HISTORY
Male aged about 53 years walks in to the OPD with complaints of acute gastritis and chest pain. He meets the Physician seeking medical help. He was advised for the following investigation as the physician suspected cardiac arrest.
1. Echocardiogram
2. 2 – D Echo – heart and
3. 2 – D Echo – abdomen.
Reports read that his heart was healthy and functional. While his 2 – D echo abdomen reports read acidic reflex. He was prescribed appropriate medication by the same physician.
During his second visit to the hospital, he came up with two more symptoms added to his previous set of complaints which include frequent nausea and irritable bowel movement. He was assessed again and the reports were compared. The comparison reports made the physician understand that the patient was into irritable bowel syndrome – IBS and was prescribed medications for the same. Physician suggested the patient to meet a psychologist to take further treatment and specified to the patient that his mental health condition was not in the state of equilibrium as a result of which he had been facing the issues. The patient neglected the doctor’s advice.
VISIT TO THE THERAPIST
The patient calls CCPC founder Pavan M Srivatsa to book an appointment as per the advice of the physicians he consulted (as many as 12 physicians, gastrointestinal specialists and cardiology specialists in the span of 3 months). He, in the first call specified that he had been taking prescribed medication which includes “lyster 0.5mg” (PSEUDO NAME) for his sleep.
SOCIO DEMOGRAPHIC DATA
AGE: 53 YEAR
GENDER: MALE
MARITAL STATUS: MARRIED
FAMILY: WIFE, PARENTS AND A DAUGHTER
OCCUPATION: MANAGER – FINANCE @ PVT. LTD.
PRESENTING COMPLAINTS
1. Irritability since 1 year.
2. Disturbed sleep since 1 year.
3. Nightmares since 5 months.
4. Aggression and inability to express it because of the family situation since 3+ years.
5. Work stress since 5 years.
6. Excessive worrying about his daughter since 4 years.
7. Inability to handle home situation because of 3 generation population under the same roof since 7 years.
8. Irregular food habits since 1 year.
9. Excessive worrying about personal health due to pandemic and otherwise since 5 years.
10. Pain in the chest since about 1 year.
11. Irritation in the stomach and chest since 2 years increased since about 5 months.
12. Shivering since 3 weeks.
13. Excessive medication since 2 years.
14. Hypertension and hypothyroidism since 12 years and 2 months
HISTORY OF PRESENTING COMPLAINTS
Client explained that he had been visiting doctors for proper medication and satisfactory treatment for his hypertension and hypothyroidism since the day he was diagnosed (since 12 years and 2 months). He explained that he had visited homeopathy, Ayurveda and allopathy for treatment while his health has been worsening over a period of time. On probing it was understood that he had been irregular with his medication as he was not convinced with the treatment plan. He added to it that he had been changing doctors frequently as he thought that the doctors were not understanding him properly. “The doctors saw me as a patient with those problems and never saw me as a human being. They labelled me as a mentally ill person and asked me to visit mental health care hospitals.”
On probing it was evident that he had considered taking help from mental health care hospitals. On probing, he explained that he had visited the following mental health care hospitals for treatment. Which include:
1. NIMHANS, Bangalore.
2. St. John’s Hospital, Bangalore.
3. Manipal, Udupi.
4. Metro hospital, Shimoga.
5. Dr. Sridhar Hospital, Shimoga.
“Treatments were not up to my expectations. They only prescribed medication. Also, they asked me to visit them frequently (2 months once on an average) which was not possible. So, I gave up on medications too. Now, I don’t know whom to consult and what treatment to take.” the client said. On probing, the client explained about the medications he had been taking presently. He also explained that his thyroid and hypertension are under control because of the medicines. He added to it that his sleep is better because of the medicine “lyster 0.5mg” and would worsen if he has no “lyster” in his daily medicine. He also explained about his past history.
He started with his experience as an adolescent. He was angry and sad when he was talking about the situation where his friends committed suicide – hanging himself as he was mentally ill. “I started smoking cigarettes after this incident. I don’t know why I started it. I was addicted to smoking. I used to smoke at least a pack a day. I had to quit smoking after my marriage was settled. Because, I didn’t want my wife to call me a smoker.”
He continued saying that he was not able to cope up with the withdrawal symptoms (anger, palpitation and muscle tension) and had started smoking again after confessing it in front of his family (mother, father and wife). “I smoke about 12 cigarettes a day. To be honest with you, when I hear my family members fighting, I feel like smoking cigarettes. (puts his head down)”
Client got married when he was 25 years old (as per the norms of his culture) and is having a satisfactory relationship with his wife. He explained that his mother and his wife were and are still, having a few issues as a result of which they fight verbally.
“I don’t know whom to support. I don’t know what makes them fight over such small issues.”
He then gave an example of the food menu where the wife prepares food which the client’s mother isn’t satisfied for. According to the wife – as the client said, was a balanced diet wherein, the mother wanted the stapled food according to their culture and tradition.
Client has a daughter who is now in her 3rd year engineering. He explained that his mother and his wife are having issues with the daughter for the dresses she wears, the attitude and the behavior of the daughter. “She is appropriate to her age and present generation. These people haven’t understood and accepted her for this. As a result of which there are fights between these three people which makes me more stressed.” the client said. Client was angry at the mother, her wife and his daughter.
