PSYCHODYNAMIC
FEATURES OF DEPRESSED PATIENTS WITH DEPENDENT PERSONALITY DISORDER AND
HYPOKALEMIA: A CASE REPORT
����������������������������������������������������������������������������������������������������������������������������������
Muhammad Alim Jaya1, Andi Karlina
Syahrir2
1Departemen
Ilmu Kedokteran Jiwa, Fakultas Kedokteran, Universitas Muslim Indonesia,
Makassar, Indonesia
2Departemen
Biokimia, Fakultas Kedokteran, Universitas Muhammadiyah, Makassar, Indonesia
*Email untuk Korespondensi: [email protected]
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Keywords: Depression;
Dependent personality disorder; hypokalemia |
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ABSTRAK |
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Depression
is one of the most common mental disorders in society. Depression is
influenced by several factors, including the personality of the sufferer and
the existence of a comorbid disease that aggravates the symptoms. Several
previous studies have not clearly reported on the psychodynamic picture of
depressed patients with dependent personality disorder accompanied by
hypokalemia. The study aims to provide a psychodynamic picture of depressed
patients with dependent personality disorder accompanied by hypokalemia. A
man, 26 years old, an Indonesian citizen, came with the main complaint of
feeling helpless to do anything that has been burdensome for the last 2
months. The complaint was felt to be aggravating after he started working as
a private employee. The patient feels insecure in his ability to complete the
work assigned to him and feels that he is looked down upon by his peers and
superiors. Patients often miss the figure of their deceased father. In
addition, the patient has suffered from hypokalemia since he was in high
school and has taken potassium supplements until now. The symptoms of
depression experienced by patients are aggravated by the presence of
dependent personality disorders and hypokalemia suffered by patients.
Dependent personality disorder lowers the patient's confidence, and
hypokalemia aggravates the vegetative symptoms he experiences, such as body
weakness, decreased appetite, and palpitations. Dependent personality
disorder and hypokalemia are very influential in aggravating the clinical
symptoms experienced by depressed patients. |
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Ini
adalah artikel akses terbuka di bawah lisensi CC BY-SA . This is an open access article under the CC BY-SA license. |
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INTRODUCTION
Depression
is a mood disorder and is one of the most common mental disorders in society (Malhi and Mann, 2018; Roberts et al., 2019). Depression is characterized by a sense
of sadness, pessimism, apathy, and loneliness (Korczak et al., 2023). Everyone experiences feelings of
sadness at times, but these feelings of sadness usually pass quickly within a
few days. Some people who experience depression do not experience sadness but
experience feelings of emptiness, emptiness, and apathy. In depressed people,
this feeling of sadness lasts for days, so it can interfere with work,
studying, eating, sleeping, and pleasure (Malhi and Mann, 2018; Noetel et al., 2024; Pearce et al., 2022). The feelings of helplessness,
hopelessness, and worthlessness sometimes last for quite a long time (Harrison et al., 2022).
Many
factors can cause depression, including biological factors (genetics, comorbid
diseases), psychological factors (personality traits, ego defense mechanisms),
and social factors (the influence of environmental support). Several previous
studies have reported the potential influence of these factors in inducing
depression (Remes et al., 2021; Saasa and Miller, 2021). In fact, some studies report molecular
biological mechanisms that are influenced by these factors (Anderson et al., 2022; Stretton et al., 2021; Tripathi et al., 2019). Unfortunately, it is very rare to find
cases of depression accompanied by all of these factors at the same time, and
there is no research that clearly explains how the psychodynamic picture of
depressed patients is affected by these factors (Xu et al., 2024).
In
this case report, we reported on how the psychodynamic picture of depressed
patients with dependent personality traits who also suffer from hypokalemia.
This psychodynamic formulation is very important, especially in determining the
right type of non-psychopharmacotherapy therapy for the patient (Iannitelli et al., 2019; S�rbye et al., 2019).
