Aishwarya Rao

C016258

FIELD WORK REPORT

Name: Anandi Trivedi

Sex: Female
Age: 25yrs
Education: 12th pass (enrolled for graduation but couldn’t finish)
Occupation: Housewife
Marital status: Divorced
Socio economic status: Belongs to a lower socio-economic strata
Informant: Mother
Nature of information: Adequate and reliable

Presenting Concern: Patient feels low all day and doesn’t feel like working all day long. She
keeps lying in the bed the whole day and the patient is unable to get sleep. She sleeps
approximately two-three hours a day thus feeling tired the whole day. She also has mild
headache the whole day. As informed by the informant the patient doesn’t pay attention to
her kids and keeps lying in the bed and patient’s mother has to take care of the children.
Patient’s major concern was that she was unable to sleep. Her sleeping pattern got disturbed
after her divorce. She started to feel low and stayed in her bed all day.

History of presenting concern

Onset: As informed by the patient herself, this feeling of sadness and loneliness had started
about two and a half years back when she got a divorce from her husband. Since then her
sleeping pattern has been disturbed. Initially her mother thought she is just sad but later on it
started to interfere with her daily life.
Precipitating factors: Patient’s divorce was the precipitating factor, which had a drastic
impact on many areas of her life.
Course of illness: Her course of illness is continuous. She has been feeling low every day
since past 2.5 years and is unable to sleep at night. She has also been on medication since last
1 year which has helped her in reducing her head aches but her sleeping pattern is still the
same.
Associated disturbances: She keeps thinking about her divorce due to which she is unable to
sleep. She sleeps only for 2-3 hours daily. She is not able to work because she feels tired the
whole day. She reported that she thinks the divorce happened because of her. She blames
herself for the divorce. She is also unable to take care of her children as she cannot
concentrated on her work and she also feels very tired whenever she tries to work. She
worries a lot about the future of her children as she is financially dependent on her father
currently.
Negative History: There are no temper outbursts, no recurrent thoughts of death, no vomiting,
no history of trauma, no fever, no history of physical illness, no history of alcohol abuse, no
reported hallucinations or delusions.
Complaints and their duration: The patient reported that her sleeping pattern started to get
affected 2.5years back. She also reported that she is unable to concentrate on things in her
daily life and gets lost in her own thoughts.
The information provided by her is reliable and adequate. Informant shared the same
information when enquired.
Past history: There has been no past record of physical or psychiatric illness.
Family History

Anandi is a 25year old female and had been divorced from her husband, for a little more than
two and a half year. She has two children. She used to live with her husband and her children
and her mother in law before the divorce. After her divorce she moved to her mother’s house
where she stays with her father, mother and her children.
She also reported that there has been no chronic physical or psychiatric illness within the
family. There has also been no abuse of alcohol or any other substances within the family.
The information provided by her is reliable and adequate. Informant shared the same
information when enquired.
Personal History
Birth and early development: Not taken
Behaviour during childhood: Not taken
Physical illness during childhood: No reported physical illness in childhood
School: The patient attended school till the 12th standard. She had resumed her college
education on a part-time basis when her second child was 1 year old. She had hoped to finish
her bachelor's degree but due to the house hold burden she was unable to do so.
Occupation: She is a housewife
Sexual history: Not taken
Marital history: the patient got married at 18years of age. She had her first child at the age of
19 and her second child at the age of 20. She got divorced with her husband at the age of 22
and since then her issues began. According to the patient, the husband was not able to spend
time with her as she was busy taking care of her two children and her family and also her
studies. She then reported that her husband then found having an affair with some other girl
and later on he demanded for divorce and married that other girl. This affected her
emotionally as well as financially. She was not doing any job and her husband was the only
working member in the family. When she shifted to her mother’s house her expenses were
taken care by her father. The patient misses her husband and blames herself for not being able
to take care of her husband. She always wanted to be a perfect wife and she disappointed
herself and others around her as reported by the patient.
Use and abuse of alcohol, tobacco and drugs: The patient doesn’t chew tobacco and she never
had alcohol or any kind of drug.

