Table of Contents  
LETTER TO THE EDITOR
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 415-416  

A case report of dysthymia, resulting from disfigurement related erratic perception of systemic sclerosis


Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication17-May-2016

Correspondence Address:
Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.167999

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How to cite this article:
Kar SK, Somani A. A case report of dysthymia, resulting from disfigurement related erratic perception of systemic sclerosis. Med J DY Patil Univ 2016;9:415-6

How to cite this URL:
Kar SK, Somani A. A case report of dysthymia, resulting from disfigurement related erratic perception of systemic sclerosis. Med J DY Patil Univ [serial online] 2016 [cited 2022 Dec 2];9:415-6. Available from: https://www.mjdrdypu.org/text.asp?2016/9/3/415/167999

Sir,

Systemic sclerosis is a disorder that involves multiple organ systems and follows a long course with poor clinical outcome. [1] Dermatological changes are frequently seen patients of systemic sclerosis. Contracture of the joints of the extremities and degenerative or erosive arthropathy are also reported. [1] These changes lead to cosmetic disfigurement and often embarrassing for the patients. Disability and disfigurement due to systemic sclerosis leads to significant self-image dissatisfaction and distress. [2],[3] The cumulative effects of disability, self-perception, pain and disfigurement are responsible for anxiety and depressive manifestations in systemic sclerosis. [4] In this case report, we highlighted the impact of degenerative cutaneous and skeletal changes in the hands of a patient with systemic sclerosis that attribute to psychological distress.

A 50-year-old housewife was referred for psychiatric consultation for her complaints of poor appetite, weight loss and disturbed sleep. Her husband had also reported about change in her behavior in past 4 years in the form of remaining withdrawn to self, decreased interest in interaction with family members and friends, avoiding going outside home and death wishes. She was suffering from systemic sclerosis since 1996 and was on treatment for the same. Over past 10 years, she had developed Raynaud's phenomenon and thickening of the skin all over her body with prominent changes on face, neck and extremities. She was having severe gastro-esophageal reflux symptoms. She was on calcium channel blocker (nifedipine) for the symptoms of vasospasm (due to Raynaud's phenomenon) and anti-reflux agents (pantoprazole and domperidone) for gastro-esophageal reflux.

There was an increase in disfigurement of the face with decrease in mouth opening and cutaneous changes in last 4 years. She also had contracture in joints of upper extremity with digital ulceration and degeneration [Figure 1], which temporally correlated with onset of psychiatric symptoms. There was no other significant medical or surgical illness in the patient. There was no past history or family history of psychiatric illness. Premorbidly, she was well adjusted to life. Mental status examination of the patient had revealed - depressed affect, pessimistic view toward the future, somatic preoccupation, death wishes, preoccupation with a negative self-image. Based on the history and mental status examination findings, a diagnosis of "Dysthymia" was made as per International Classification of Diseases-10, diagnostic criteria. [5] She was prescribed antidepressant sertraline at a dose of 50 mg/day, which was later increased to 100 mg/day. Benzodiazepine - clonazepam was prescribed at a dose of 0.25 mg, as and when needed basis for anxiety and zolpidem 10 mg at bed time was prescribed for insomnia. Supportive psychotherapy was given, and relaxation exercises were taught. With this treatment, patient had shown an adequate response over next 4 months, on follow-up. The patient initially believed these changes in her fingers (ulceration, hypopigmentation and erosive arthropathic changes) as Hansen's disease that is not uncommon in India. Hansen's disease is a chronic debilitating illness with a stigma attached to it and patients poor knowledge and misinterpretation led to her psychological distress.
Figure 1: The figure shows hypopigmentation of the skin over the digits, tightness of the skin giving the glistening appearance, pitting of nails and degeneration and absorption of the distal phalanges in both hands

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Supportive psychotherapy, relaxation exercises, antidepressant treatment and proper health education (explaining about systemic sclerosis) were helpful in reducing her distress.

In the above case it is fair to conclude that misinterpretation of the bodily changes and identifying them with more stigmatizing illnesses is more likely to produce psychological distress, which is often out of proportion to the underlying illness, itself.

 
  References Top

1.
Generini S, Fiori G, Moggi Pignone A, Matucci Cerinic M, Cagnoni M. Systemic sclerosis. A clinical overview. Adv Exp Med Biol 1999;455:73-83.  Back to cited text no. 1
    
2.
Benrud-Larson LM, Heinberg LJ, Boling C, Reed J, White B, Wigley FM, et al. Body image dissatisfaction among women with scleroderma: Extent and relationship to psychosocial function. Health Psychol 2003;22:130-9.  Back to cited text no. 2
    
3.
Haythornthwaite JA, Heinberg LJ, McGuire L. Psychologic factors in scleroderma. Rheum Dis Clin North Am 2003;29:427-39.  Back to cited text no. 3
    
4.
Müller H, Rehberger P, Günther C, Schmitt J. Determinants of disability, quality of life and depression in dermatological patients with systemic scleroderma. Br J Dermatol 2012;166:343-53.  Back to cited text no. 4
    
5.
The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. Available from: http://www.who.int/classifiations/icd/en/bluebook.pdf. [Last assessed on 2014 Jun 6].  Back to cited text no. 5
    


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