DEPRESSION IN OLD AGE
Old Age: Sync with Wisdom or Sink in Despair.
Abstract : (What makes old age hard to bear is not the failing of one’s faculties, mental & physical, but the burden of one’s memories so truly said by W. Somerset Maugham. Integration of Personality Theory by Eric Erikson through a case of 92 years old man. How an evolution of life experiences plays major role in perception of self-worth and making life meaningful explained along with drug picture)
Name: Mr. MB, Age: 92years, Education: M.com. Date: 14.11.2018
2 elder brothers and 2 elder sisters.
| Location | Sensation | Modalities | Accompaniments |
|---|---|---|---|
| Mind
Since 2 years Since 6 months Increased |
Lack of interest in anything, TV, Newspaper, book, garden, going out
Nothing seems interesting. Hopelessness Despair of recovery Lonely feelings Sadness Feels he is unfortunate Worthless feeling Lack of appetite Sleep disturbances Doing regular chores by himself No suicidal thoughts |
A/F death of brother and friend < when alone | – |
Physical generals:
- Sensory deafness both ears wearing hearing aids.
- Small Warts on face, neck, back
- Dryness of skin and body becomes cold very easily.
- Appetite: reduced
- Craving: sweets2
- Perspiration: scanty
- Stool: constipated, non- satisfactory, once a day, takes purgatives once / 15 days
- Thermal state: chilly
- Family history: Mother : Depression, brother: DM, sister : anxiety pronne
Life space:
“I have lost all my brothers, sisters and friends. I am alone at 92 years. Physically I am healthy but I have no interest in life I have hurt feelings and it pricks me a lot (Showing heart region). Please help me.” Patients started as soon as asked let me know your concern. On asking what pricks you… took him to a flashback journey.
Mr MB was born in a poor Marathi family in Mumbai. He was given to his grandfather since his birth as parents already had 4 kids (2 sons and 2 daughters) & they couldn’t financially afford to bring up patient. Whole childhood passed in hardships. GF loved him though he always felt left out. After demise of grandfather at age of 10 years he was brought to his parents’ house where he found it difficult to feel belongingness with siblings. There was constant sadness as he could see parents could make love to all except him and siblings couldn’t accept him as he came in picture later and found difficult to share things with him. They picked up fight with him many times. All these experience made him sad, rejected, lonely and unfortunate. Frequently he complained God “why I am only suffering?”
What have I done wrong?
He studied M.Com and took job as clerk in Pune. With sheer hard work he could manage good promotions, got married & settled in Pune. He has 2 daughters and one son. All are well educated, married & well settled.
He regretted over few instances.
- He couldn’t take care of his parents the way he should as he was staying away and didn’t have time. Other brothers did their duties. He had frequents fights with them. He was irritable by temperament.
- He retired on 31st December 1985 & on 15th Jan 1986 there is death of wife. Though he couldn’t share how sad he was from within after demise of wife as she was his only support.
- He didn’t have good relations with DIL, there were constant arguments between them as he was unorganised. Now since 6 years he has been staying with son who is staying in Vadodara & working with MNC. His grandchildren are married and staying in Mumbai. They didn’t have much communication with him as everyone there has busy life. Son has extensive travelling so he has been staying with care taker. During this time he feels very lonely and slips in brooding past memories. He believes that he has been thrown out of Mumbai house and sent with son here in Vadodara. He thinks he is been singled out for this suffering. He is the only one in this world who is been suffering. He is most unfortunate. (Note: patient was brought by his son, according to him he is more or less pessimist in his life.)
- His brother died two years before and one friend died 6 months back, since then he has been gradually sinking in more depression.
Diagnosis: Major Depression superimposed on Dysthymia.
Life space history shows continuous low line sadness which confirms dysthymia. According to present severity of symptoms, reduced daily activity & productivity, duration of depression it seems that it has been superimposed with major depression.
Case discussion:
According to Eric Erikson’s personality theory, the developmental task at old age is ego integrity v/s despair. He reflects back and calculates his experiences of being worthy which adds despair when he rarely find his success/ satisfaction. Such brooding fills him with existential vacuum leads to depression.
This theory comprises of eight stages from infancy to adulthood. During each stage, the person experiences a psychosocial crisis which could have a positive or negative outcome for personality development. Successful completion of each stage results in a healthy personality & development of basic virtues. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time.
| Stage | Basic Conflict | Important Events | Outcome |
|---|---|---|---|
| Infancy(birth to18 months) | Trust vs. Mistrust | Feeding | Children develop a sense of trust when caregives provide reliabilty, care, and affection. A lack of this will lead to mistrust |
| Early Childhood(2 to 3 years) | Autonomy vs. shame and Doubt | Toilet Training | Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt |
| Preschool(3 to 5 years) | Initiative vs. Guilt | Exploration | Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval , resulting in a sense of guilt |
| School Age(6 to 11 years) | Industry vs. Inferiority | School | Children need to cope with new social and academic demands. Success leads ti a sense of competence, while failure results in feelings of inferiority |
| Adolescence(12 to 18 years) | Identity vs. Role Confusion | Social Relationships | Teens needs to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. |
| Young Adulthood(19 to 40 years) | Intimacy vs. Isolation | Relationships | Young adults need to form intimate , loveing relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. |
| Middle Adulthood(40 to 65 years) | Generativity vs. Stagnation | Worl and Parenthood | Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. |
| Maturity(65 to death) | Ego Integrity vs. Despair | Reflection on Life | Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair. |
His life space analysis shows rejected, friendless, abandoned feelings, poor communication ability with average interpersonal relatedness. He feels he has done something wrong and so he is only singled out and suffering. Hura is the final selection.
Case management:
Hura 200, 3 doses weekly was given for two month. Every week, step by step guidance has been offered. Son has been orientated about psycho-social aspect of geriatric depression. As a son he can spend quality time and remind good time of his life which can make him worthy.
Role of care taker has been explained.
Twice in week let grandson talk to him with sense of belongingness. He was made member in one trust where group of oldies get-together to serve food to hospital patients. Care taker takes him twice or thrice in a week. This experience has added lot of value. He found meaning somewhere in life. Gradually over 3 months he started talking to few group members. Sadness and brooding has reduced relatively. He is now watching TV and reading newspaper.
Totality of symptoms:
- A/F grief
- Friendless he is. Forsaken
- Isolation sensation of
- Sadness as from misfortune
- Unfortunate he is
- Delusion being single out for wrath of God.
- Reproaching himself
- Wrong- done wrong he has
- Broods over disappointments, over his conditions
- Despair recovery of
Abbreviations:
GF = Grand Father, DIL= Daughter In Law
Reference:
Synopsis of Psychiatry; by Kaplan https://www.brookings.k12.sd.us/Page/1133
