We describe a case of a 48-year-old male who came to the emergency department of the Valme Hospital for persistent autolytic ideation and hearing loss.
Regarding psychiatric history, she had been admitted to the Acute Mental Health Unit on several occasions since 2007, with diagnostic orientation, at the last admission of moderate depressive episode (F32.1 ICD-10).
He was being treated with risperidone 3 mg/24h, ac. valproic 1500 mg/24h, citalopram 20 mg/24h and flunitrazepam 1mg/24h.
At the time of the current admission and for six months, in the context of mourning for the death of their daughter, reported increased anxiety, sadness, anhedonia, apathy, abandonment of activities, and external space.
They were imperative and insulting voces that had important behavioral and affective repercussions on him: "It started as a rumor and now they are clear, as if someone talked to me.
They become stronger and I cannot control them, they tell me to hurt me, they also insult me."
He was conscious, self-oriented and allopathically oriented, euprosexic.
His attitude was of collaboration and showed no gross alterations in superior functions.
Language was fluid, spontaneous and coherent.
She reported feelings of guilt for her recent death, distrust of all those around her, and disdain and loneliness in relation to her vital situation.
I had ideas of death and self-lysis.
She complained of insomnia with intermittent awakenings and frequent nightmares.
She had no family and social support and had progressively abandoned her work.
1.
Minutes
Childhood and adolescence
His fathers were very young, and he, who was the eldest of six brothers, remained in Spain to take care of his father-in-law grandparents.
Remember a happy childhood, protected and fixed by them, to those who came to consider as their parents.
I kept your grandfather as a good person, responsible and worker.
To her grandmother, "A saint, hanging on me and everyone."
She lived with them her aunt and her son, with whom she had played games and affection.
I spend childhood and adolescence separated from their parents.
Although these returned from the country to which they migrated, they never integrated into the nuclear family.
Without understanding why, he sometimes said he had felt guilty for it.
He described his mother as distant and selfish; his father more affectionate, but both, "You are unable to do anything for me".
It was created with a higher economic level than their brothers, which aroused in these constant fears and criticisms and in it clear distrust in the relationship.
At school and school he was exemplary, had good grades and never had problems with his peers and teachers.
At that time, he described himself as "Work, handsome, kind and handsome to everyone...".
He studied in higher education and later worked in his profession successfully for years.
Adult life
After a normalized girlfriend, she married and had two children: a girl and a boy, six years younger.
Marriage was not right, she felt that her wife was allied with her mother, and only rarely could she impose her judgment.
His daughter, for him, was "the only one in the world that defended me and supported me in the face of criticism."
The first conflict became relevant fifteen years ago when his grandparents died.
For issues related to heredity, she felt harshly criticized by her parents and siblings, and then called him "Good and exploited child."
Two or three years after the episode discussed, she had important problems at the work level; a topic that generated a deep discomfort; she began to feel intensely insecure and suspicious, progressively reducing her professional work.
Then, marital conflict became apparent and after the marriage separation, one year before admission, the elder daughter became seriously ill and died six months later.
She lived alone and maintained a relationship with the neighborhood where she was sent.
He enjoyed small tertulias in the nearby bars, which he abandoned because of his growing irritation, facilitated by the abusive consumption of alcohol.
Brief Psychotherapy
The patient was proposed to perform a brief dynamic psychotherapy during his admission to the Acute Unit.
The number of sessions did not take place at the beginning, leaving this behind the evolution and time of admission.
Twelve 40-minute sessions were held.
The following inclusion criteria were taken into account: the ability of the patient to think about his feelings, the existence of several significant relationships in the past and the good ability to bond with the therapist.
1.
Psychodynamic Impairment Hypothesis
The adaptive mechanisms of the self deployed since childhood such as constancy, work ability, responsibility, surrender to others and affective warmth provided the patient with an adequate self-image for years.
None of these qualities had managed to remain after the hard blow of his daughter's death (trigger factor).
Debilitated at the marital level by the failure of the relationship, at the professional level by the labor and socially isolated by the consequences of the child's nuclear consumption, at the professional level by the excessive consumption and social isolation due to the consequences of alcohol, child's nuclear desires stages of excessive consumption, including emotional conflict.
Feelings of guilt, distrust, disgust and loneliness, which in the present provoked an important sense of self-image, limits of self and sense of reality.
Vented by the implementation of defensive mechanisms such as introjection, internalizing the persecutory object, the voces and identification with the idealized object, the daughters of their own destiny show themselves as incapable.
1.
Work at the Focus
Taking into account the initial psychodynamic hypothesis, feelings of guilt, distrust, disgust and loneliness were selected as a therapeutic focus.
These feelings were addressed from a cognitive, emotional and behavioral perspective, trying to facilitate patient identification, expression, regulation and transformation:
Feeling guilty: she was terribly guilty of the disease and subsequent death of her daughter.
The expression of this feeling was facilitated, increasing the awareness of its presence in the past.
The fantasies of omnipotence and magical beliefs, the acceptance of their own limits and the recognition of the limits of human nature were approached.
To favor the repair of the damage and the transformation of the feeling, the conduct of help and delivery to the other patients was encouraged, people in need like him.
Feeling of distrust: feeling that emerged after family and work conflict.
With the intention of working with self-confidence, based on the possibility of trusting others, an attempt was made to restructure the image of lost self-esteem and generosity, reinforcing the emotional context of corrective action.
In addition, he was asked to contact his mental disorder and mental illness in another city, with which he had maintained a relationship of trust and attachment.
Feeling sick and loneliness: The death of their grandparents and their daughter, divorce and social isolation both feelings expressed.
The mourning was resolved, facilitating the identification and expression of anger by the death of their loved ones and pointing to the permanence of object relations inside.
In addition, the importance of the assistance received from abroad from the health institution was highlighted.
To recognize this moment awareness of the fear of facing his situation, of living alone and then was proposed to restart telephone contact with friends and partners.