This
study aims to provide a
psychodynamic picture of depressed patients with dependent personality disorder accompanied by hypokalemia. The very complex picture of psychodynamics
causes research like this to still be very rarely reported. This study is
expected to be a reference for the psychodynamic picture of depressed patients
and assist clinicians
in determining the treatment plan of depressed patients with dependent
personality traits who have comorbid hypokalemia.
We
have obtained consent from patients. The patient's details have also been kept
confidential, and we have obtained the patient's written consent to publish the
details of the case.
A 26-year-old man, accompanied by
his mother to the Psychiatric Polyclinic with the main complaint of feeling
helpless to do anything, has been aggravated in the last 2 months. Patients
feel insecure and feel looked down upon by others. This has been felt almost
every day since the beginning of work because patients find it difficult to
adapt to their new work environment. The patient loses interest in doing his
favorite activity. Patients also often feel empty and alone and think that no
one cares about them. The patient feels himself or herself becoming sensitive
and irritable. The patient feels pessimistic about his future life because the
patient has no future plan, and the patient even had suicidal thoughts.
Patients have difficulty focusing and concentrating. Patients also feel the
absence of an emotional reaction to the surrounding environment. Patients
experience sleep disorders where it is difficult for patients to start sleeping
and usually wake up earlier than usual. There is weight loss due to decreased
appetite.
The patient had a history of the
same complaint about 6 years ago. At that time, the patient felt very sad,
cried more often, locked himself in his room, and ate little for almost 1 year.
This happened after the patient's father died. The patient can improve on its
own at that point.� The patient had been
admitted to the hospital several times because he had hypokalemia. The patient
had lost enthusiasm in completing his education at that time for several
months. Until finally, the patient's emotional condition improved without
treatment, assisted by emotional support from his family, who said that he had
to continue his education to be able to realize his father's dream to see
himself become a successful person.
In the mental status examination,
a man of medium height was observed sitting listlessly in front of the
examiner; the patient's face looked suitable for his age, his face looked
lethargic, and self-care made a good impression. Awareness of the quantity of
mentis compositivity and good quality. The psychomotor is quite calm; the body
movements slow down slightly, and during the interview, the patient looks down
more often. Speech is less spontaneous, slow, and relatively small voice
volume; articulation is clear, intonation is monotonous, and answering
according to questions. Attitude towards cooperative examiners. The results of
the intellectual function examination obtained general knowledge and
intelligence of the patient in accordance with their level of education.
Orientation of time, place, and good people. Long-term and immediate memory is
good, and the medium and short-term are quite good. Concentration and attention
are quite good. Abstract thinking is good, creative talent is absent, and
self-help skills are quite good. In the affective examination, a sad mood,
depressive affect, harmony, and palpable mood were obtained. No impairment of
perception and self-experience was found. In the thinking process, sufficient
productivity is obtained, relevant and coherent, and no language skills are
found. The content of the mind is in the form of preoccupation about feeling
helpless and useless and feeling that he has not succeeded in realizing his
father's dream; there are irrational ideas in the form of labeling and jumping
to conclusions, and there is a history of suspicious ideas and suicidal ideas.
During the interview, the impulse control ability was good, the value power was
good, and the patient had a degree 5 insight.
In the physical examination, good
nutritional status was obtained, and internal and neurological examinations
were within normal limits. Psychometric examinations obtained a PHQ-9 (Patient Health
Questionnaire-9) score
of 20 (severe depressive symptoms), HDRS (Hamilton Depression Rating
Scale) score of 24 (very severe
depression), and HARS (Hamilton Anxiety Rating Scale) 27 (moderate anxiety). The results of the IQ assessment
were obtained, and the patient was classified as intelligent. Laboratory
results of blood potassium levels of 2.2 mmol/L
RESEARCH METHODS
This
study uses a qualitative method with a case study approach to explore
psychodynamic characteristics in depressed patients with dependent personality
disorder and hypokalemia. The case study method was chosen because of the
nature of the research, which focuses on an in-depth understanding of the
individual in a particular clinical situation, allowing for a thorough
exploration of the patient's experience.
