ABSTRACT | PDF

CASE CONFERENCE

Adjustment disorder, prolonged depressive reaction

Debjit Roy
Postgraduate Trainee of Psychiatry
Silchar Medical College and Hospital 

Patient N., a 23 years old married Muslim male, belonging to low socioeconomic status and hailing from rural area was referred to psychiatry outdoor patients' department (OPD) by Medical Officer through Superintendent of Central Jail and was admitted in under trial prisoners' (UTP) block under psychiatry department. The informant in this case was his father and information obtained was adequate and reliable. Chief complaint, according to patient, were decreased sleep; feeling of uneasiness, discomfort, lethargy; low mood; getting easily annoyed; and occasional death wish. According to father, there was no behavioural disturbance and he did not know the reason for referral. Course of illness is continuous. Life event was being taken into custody four months back. There is no significant precipitating factor. Patient was an undertrial jail inmate in Central Jail for last four months on charges of possession of illegal arms or weapons, ten years back and presently he had been referred for aggressive behaviour and decreased sleep by the jail authority. Patient said that when he was 13 years old, one day he went with his family to the nearby forest to collect firewood. As he was working, some men came and gave him a packet and asked him to look after it until they come to collect it. He looked into the packet  and saw that there were some weapons and bomb-like things in the packet. He informed his father about it. His fdather and other villagers reported the matter to the police. The police filed a case against him and took him into custody for 90 days but was later released on bail. Following his release, started working as a driver. But he had to appear before the court on days of hearing. This continued for about eight to nine years during which he got married and also fathered a child. But he failed to appear before the court for the last two hearings on account of his daughter's illness. For that reason he was again taken into custody. After staying for ten days in the jail, his sleep had decreased with delayed onset. He would sleep only for two to three hours in the night. He attributed it to both the adverse living conditions in the jail and his worry about his family. He also complainted that in the jail he felt very weak, vague feeling of discomfort, and uneasiness. He felt as if his whole body was in pain. But there was no history of any physical assault inside the jail. He also experienced low mood. He kept thinking about his family all the time. He did not like talking to the inmates or playing cards with them. He also did not feel like eating sometimes. He grew irritable, got angry even at the slightest pretext. If anybody asked him about his crime, he got irritated though he never engaged in any form of physical fight. He also had occasional thoughts of ending his life. He thought that he had been falsely framed and all his dignity and respect in the society had been lost due to this. But he never made any plans on how to commit suicide. These symptoms persisted till two days after admission in the hospital, and was subsequently symptomless. There was no significant past medical, and surgical history. There was no history of any psychiatric illness in the past. He was born at his home by normal vaginal delivery. There was no history of any complication in the intrapartum or postpartum period. He attained his milestones at proper ages. He had friends in the neighbourhood with whom he used to play and engage in other recreational activities. He had been educated upto class seven. Due to financial reasons and also lack of interest, he left his studies. He worked as a mechanic from age 14-16 years. Thereafter he worked as a driver earning 3000-4000 rupees per month. There is no history of any childhood sexual abuse. He attained puberty at around 12 years, gained sexual knowledge from his friends, first masturbated at 15 years of age. He has had unprotected sexual intercourse with female sex worker on two occassions. He was married for one and half years. His marriage was arranged, nonconsanguineous, maintained harmonious relation with wife. He used to take alcohol on and off for five years. He used to take 180 ml of Indian made foreign liquour (IMFL) in one sitting, last intake was four months back. He also used cannabis on and off for last two to three years. It was very infrequent though, two to three puffs in one sitting; last intake was three and half months back in the jail. He lived in a joint family. Head of the family was his father. Earning members were his father, brother and he himself. There was no history of any significant psychiatric illness in the family. Premorbidly he was a religious man. He offered namaz two to three times a day. He had adequate number of friends. He spent most of his free time socializing with friends and other people. His stress coping was adequate. He liked traveling to different places. Blood pressure (B.P.) was 110/70 mm of hg and pulse 78/min. On examination, right side of chest was depressed due to absence of pectoral muscle. Human immunodeficiency virus (HIV) 1 & 2 was negative and Venereal Disease Research Laboratory (VDRL) not reactive. Mental state examination showing athletic built, adequately maintained hygiene, spontaneously interacting with the interviewer with normal psychomotor activity with established rapport with relevant and coherent speech with euthymic mood with a stable and appropriate affect and content of thought revealing guilt feeling without any perceptual disturbance with intact memory, proper orientation, with normal abstract thinking, judgement and reasoning with level four insight. Provisional diagnosis was adjustment disorder with prolonged depressive reaction (F43.21). Differential diagnosis was mild depressive episode with somatic syndrome. In psychometric testing, apart from Rorschach, intelligence quotient (IQ) was also done which revealed score of 90. Hamilton depression (HAM-D) scale score was ten and brief psychiatric rating scale (BPRS) score was seven.

 

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