Journal of Depression and Anxiety
Open Access
ISSN: 2167-1044
ISSN: 2167-1044
Case Report - (2024)Volume 13, Issue 2
This article spins around a 45 years old male, had done MA (Urdu) and a fax operator 1st born among 4 siblings and married came with the complaints of worrisome thoughts, difficulty in making decisions, restlessness, headache, sadness, fatigue, guilt, helplessness and lack of concentration since last three years. The patient was diagnosed as suffering from “persistent depressive disorder “according to the Diagnostic and Statistical Manual (DSM). Bad economic condition was the highest factor to provoke persistent depression. The psychological assessment includes formal and informal assessment. Informal assessment included; Clinical interview, behavioral observation, subjective ratings of presenting complaints and daily thought record. Formal assessment included BDI and BAI. Cognitive Behavior Therapy (CBT) was conducted for treatment. According to psychological assessment after treatment and according to subjective ratings of presenting complaints the patient reported approximate 70% improvement in his condition.
Depression; Anxiety; Cognitive behavior therapy
Despondency and sadness is diagnosed by depressive disorder according to DSM. Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depression, major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems [1]. Over 80% of people have symptoms of clinical depression and the number of patients increase 20% per year, researches proved that women are more affected by men.
In this case a man 45 years old came with a problem, his problem started back in 2010, and one month before his daughter’s death who was 10 years old, his daughter was ill since 5 months. Subsequently, one month before the death of his daughter, he became quite, hopeless because his daughter headache problem did o shake and not improved and to hear the news of death, his body started shuddering. After the death of his daughter he faced economic crisis as he spent all his savings (money) and also took debt for managing her treatment.
On those days the patient’s eldest son and daughter failed in their examination despite hard work. This left a strong negative impact on patient’s mind and he started to think that something bad will happen, subsequently in 2012, patient had dispute with his colleague on the basis of professional jealousy. As a result boss insulted him for no reason, this incident left patient with sorrow and boss depresses his self-respect and a state of constant tension for him. Later on patient father died due to cardiac issues, he was close to him after death of his grandfather, and he felt alone and thought he loses his last emotional support, death of his father leads to fatigue, sleep disturbance, helplessness and loss of concentration .moreover patient encountered an accident in 2013 which result in facture of leg and injury to back bone. Doctor prescribed him complete bed rest for six months, during the rest he felt worried regarding financial issues as he was only early hand of the family, this increased restlessness in patient, intensified his headache, physician prescribed him Surbex Z and Citanew and referred him to psychiatry department with the complaints of sadness, sleep disturbance, fatigue, guilt, difficulty in concentration, restlessness, headache and worrisome thoughts.
The patient linked his presenting complaints to his past events in which he made verbal argument with some religious person belonging to the opposite sect, and got emotional and said blasphemous words. He also reported that in his childhood a flood came in the area and leads to destruction of all their house and property. He felt guilty that he could not save Quran he thought that his current problems due to his carelessness at the time of flood. These recent some years incidents become the major trauma which he linked with his past events otherwise he has no genetically problem and also his birth was normal and achieved all his milestone at appropriate age. No neurotic traits were reported at that time and he achieved his puberty and educational and marital aspects of life appropriately.
According to Beck depression is associated with a negative trait. Negative views of the self, world and future constitute this trait. This model proposes that in childhood, people with depression acquired negative schema through experiences, such as loss of parent or social rejection of peers. Schema are a set of underlying beliefs that shape the way a person make sense of his or her experiences [2]. The negative schema is activated when the person encounters similar situations which originally from the schema. When the negative schemas are activated, they cause cognitive biases which in turn maintain the schema. In the present case of patient, he views himself as quite inferior as compared to others, view future as hopeless and view others as manipulative patient lost his mother in childhood and also faced prejudice from relatives. This lead to the formation of schema as helpless and vulnerable. This schema in turn leads the patient fails to notice any positive feedback about himself (like his achievements in education) rather he just focus on all events that are inept (i.e., his argument with religious person, his failure to save Quran and paintings of father, his low financial position) [3].
According to Seligman learned helpless theory of depression, the important trigger of depression is defined as expectation that the person cannot change the situation and the desirable outcome will not occur. It is triggered by life events that have important consequences for the person. Person who attributed the events as internal, stable and global tends to feel sleep disturbance, poor concentration and sadness. The feeling of low confidence in one’s ability undermines the confidence that they can cope with the life challenges. The stressful life events activate a psychological sense that life events are uncontrollable. This negative attribution style also finds in person who have anxiety features. When he got hopeless regarding treatment of his daughter, he experiences head ache and sleep disturbance. His symptom exacerbated after the death of his daughter and according to him this loss is permanent and related to many areas of life (health, finance). His self-inferiority boosts him thought that he cannot cope with future life challenges as well which leads to the anxiety features of restlessness, lack of concentration and worrisome thoughts [4].
