty such as being in debt and being unable to buy food with CMD . A
population based longitudinal study of women found that belonging to a low
income category was associated with increased 12 month incidence rates of
CMD.
3) The third association is that between low education and high risk for CMD.
In three studies from India, people who are less educated were at greatest risk
to suffer from depression.
4) The relationship between, violence and trauma (e.g. such as spousal violence
or trauma following conflict or a disaster) is a major determinant of depression.
5) Finally, as explored above, the relationship between chronic physical health
problems and disabilities are also determinants of depression.
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THERAPY AND TREATMENT
Drug Therapy is very much useful in the treatment of depression using
antidepressants which have relieved severe depression and undoubtedly
prevented suicide in tens of thousands of patients all over the world.
Electroconvulsive theory – ECT to affect the brain chemistry, Psychotherapy
which also affects the brain chemisty, Individual and group therapy is all very
effective in the treatment of depression psychosis.
Due to the cognitive and personality similarities between unipolar depression
and bipolar disorder, it would seem that psychosocial treatments for unipolar
depression should be equally effective for bipolar disorder. Demonstrating
equal efficacy becomes more important in light of the fact that mood stabilizers
used to treat mania are not as effective for depression (Hlastala et al., 1997).
Family and interpersonal psychotherapies, two well-studied interventions for
bipolar disorder, have been found to alleviate depression, but not mania (Frank
et al., 2000; Miklowitz et al., 2000). Similar treatments have been found to be
effective for unipolar depression, suggesting that bipolar disorder might be
responsive to psychosocial interventions used for unipolar depression
(DeRubeis & Crits-Christoph, 1998; Frank et al., 2000; Kolko, Brent, Baugher,
Bridge, & Birmaher, 2000).
David Markowitz and his colleagues found that family tension is associated
with relapse in bipolar disorder, preliminary studies indicate that psychosocial
treatment directed at helping families understand symptoms and develop new
coping skills prevents relapse (1996). Similarly clarkin evaluated the
advantages of adding psychosocial treatment to medication in inpatients, and
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found that it improved adherence to medication for all and resulted in better
overall outcomes for the most patients compared to medication alone.
Further study confirms that psychosocial treatments may be a desirable initial
strategy so that people can avoid the various medical risks associated with long
term use of medication and women of childbearing age may feel free to
conceive. There is evidence that psychological treatments alter neurochemicals
correlates of depression. It has been found that patients treated with cognitivebehavioral procedure had a substantially lower relapse rate (35%) than patients
in the clinical management position (70%).
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A CASE OF DEPRESSION
Initials of the subject
: C.C.
Age
: 26 years
Gender
: Female
Marital Status
: Married
Occupation
: Housewife
Socio Economic Status
: Lower income level
Language
: Tamil
Informant
: Husband
Institution
: ………………..
Complaints
C.C. was under Depression and she felt things would get into her mouth and
she would swallow spoon, stick and glass. As per her husband, she was talking
alone in solitude without knowing what she was speaking. She would knock
the doors of neighbors. She had the burning sensation all over her body. She
was hesitating to take tablets, kept breaking things at home.
History of illness
C.C. felt that she would eat some objects especially bottle caps and tumblers
while drinking water and kept saying and worrying about it. She did not beat
her child, she did things being alone like cooking. She slept only after taking
sleeping tablets. She was afraid of giving rupee coins to the children feeling
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that they may swallow, this feeling was there since she got hit by a scooter 3
months before. She wanted to run away because of the ill treatment of her
husband and the burning sensation in the body. She had been admitted in IMH
since 7 days. She had come to IMH eight months before, IMH had prescribed
tablets and wanted her to get admitted in the hospital but she could not get
admitted since her husband did not have Rs.150/- to pay as admission fee and
there was short of money to travel back.
As per her husband, she had the habit of speaking in solitude even before
marriage but this statement might not be true. In the beginning, she did not go
out and talked to the neighbors about swallowing things, this behavior started
only recently, otherwise she was seen shaking her head and speaking alone.
C.C. did not take the medicine regularly what was prescribed by IMH during
their previous visit.
Family History
C.C. was married for three years and she had one girl child. It was an arranged
marriage. She lost her father four years before and lost her mother three years
before. She had one brother and three sisters who were married as per C.C.
and there were two more brothers got to be married as per her husband. She
lived in Kattur, she did not study. Her four year old daughter is studying in
LKG. When C.C. was in IMH, the brother in law looked after the child. The
child had met with an accident one month before. It was told by her husband
that her mother had similar problems like her.
Living Conditions
Her husband seemed to quarrel with her and beat her after drinking. They lived
in Ponneri and the husband’s parents lived in Vaidhigamedu at Minjur.
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Generally, most of the time, C.C spent her time alone, watching TV, washing
clothes and spent time with her girl child when the child was at home.
Personal History
C.C. was brought up by the parents along with one brother and three sisters.
She lived in Kattur. She did not have any basic education. She had normal
developments physically and mentally.
She did not have much friends since she was neither much outgoing nor she
had gone to school. She did not have any hobbies or interests other than
watching Television and doing household works.
She was married and had a girl child. She lived near Ponneri after marriage.
She was working before getting married doing household works and after
marriage, she never went for work.