Research Design
The
study was designed as a descriptive case study, in which researchers conducted
an in-depth analysis of a single patient with a diagnosis of depression,
dependent personality disorder, and hypokalemia. This approach allows
researchers to understand the relationship between psychological dynamics,
personality, and physical condition of patients more comprehensively. The main
focus is to explore the psychodynamic mechanisms, attachment patterns, and
emotional responses of patients to the conditions they are facing.
Research Subject
The
study subject was a hospitalized patient with a comorbid diagnosis of major
depression, dependent personality disorder, and hypokalemia. Patients are
selected based on relevant clinical criteria, including significant depressive
symptoms, strong patterns of emotional dependence, and the presence of a
medical condition of hypokalemia.
Research Instruments
The
instruments used in this study include semi-structured, in-depth interviews and
participatory observation of patients during treatment. Interviews were
conducted to explore the patient's emotional experiences and patterns of
interpersonal relationships, while observations were conducted to understand
the dynamics of behavior and emotional expression in the clinical setting.
Data Collection Techniques
Data
was collected through face-to-face interviews conducted several times over a
period of time, as well as clinical records of patient interactions with
medical personnel and families. All interviews are recorded and transcribed for
further analysis. Secondary data such as the results of a patient's medical
examination are also used to provide additional context in psychodynamic
analysis.
Data
Analysis Techniques: The analysis was carried out using a thematic analysis
approach, in which the main themes emerging from interviews and observations
were identified and linked to psychodynamic theories. This process involves
data codification, categorization, and in-depth interpretation of the dynamics
of the patient's relationship with others, self-defense mechanisms, and
emotional responses to his or her medical condition.
��������������� Here,
we formulate a psychodynamic picture of the patient as a man, 26 years old, the
second child of three siblings, unmarried, comes with the main complaint of
feeling helpless to do anything accompanied by physical complaints such as
heart palpitations. The onset of these symptoms is associated with stressors
that are appreciated in the form of a new work environment, not having a
permanent job, and dependence on the figure of the father.
��������������� Some of the predisposing factor
hypotheses that can be associated with the disorder experienced by the patient
are personality traits that lead to dependence, low self-confidence, and the
patient's deceased father. The mental problems experienced by patients have the
potential to continue due to perpetuation factors in the form of patients
having a history of hypokalemia, the absence of a father surrogate, and a lack
of interpersonal relationships with the surrounding environment. However,
patients have protective factors in reducing their psychological constraints,
namely good intellectual function, no history of psychoactive substance abuse,
no family history of mental disorders, quite responsive to therapy, good level
of education and understanding of religion and Support System the good
of the family.
��������������� According to Freud's
psychosexual development and Erick Erikson's psychosocial development (Knight, 2017; Lantz and Ray, 2024; Orenstein and Lewis, 2024), no problems were identified from the
oral phase to the beginning of the anal phase. When entering the anal phase,
the patient began to be trained in toilet training by his mother at the age of
2 years, and the patient already understood if he wanted to have a bowel
movement or defecation at the age of 3 years. Even at the moment, Toilet
Training is quite good. However, patients rarely interact with their
parents because of their parents' busyness and that of other caregivers (babysitters).
The caregiver also rarely accompanies the patient when interacting. Therefore,
the patient's desire to have something can rarely be expressed by the patient
and tends to be less fulfilled by the patient's parents, so the patient grows
up to be a shy and doubtful child (Chen et al., 2021; Corradi, 2024).