Premorbid personality
The patient reported that her nature has been very calm the since childhood even after her
divorce her personality remained the same. She also reported that whenever she had fights
with her husband she always used to remain calm and listen to him. The patient had interest
in studying and wanted to complete her graduation and work afterwards. She also used to
stitch a lot before whenever she got time. After her marriage the patient loved taking care of
her house and her in-laws and children. She loved to make everybody happy and used to get
very encouraged whenever anyone praised her.
Attitude towards others: The patient used to participate in social gatherings like marriages or
birthday parties and she used to love to go to school in her school days. She also used to love
doing things for her in-laws.
Attitude towards self: The patient always was very proud of her self that she is always
scoring well in her tests and she was always encouraged by her performance in classes and
encouraged by the praises from her in-laws.
Moral and religious attitudes and standards: Not enquired
Mood: The patient reported that she used to be very satisfied with her life earlier and used to
feel happy about everything she had done on a particular day and used to go to bed with a
feeling that she had been productive and had made everyone around her happy. She used to
be very happy all the time.
Leisure activities and interests: The patient loved to stitch and study. She used to like reading
story books. She also used to paint sometimes and she loved to do gardening on her
weekends. She also loved to cook for her family.
Fantasy life: she always wanted a life where she would manage her house on her own without
giving anybody a chance to complain, she wanted to be a perfect wife.
Reaction pattern to stress: she used to stress a lot whenever something used to go wrong or
she used to make a mistake. When she was unable to balance between her studies,
housework, taking care of children and taking timeout for her husband she used to get very
upset with herself and she also left her studies because of this reason.
Habits: Patient was always very punctual and used to do all her work with perfection. She
used to love it whenever somebody used to praise her.

Mental Status Examination

General behaviour
The patient reported that she spends her whole day lying in bed and just thinking about what
had gone wrong and blaming her own self for the divorce and feeling sad. She is unable to
sleep the whole day in spite of being in the bed the whole day. She sleeps for 2-3 hours a day.
She stopped her education as there was a lot of work pressure on her in her home. The patient
was dressed appropriately in clean clothes. Her nails were cut properly. Patient did not look
ill or disturbed. The patient was conscious and was aware of where she was and what she was
doing. The patient seemed relaxed. She was not hesitant at any instance. Her responses were
normal, she answered to the questions that were being asked. The patient was attentive and
cooperative. Rapport could be established between the patient and the psychiatrist. The
patient made eye contact many times. Patient’s behaviour was not disoriented.
Psychomotor activity
Talk: The patient spoke only in response to the question. Volume of speech and the tone was
adequate. Reaction time of the patient was also proper. Prosody of speech was maintained.
She could see properly and hear properly. The information that she was providing was
relevant.
Thought: The patient’s stream of thought was appropriate. There was no form of obsession.
She did not have any kind of overvalued ideas and delusions. The patient did not have any
suicidal thoughts.
Mood: The patient feels sad the whole day and has been feeling sad since past few years.
When asked more about her emotion she did not further respond. Her mood remains the same
at home or anywhere she goes (when forced by her mother). Her mood doesn’t elevate even
when she is around people or in a place where there is a situation where everyone is happy.
Perception: The patient did not have any hallucinations. There was no disturbance in
perception.
Insight: The patient was aware about her condition and was excepting it. She recognizes the
presence of illness but gives explanation in physical terms. She does realize the cause of her
symptoms.
Summary of the case
The patient is a 25-year-old female whose presenting concerns are not being able to sleep
more than 3-4 hrs. And feeling low and tired the whole day. She is unable to work in her
home as she feels tired the whole day. She also has minor headache throughout the day. She
is also not able to take care of her children as she is unable to concentrate. Whenever she
starts working she gets lost in some thoughts and forgets what she had to do. She keeps
blaming herself for the divorce all the time and feels sad. All these issues started 2.5years
back after her divorce. She has been taking medication since past one year. Her medication
helped with reducing her headache but she was still unable to sleep. The medication didn’t
solve her issue of not being able to sleep. There is no presence of psychotic symptoms.
Case conceptualization
Patient’s low mood and other issues were clearly precipitated by her divorce, which had a
drastic impact on many areas of her life. Increased financial burdens were clearly part of this
picture, but interpersonal relationships were even more meaningful. Nevertheless, her
relationship with her husband had been one important part of the way in which the patient
thought about herself. She had lost one of her most important roles (as a wife). She was not
able to keep everybody happy and her fantasy of being an ideal housewife was not coming
true. She wasn’t able to set a balance in her life thus leading to such consequence. The patient
seems to be very de-motivated.
The patient was diagnosed with major depressive disorder by the psychiatrist with no sign of
any psychotic symptom. I’m satisfied with the diagnosis made by the psychiatrist as the
patient meets the DSM-V criteria.
Proposed/ Ongoing treatment/ Intervention plan
The patient is currently on anti-depressants. Before planning any intervention it is very
important that areas of his childhood experiences, her beliefs and values should be asked
about. This will help in planning the intervention as the areas which need to be worked on
will be clear.

