Dynamic Consultations with Psychiatrists. Jason Maratos

a more balanced view of herself.

References

      1 Garland, C. (1982). Group analysis: Taking the non‐problem seriously. Group Analysis, 15, 4–14.

      2 Garland, C. (2015). Group analysis: Taking the non‐problem seriously. In J. Maratos (Ed.), Foundations of group analysis for the twenty‐first century (pp. 53–70). Karnac.

      3 Krupnick, J. L., Sotsky, S. M., Elkin, I., Simmens, S., Moyer, J., Watkins, J., & Pilkonis, P. A. (2006). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Focus, 4(2), 269–277.

      4 McCabe, R., & Priebe, S. (2004). The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings. The International Journal of Social Psychiatry, 50(2), 115–128.

Mrs. A

      Mrs. A is a 60‐year‐old widowed housewife living with her two grown sons.

      Presenting Condition

      Mrs. A presented with a depressive mood of 1 month, with negative ruminations, chest tightness, dizziness, and insomnia. She had decreased motivation and was barely able to maintain her usual interests in exercise and church activities.

      History of Present Complaint

      Mrs. A had two recent stressors leading to the current episode of depressive mood. The first was that her younger son, who lives with her, was having some work problems but did not elaborate the details to her. She said her son was quiet and she was afraid that he might have depression.

      The second stressor was that she had a gathering with her old classmates and during that, she compared herself to her classmates. She felt herself shorter, widowed, lower financial status, and could not achieve what her friends had achieved in their careers. She felt that she was inferior to them. She ruminated about these two ideas and started to develop a pervasive low mood, chest tightness, dizziness, and insomnia.

      Family History

      Mrs. A had no known family history of any mental or mood disorders. She had two older sisters.

      Personal History

      Mrs. A was married at 21 years. She enjoyed a good marital relationship. She described her husband as tall, strong, reliable, and caring. She felt grateful for having a good husband, and her husband was not bothered by their difference in height. Her husband died in December 2015 of cancer.

      Mrs. A has two sons and one daughter, all in their early 30s. Her older son divorced and is currently living with her. Her older son worked in the government in the environmental and health department. Her younger son is also living with her and is currently working as a fireman. Her younger son will be getting married early next year and will be moving out later this year to live in a flat, which he has bought with his fiancée. Her daughter lives abroad and is currently a student in nursing school. Mrs. A. has regular contact with her daughter over the phone. Her daughter has a stable boyfriend abroad and has no plans to return to the city.

      Mrs. A is happy about her younger son's upcoming wedding. However, she preferred them to have a private marriage, perhaps somewhere overseas, instead of having a big banquet. She felt that it would be troublesome for her to organize a banquet, and she would have difficulty finding a suitable dress because she felt she was short and not good looking.

      Personal History

      Mrs. A. was born in another city. She had two older sisters, who were caring toward her during her childhood. She grew up in the country with normal upbringing, and her childhood was uneventful. She was educated in the country until secondary 2 level. She then came to the city early in her 20s and got married.

      Mrs. A worked in a garment factory and in a restaurant as a food seller before. Her longest employment was for 3 years in a restaurant. After she got married, she became a housewife.

      Mrs. A is a nonsmoker and nondrinker. She has no substance abuse or forensic record. She is even‐tempered, a little prone to anxiety, pessimistic, and passive in her personality. She enjoys exercise every morning as a hobby. She is a Christian and goes to church weekly. Her friends are mostly her old classmates, neighbors, and “church‐mates.”

      Past Psychiatric History

Mrs. A was first known to the mental health service in 2006. She was seen twice in the clinic at that time for generalized anxiety disorder with insomnia, but she defaulted at follow up. That episode was triggered by an event of a gas explosion in the flat below her apartment. This event was widely publicized in the city. The explosion occurred in the context of domestic conflict. There were three deaths in the incident including two residents of the flat and an old lady of a neighboring flat. The person who set the gas explosion was an elderly man who was the owner of that flat and who was later jailed. In the afternoon of that day, Mrs. A was suddenly woken up by a loud noise and some smoke. She saw her own windows and glass drawers broken. She evacuated downstairs immediately. When she arrived at the balcony, she looked up to see the fire scene and was overwhelmed with fears. It was arranged for her to stay in the community center for one night and then in a temporary housing unit for 3 months. Afterward, she suffered from a startling response and apprehension whenever she heard a loud noise or passing the floor of the incident when she returned to live at home. These symptoms lasted for about a year and then gradually subsided. She was referred by a social worker to receive a psychological intervention at that time. She recalled that the clinical psychologist taught her some relaxation techniques involving muscle relaxation and listening to relaxing music. She did not practice the techniques often and the psychologist service was terminated after 1 year when her symptoms subsided.

      A few years later in 2011, Mrs. A presented to the psychiatric clinic again. This time she was troubled by menopausal symptoms. She developed low mood, poor sleep, and appetite, was feeling anxious, experienced chest tightness, dizziness, and had poor motivation. She attributed these complaints to depression because she felt her symptoms were similar to the description of depression she read in newspaper articles. She was started on fluoxetine and had regular follow up in the clinic. She achieved remission shortly after the start of antidepressants.

      Two years later, in 2013, Mrs. A suffered a relapse of depression. This time it was triggered by her daughter having a road traffic accident abroad. It was a minor accident; her daughter was only mildly injured and made a good recovery. She was worried and then developed persistent low mood, poor sleep, loss of appetite, chest tightness, and dizziness. She had lack of motivation, and she did not want to see anyone at that time. She stopped her usual habit of daily exercise with her neighbors. She was added on Deanxit in the clinic. She achieved remission again shortly after adjustment of the medication.

      In the next 2 to 3 years, her husband suffered from multiple physical problems, including cancer of the lung and prostate, with brain metastases, complicated by epilepsy. Her husband was physically frail in the last few years of life, and she had to take care of him. Her husband eventually died in December 2015. She had a normal grief reaction. She missed her husband, but she soon accepted the loss. She felt that his death was a good way to end her husband's long‐term suffering from the illness.

      Mrs. A then had a stable mental state until the current episode of depressive mood, which was triggered by younger son's change in work duty and her gathering with old classmates. She advanced her clinic appointment this time, and her antidepressant dosage was adjusted. She soon achieved remission again after around 1 month.

       Present Treatment and Management of Case

      The