��������������� In the phallic, parents
limit and control the patient's association more because the patient's parents
are worried that something will happen to the patient. The patient was only
allowed to play in the house, so the patient did not have the opportunity to
play with other children in the neighborhood around his house. All the needs of
the patient are prepared and arranged by the parents at this age so that the
patient does not get the stimulation to learn to prepare simple needs for
himself. The patient's initiative is also not achieved well, so the patient
grows into an excessive child in guilt (Corradi, 2024; Lantz and Ray, 2024; Rabeyron and Massicotte, 2020).
��������������� Entering the latent phase, the
patient fails to develop his competencies because everything is regulated and
determined by his parents. The patient's interpersonal relationships and
socialization skills are very lacking due to overprotective behavior from his
parents. This makes patients less free to explore and more likely to feel
inferior. The foster care and interaction between parents and children form
personality traits that are dependent on the patient. Because patients are not
confident in their competence and are always afraid to make mistakes at work or
make decisions, this makes the patient always return all decisions to his
parents (Tarzian et al., 2023; Zhang and Guo, 2018).
��������������� In his development, the patient
is very close to his father and makes his father his ideal figure. In addition,
the patient, as the only son in the family, made his father have high hopes for
the patient so that he would become a person who could be proud of his family
in the future. This makes the patient very dependent on his father. Even when
choosing a major while in college, the patient asks and follows his father's
advice without thinking about other considerations. During college, the
patient's father was always there to help with all his problems during college.
According to Object Relations Theory, depression is caused by the
problems a person experiences in developing healthy representations of
relationships. A person's mood and emotions can only be well understood based
on the background of the relationship experienced by the person (Caligor et al., 2023; Shahar, 2021). Furthermore, depression is a
consequence of the constant struggle experienced by depressed people to try and
maintain emotional contact with the desired object (Caligor et al., 2023).
��������������� Based on the analytical pattern,
the patient felt very dependent on the relationship with his father and felt
very deep grief over the loss of the relationship when the patient's father
died. This is caused by the disruption of the parenting relationship with the
main object and is characterized by feelings of helplessness and weakness (Marfoli et al., 2021; Quirin et al., 2022). A person with analytic depression
experiences a huge fear of being abandoned and struggles desperately to
maintain direct physical contact with the object of need satisfaction (Marfoli et al., 2021).
��������������� After his father's death, the
patient felt that he had failed to meet his father's standards of expecting the
patient to be a successful person and have a permanent job as the only son in
the family. Introductive depression arises from a harsh, relentless, and highly
critical superego that gives rise to feelings of worthlessness, guilt, and
failure. A person with introspective depression experiences an intense fear of
losing the approval, recognition, and love of a desired object (Quirin et al., 2022).
��������������� The patient's current condition
does not have a permanent job, and the patient considers himself unable to be
like his father as a result of the patient's failure to establish self-worth,
self-regard, and a sense of wholeness that is hampered (Batchelder and Hagan, 2023; Muris and Otgaar, 2023). What happens to the patient is a
deficient self, which is very vulnerable to self-fragmentation (Mart�nez et al., 2021). Condition self-fragmentation
This puts the patient in a very sad condition because he wants to be perfect by
doing his best to gain good recognition and acceptance from others. This can be
seen when studying and working; patients enter college through the achievement
path and try to complete their education in order to realize their family's
expectations, adapt, and enjoy their work. Through this pattern, patients gain
affirmation and empathy when they achieve, and patients then develop their
confidence. However, Self-esteem, which was built along with self-cohesiveness,
is lacking where the patient always needs gratuities and recognition from those
around him (Baptista et al., 2021; Mart�nez et al., 2021; Muris and Otgaar, 2023). Therefore, patients are always worried
about how others perceive them.
In conclusion, dependent personality disorder and hypokalemia are very
influential in aggravating the clinical symptoms experienced by depressed
patients. Personality disorders are also greatly influenced by parents'
parenting of children. Therefore, hopefully, this report can be a lesson for
every parent who is raising their children. This case report could also be the
basis for further research on hypokalemia-related depression linked to
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