Several psychological models have been proposed to account for the development of major
depression. Each model focuses on somewhat different features of depressive disorders (e.g.,
interpersonal relations, inactivity, or self-deprecating thoughts), but most share an interest in
the role of negative or stressful events in the precipitation of major depression. Freud's
explanation for the development of depression began with a comparison between depression
and bereavement. The two conditions are similar. Both involve a dejected mood, a loss of
interest in the outside world, and an inhibition of activity. One principal feature distinguishes
between the person who is depressed and the person who is mourning: a disturbance of self-
regard. Depressed people chastise themselves, saying that they are worthless, morally
depraved, and worthy of punishment. Freud noted the disparity between such extreme
negative views and the more benign opinions of other people who do not hold the depressed
person in such contempt. In other words, the depressed person's view does not seem to be an
accurate self-perception. Freud went on to argue that depressed people are not really
complaining about themselves but are, in fact, expressing hostile feelings that pertain to
someone else. Depression is therefore the manifestation of a process in which anger is turned
inward and directed against the self instead of against its original object.
Freud argued that the foundation for this problem is laid in early childhood. For various
reasons, people who are prone to depression have formed dependent interpersonal
relationships. This dependency fosters frustration and hostility. Because these negative
feelings might threaten the relationship if they are expressed openly, they are denied
awareness. Problems then arise when the relationship is ended, for whatever reason. The
depressed person's ego presumably identifies with the lost loved one. The intense hostility
that had been felt for that person is now turned against the self, or introjected. Following this
model, treatment would consist of an attempt to make the client aware of these unconscious,
hostile impulses. Their more direct expression would presumably eliminate the depression.
Therefore, patient’s childhood should be looked into very well.

Also her belief that she needs to be perfect and she needs to make everyone happy should be
looked into. She should be made to learn that own happiness comes first. She should be made
aware about self-worth. More recent attempts to explain the development of depression in
psychological terms have borrowed and extended various aspects of Freud's psychoanalytic
model. One important consideration involves his observation that the onset of depression is
often preceded by a dependent personality style and then precipitated by the loss of an
important relationship. Personality factors and relational distress may help to explain the fact
that women are twice as likely as men to develop major depression. Dependent people base
their self-esteem on acceptance and approval by others. Some authors have suggested that,
throughout their social development, women are frequently taught to think this way about
themselves (Gilligan, 1982). An extension of this hypothesis holds that women are more
likely than men to define themselves in terms of their relationships with other people.
Women would then presumably be more distressed by marital difficulties and divorce. In our
patient’s case, the loss of her relationship with her husband was certainly an important
consideration in the onset of her depression. Her sense of self-worth was severely threatened
by the divorce, in spite of the fact that her marriage had been far from ideal.
Patient’s treatment can involve a combination of psychotherapy and antidepressant
medication. Following the social learning/interpersonal model, the therapist can focus on
increasing patient’s activity level and helping her learn new social skills. By encouraging
activities such as stitching, the therapist can hope to interrupt and reverse the ongoing,
interactive process in which social isolation, rumination, and inactivity lead to increased
depression, depression leads to further withdrawal. The development of new response
patterns involving interpersonal communication and parenting skills, the therapist can enable
the patient to deal more effectively with future stressful events. Increased social activity and
more effective communication would also lead to a more supportive social network that
might help reduce the impact of stressful events.
Interpersonal psychotherapy, or IPT (Frank, 1996) can be another way of treating the patient.
The focus of IPT is the connection between depressive symptoms and current interpersonal
problems. Relatively little attention is paid to long-standing personality problems or
developmental issues. The treatment takes a practical, problem-solving approach to resolving
the sorts of daily conflicts in close relationships that can exacerbate and maintain depression.
Deficits in social skills are addressed in an active and supportive fashion. The depressed
person is also encouraged to pursue new activities that might take the place of relationships
or occupational roles that have been lost. Therapy sessions often include nondirective
discussions of social difficulties and unexpressed or unacknowledged negative emotions as
well as role-playing to practice specific social skills.
Some natural ways can also be effective. As the patient doesn’t do anything the whole day he
can be taught some exercises that she can do in morning so that she feels energized and feels
motivated and active. Exercise releases happy-making endorphins, which act like natural
anti-depressants. Exercise seems to improve depressive symptoms in people with a diagnosis
of depression when compared with no treatment or control intervention, however since
analyses of methodologically robust trials show a much smaller effect in favour of exercise,
some caution is required in interpreting these results. (Rimer J, Dwan et al. 2012)

As the patient remains indoors the whole day we can ask her to expose himself to sunlight,
which can boost mood and increase Vitamin D levels. Vitamin D affects the amount of
chemicals called monoamines, such as serotonin, and how they work in the brain. Many anti-
depressant medications work by increasing the amount of monoamines in the brain.
Therefore, researchers have suggested that vitamin D may also increase the amount of
monoamines, which may help treat depression.

References:
R.H. Belmaker, and Galila Agam, Major depressive disorder, N Engl J Med 2008; 358:55-
68,January 3, 2008.

Eyles, D.W., Smith, S., Kinobe, R., et al., Distribution of the vitamin D receptor and 1 alpha-
hydroxylase in human brain. J Chem Neuroanat, 2005. 29(1): p. 21-30.

Kjaergaard, M., Waterloo, K., Wang, C.E, et al., Effect of vitamin D supplement on
depression scores in people with low levels of serum 25-hydroxyvitamin D: nested case-
control study and randomised clinical trial. Br J Psychiatry, 2012. 201(5): p. 360-8.