Interview with husband
Her husband said that they had a girl child whom she loved very much. She
was speaking in solitude and he came to know that she was doing this even
before marriage and he was not told about it. After two months of marriage, he
noticed that his wife was shaking her head for no reason and was speaking
alone. He used to beat her when she never listened to him. Since five months,
she started visiting neighbors and was asking them if she had swallowed any
objects. If her mood is good, she did the work at home, prepared food,
otherwise she did not do anything. They went out very rarely. They used to
visit their relatives occasionally when there were family occasions. She used to
spend time by preparing food, watching TV, washing clothes and doing
household works.
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General appearance and behavior (Mental Status Examination)
C.C. was very cooperative in spite of feeling dizziness. She wanted to sleep but
kept saying that she would swallow some thing. She was not able to walk
straight in a normal way, she found it difficult to walk. She wanted to lie down,
she could neither sit for more time nor able to stand but felt tired and sleepy.
She was not well groomed, her hair was not combed and her body looked tired.
C.C.’s speech was less audible, she looked very dull. She had a burn sign in the
throat. Her body kept shaking, she looked fearful. She was lacking interest for
life worrying too much with hopelessness. She was attentive during
questioning and answering, but she was feeling dizziness due to the tablets she
had taken before lunch. She was having the same thought of things getting in to
her throat, repeatedly. She did not have any delusion (but she could be in the
initial stage of delusion), hallucination or illusion. She did not dream anything
making her fearful.
She was repeatedly worried if she would swallow things lacking in judgement
and insight. But she was able to recall the number of days she has been
admitted at IMH. She could not concentrate much because she was tired and
sleepy.
She was able to remember the recent incidences. She had the memory of her
child studies and the date of incidence-accident happened to her child. She was
lacking in general knowledge, abstract thinking, insight and
concentrate more on abstract things like social judgements.
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not able to
Psychological Assessment
She was under depression, diagnosed as Major Depressive Disorder –
Schizophrenic. C.C.’s illness can be diagnosed under Axis I – DSM-IV TR
classification which is connected with the clinical syndromes like mood
disorders, schizophrenia, generalized anxiety disorder. Other conditions are to
be focused for clinical attention.
Various tests can be administered to C.C. to find out more about her
personality, attitudes and goals.
Eysenck’s Personality Questionnaire (EPQ) could be used to find out her
personality like Psychoticism, Extroversion, Neuroticism and Lie scale.
Symptom sign Inventory (SSI) could be administered to get a better idea of the
clinical picture on Anxiety, Depression, Mania, Paranoia, Obsessivecompulsive, Schizophrenic, Hysteria and Neurasthenia.
Sentence Completion test (SCT) was administered to find out about C.C.’s
attitudes, goals and her relationship in different areas. She had positive attitude
towards her child. She had negative feeling towards her husband. She had fear
that something she would swallow harming herself or her child would swallow
harming her.
Counselling the husband
Since husband never spent time with her and did not care much for her, the
husband was asked to spend time with her, take her to the relatives often, go
out for movies, visit places for change in her environment and mental status.
Counselling the Client with Delta Healing
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After collecting the History, the strengths and weakness of the Client was listed
out . Her Strengths were:………..Her weaknesses were: ……………
Using Paris window and Scale of Self love, the Client was asked to think
logically how things could get into her mouth. She was asked to do activities
which interested her more, to spend more time with her kid. She was also asked
to do those activities in which she had interest.
Based on the above discussion, the following suggestions were framed for Self
empowerment”
Suggestion:
Then the Client is given Induction with the following step by step procedure:
1. Overcoming the resistance of conscious mind by message units
2. Progressive relaxation
3. 20 step Deepening and
4. Mind Scan
During the Mind Scan, the following were noted:
MIND SCAN AND ENERGY RELEASE CHART
SCAN-FRONT AND BACK
BEFORE
FEET
LEGS
KNEES
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AFTER
THIGHS
HIPS
MID-SECTION OF BODY
STOMACH
ARMS
HAND
FINGERS
NECK MUSCLES
SCALP
FOREHEAD
EYELIDS
EARS
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NOSE
JAW MUSCLES
NO. OF ENERGIES CAME ACROSS:
WHICH PART:
COLOUR:
NAME:
SINCE HOW LONG:
WHY-REASON:
RELEASED OR NOT:
At times when Client was not able to visualize, he was asked to recall the
incidences of emotions that had taken place in his life time and following
methods are used to heal the emotions:
1.
2.
3.
4.
5.
Recalling the incidences
Re-experiencing the emotions physically, mentally and emotionally
Making the Client understand the situation using the logical mind
Rescripting the situation or incidence
Desensitizing with Anchors and Triggers
Suggesting the Client for Maintenance of health by PsychoNeurobics
The following Psycho Neurobics Exercises were suggested for the Client:
1.
2.
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3.
4.
Summary and Conclusions
The condition of the client was affected badly due to the ill treatment of her
husband and due to the incidence happened to her child who met with an
accident few months before. The Client herself had also met with a scooter
accident making things worse.
Unless there is a change in the environment and the current situation, it might
be difficult for the patient to overcome the depression although she took
medication. Even for the patient to take medicine there had to be someone to
monitor and husband could not do this as he would be out for work during the
day.
The husband was asked to find out ways that one of the relative could live with
her for some time until she got improved, to monitor that she took medicines
without fail and also to give her psychological support.
The Expected feedback through PsychoNeurobics and Delta Healing:
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