Client then started explaining about his physiological illness. He explained that he was diagnosed with hypertension at an early age of 41. It was then, he realized that he was having thyroid issues. The then physician prescribed him medications for the same. As he was not satisfied with the treatment plan, he had been visiting different doctors and had been changing his medicines since then.
Presently, as the client explains, he has been experiencing difficulty concentrating on his work and sleep (disturbed sleep). He further explained that he had been getting nightmares which are contributing to his deteriorating health and disturbed sleeping patterns. He mentioned that his occupational efficiency has decreased, his relationship with his wife has been affected, his relationship with his parents has been affected and his relationship with himself has been affected while, his relationship with his daughter has not been affected at all. He continued saying “my daughter is my best friend. We make sure that we spend some quality time with each other forgetting everything.”
Client explained that his father is active and a peaceful person who has understood the meaning of life. He further explained that his father was his role model.
“My dad never gets annoyed when my wife or his wife shouts at him or makes a scene. He keeps himself calm and continues doing his work without being affected.”
CONTENTS OF DREAM
“I am walking on the sea shore. The tides are heavy and dangerous. There are two puppies in my hand and another puppy draining in the tide. I don’t know if I have to leave these two people and save that puppy or to save these two puppies I already have in my hands.”
“I am at my home sipping my coffee. I suddenly hear a lady screaming my name. I got scared. I get up and turn back to see what happened. I then see nobody in that direction. They are just shadows.”
MENTAL STATUS EXAMINATION
1. General appearance – Well kempt and tidy. Was wearing a white scarf around his right wrist. Wore a Rado watch on his left hand. A ring on his right-hand ring finger which, as the client said, was an antique.
2. General behavior – Gentle and reserved. Was on the edge of the seat during the first quarter of the session and was comfortable expressing himself as the time passed by. Client’s level of involvement in the therapy/ with the therapist increased gradually. Eye contact was well maintained since the beginning of the session and was cutting the eye contact appropriately and when the client felt uncomfortable.
3. Memory – Intact. (Immediate, recent and remote memory).
4. Judgement – Intact.
5. Intelligence – Seems normal (no psychometric tests administered.)
6. Thought content – Helplessness, confusion, dilemma and dissatisfaction. (that the client labelled as problems).
7. Emotions – Sad, anger, frustration, anxiety, helpless, happy, excited and disturbed.
8. Speech – High pitch/ volume, normal tempo.
9. Orientation towards time, place and person – intact.
10. Leve of consciousness – alert.
11. Insight – level 4 – present.
12. Suicidality or homicidally – not present.
13. Attribution to physiological illness – Present.
14. Readiness to take treatment – present (as the client walked in to the therapist to take therapy after being referred to – by the physician and psychiatrists).
NEGATIVE HISTORY
1. Loss of Consciousness – not reported.
2. History of seizures – absent.
3. History of suicide attempts or thoughts – absent.
4. History of surgery – has undergone a surgery for his appendix.
5. Drug abuse – present.
6. Psychiatric history (client) – absent.
7. Psychiatric history in the family – present (Explained that his father’s younger brother had been admitted to the hospital due to some psychological illness. He further explained that his uncle was a chronic alcoholic.
DRUG HISTORY
Smoking Tobacco
Started – 33 years ago.
Had quit smoking about 28 years ago (showed minimum withdrawal symptoms)
Started smoking again about 22 years ago and continued. Presently, the client is smoking a minimum of 7 units per day.
No other drugs used/ abused.
Also takes lyster 0.25mg for his sleep (NOT PRESCRIBED).
PERSONAL HISTORY
Birth – normal
Developmental milestones – normal
h/o childhood disorders or illnesses – not reported
academic performance – adequate
social relationship – presently strained
personal relationship – strained
interpersonal relationship – strained – associated with helplessness
premorbid personality – balanced – had issues with spouse and mother for their conflicts.
PLAN OF ACTION
1. Dream analysis.
2. Assessing ADL and medication.
3. Referral to pharmacologist for revising prescription.
4. Psychoanalysis – catharsis.
5. UPR and PAS.
6. LOC therapy, LOI therapy and adjustment therapy.
7. Relapse prevention and psychoeducation.
8. Client focused family therapy with the client’s daughter and wife. As the stress is because of circular causality.
PRESENT CONDITION OF THE CLIENT (AFTER TERMINATION)
Client aged about 53 years who had issues with how to manage stress in the family situation and his inability to handle the circumstances, who had disturbed sleep and poor interpersonal relationship, personal and social relationship had come to take therapy at CCPC. Presently the client has been completely functional and is aware about the root cause of his stress and causes of the problem situation. Also, the client’s awareness about his previous way of response to stress situation has made him aware about the other choices available to choose to respond to stress situation. The client has resumed with his work and is showing intact performance. Adding to this, the client has hired 4 farmers to farm his land in his native which adds to his present economical income. Client has reported that his sleeping pattern is adequate and normal as a result of which his days are going comparatively better than before (prior to the therapy). Client reported that he has been gradually reducing the counts of cigarettes he has been smoking and presently, he has been smoking only 3 units per day. He added to it that he wanted a couple of months’ time to quit smoking as he is using tapering method to quit his addiction.