A study was conducted to examine the association between stressful life events and onset of depression. The sample consisted of 316 participants of depression. Stressful life events were individually rated on contextual threat and dependence. Results revealed that stressful life events have a substantial causal relationship with the onset of episodes of depression.
Features (guilt, sadness, fatigue, sleep disturbance). According to Hoeksema and Susan, rumination increase the risk of depression. The most detrimental form of rumination increases the risk of depression. The most detrimental form of rumination is the tendency to regretfully ponder that why a specific event happens. Rumination predicted chronicity of depression and anxiety symptoms and may be particularly characteristic of people with mixed anxiety and depressive symptoms. In this case he kept of thinking about the financial issues caused by death of his daughter, symptoms of depression and anxiety emerges such as worrisome thoughts regarding finance and health of family, sleep disturbance, guilt over passed mistakes etc.
Therapeutic intervention
Based on case formulation, firstly build up the therapeutic alliance which is the relationship between client and therapist. Borden emphasized that therapeutic alliance consists of three major components (a) bounding (b) goal (c) task. When he sees that the therapist understands his point of view and share everything without any hesitation then start telling him about therapy daily thought record was used for identification of activating events, negative automatic thought, its intensity and duration and associated emotions [5].
Vertical decent was done to identify the core belief of the patient such as he said “My headache does not go away”, “what if my child is not feeling well” the core belief identify were “I am vulnerable” and “I am helpless”. ABC model was explained that how thoughts and beliefs lead to emotional and behavioral consequences. and explained about the connection from daily thought record. Beck‘s cognitive model of depression was used to psycho-educate regarding his current illness, then explained the links of childhood history, core beliefs, triggering events and Negative Automatic Thoughts (NATs). Cognitive restructuring was used to modify and challenge cognitive distortions once negative thought was identifying through core belief and from daily thought record, then challenged by using triple column technique.
Assigning worry time is used to restrict worry to a specific time and place and help the client to recognize that he has some control on worrying. This technique is used to decrease the association of work and home with worrying written ventilation was used to express emotions by freely writing down recollections of traumatic event which have effects on current state of illness. Guilt resolution was done to modify concept that his current problem was result of his sins and identify the situation in which he thinks he committed a sin. Problem solving technique was used to help to focus on problem. This technique was used with patient to enhance ability to take decisions and manage the problem efficiently instead of just worrying about it [6].
Mindfulness (three-minute breathing space) refers to the ability of person to pay attention to thoughts and feelings without judging them, this helps the person to distinguish a negative In this case, stressful life events lead to development of depressive thought from a subsequent worry or rumination response to that thought. The 3-minute breathing space mindfulness exercise was used to help patient access a clearer state of mind instead of reacting mindlessly to negative thoughts. Deep breathing and 16 Progressive Muscle Relaxation (PMR) used to increase relaxation with the rationale of reciprocal inhibition through the procedures of testing and relaxing the muscles, these techniques were used with patient to overcome sleep problem and reduce restlessness. Home based assignments are also given to the client (Figure 1) [7].
Figure 1: Graphical representation of pre and post assessment of presenting complaints, BDI and BAI.
Therapeutic outcome
The therapeutic outcome indicated significant improvement in the client’s presenting complaints that were realized through verbal and behavioral observation. Presenting complaints and subjective ratings which are (0-10) shows significant improvement such as his worrisome thoughts changed from 8 to 4, difficulty in making decisions from 7 to 4, sleep disturbance from 6 to 3, restlessness from 8 to 3, headache from 8 to 3, sadness from 7 to 3, fatigue from 7 to 4, guilt from 7 to 2, lack of concentration from 7 to 4 and helplessness from 7 to 4.
Beck anxiety inventory was administered on the patient to assess the severity level of patient, he obtained a raw score of 10 that falls in category of mild to moderate. This shows that anxiety score reduces from 21 to 10 [8].
Beck Depression Inventory (BDI II) was administered to assess the level of depression, in which he obtained 15 raw score that falls in category of mild to moderate thus the depression score reduce from 21 to 10. Thus if we got that patient was motivated for his treatment, he completed his work on time and practice the skills between sessions. Thus his condition improved gradually and he cope up of his problems and grasped the concept of cognitive restructuring and tried to generate alternative thoughts.
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Citation: Rasheed M, Ahmed R (2024) Persistent Depressive Disorder Characterized by Lost Inside of Self. J Dep Anxiety. 13:535.
Received: 14-Aug-2019, Manuscript No. JDA-24-1237; Editor assigned: 20-Aug-2019, Pre QC No. JDA-24-1237 (PQ); Reviewed: 03-Sep-2020, QC No. JDA-24-1237; Revised: 01-Jun-2024, Manuscript No. JDA-24-1237 (R); Published: 28-Jun-2024 , DOI: 10.35248/2167-1044.24.13.535
Copyright: © 2024 Rasheed M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.