A 67-Year-Old Woman with Depression

Abstract

A 67-year-old woman had been residing in a nursing home after having a bilateral knee amputation as a complication of long-standing diabetes. She was brought to the attention of psychiatric services due to longterm depression, recent onset of visual hallucinations of insects fl ying in the room, and tactile hallucinations of insects crawling on her body. The sensation of insects crawling on her body caused her to scratch herself repeatedly, resulting in multiple skin lesions. A dermatology consult was placed, but upon no evidence of infection or infestation, psychiatry was consulted. She appeared depressed with increased fatigue, decreased appetite, nonspecifi c weight changes, decreased sleep of 4 to 5 hours per night with late insomnia, and reduced concentration. She remained predominantly isolative and withdrawn but was not suicidal. In the past, the patient was hospitalized five times for depression, with an episode of delusions of parasitic infestation resulting in her calling the sanitation department to her home. Her social history revealed a lifestyle marked by meticulousness, obsessions about order, and cleanliness. She grew up in a low-income family, and her parents separated when she was very young. Her family’s financial limitations caused her to interrupt her education and obtain employment at an early age. As a child, she described herself as being self-reliant and resilient due to her distant and harsh parents. She married at an early age. She said her husband was unsupportive and physically abusive. They later divorced. She was disengaged from her family, departed her home country, and immigrated to the US at an early age. Since arriving in the US, she has been living alone with no close relationships. She continued to work a low-income job in the US. She had initial adjustment diffi culties, stemming from the language barrier. Over time, she adjusted well and assimilated into the culture. After her medical illness started, she again had diffi culties supporting herself and, gradually, her behavior changed. She then became very withdrawn. However, she displayed a marked indifference to her social isolation and loneliness. Treatment began with initial laboratory tests including CBC with differentials, P14, vitamin B1, B6, B12, folate levels, RPR, and urine analysis. The results of the tests were within normal limits. A computerized tomography (CT) scan of the brain, without contrast, revealed no pathologies or focal lesions. A magnetic resonance image (MRI) of the brain was scheduled to rule out any lesions secondary to the diabetes mellitus, but the patient refused the procedure. The patient was initially treated with duloxetine 60 mg once daily for depression. The dose was increased to 120 mg daily. She continued to exhibit a decrease in fatigue and appeared less withdrawn. Her sleep and appetite were initially impaired Asad Amir, MD, is Psychiatry Resident, Bergen Regional Medical Center, Paramus, NJ. Amel Badr, MD, is Assistant Program Director, Bergen Regional Medical Center. Javed Iqbal, MD, is Program Director, Psychiatry Residency Program, Bergen Regional Medical Center. Address correspondence to: Asad Amir, MD: aamir@bergenregional.com; drasadamir05@yahoo.com. Dr. Amir; Dr. Badr; and Dr. Iqbal have disclosed no relevant fi nancial relationships. The authors would like to acknowledge Sree Latha Krishna Jadapalle, MD; and Eric Fletcher, MA, for their assistance with this manuscript. doi: 10.3928/00485713-20110203-04