CASE STUDY OF A PERSON WITH TRANSVERSE MYELITIS (TM): STRENGTH BASED COGNITIVE BEHAVIOURAL APPROACH

Transverse Myelitis (TM) is one of the clinical syndrome results in weakness, sensory alterations and autonomic dysfunction. 1 and 8 new cases per million people per year found to suffer from TM (Berman et al., 1981). The depression and suicide has been observed one of the se r ious i s sue in TM. Psychopharmacologic and psychotherapeutic interventions have healthy response in TM and can improve depression as well (Centers for Disease Control and Prevention, 2015). The combination of medication, physiotherapy and psychosocial intervention can have effective results in the TM (https://hopkinsmedi cine.org) . The problem or concern is seen in strength perspective in which people see situations realistically and sees the opportunities for accompaniment by using strength based approach. A strength based approach method helps to face the challenges and opportunities to resolve problems or difficulties instead ignoring them. The core function of Strengths-based CBT is to build client strengths to overcome from distressing situation and support to improve wellbeing (Padesky & Mooney, 2012). The present case study was an attempt to use Strengths-based CBT to treat depression and anxiety in a person with TM.

AIM
To manage depression of the person with Transverse Myelitis (TM) using strength based cognitive behavioural therapy.

CASE INTRODUCTION
The client is a 27 years old married female. Studied up to 10th Std., Hindu, housewife, hails from upper socio-economic status of rural background of Nagaon district of Assam. The client was brought to LGBRIMH with chief complaints of pain in lower back, leg and abdomen, numbness, stiffness, tightness in muscles weakness, Sexual dysfunction and low mood, decreased interest in activities, decreased sleep and decreased appetite.

METHODOLOGY
The single subject case study design was used in which pre and post- assessment was carried out to assess baseline data along with Psychiatric social work intervention using strength-based cognitive behavior therapy. Through an in-depth case study using face to face interview with the client and family members the detailed clinical and social history of the clients was assessed. After exploration of information psycho-social formulation was made and a psychiatric social work intervention was provided at individual and family level. Written informed consent was obtained from client beforehand and case study was undertaken with the permission of scientific committee and ethical committee of LGBRIMH, Tezpur.

Measures:
Semi-structured clinical and socio-demographic data sheet was prepared for the present case study which include sex, age, religion, education, occupation, marital status, etc.; Family Assessment proforma (Bhatti & Varghese, 1995) was applied to study family dynamics (Boundary, sub systems Leadership, decision making, Role structure, funct ioning, Communication, Reinfor cement pat tern, Cohes ivenes s , Adaptive Patterns and Support System). Family Assessment Device (Epstein, Baldwin, & Bishop, 1983) used to measure different aspects of family functioning (Problem Solving, Communication, Roles, Affective Responsiveness, Affective involvement, Behaviour Control, General Functioning). Beck Depression Inventory ( Beck et al., 1961) used to study level of depression and Beck Anxiety Inventory (BAI; Beck & Steer, 1988) to see the severity of anxiety.

BRIEF CLINICAL HISTORY
Index client was apparently normal and maintained well 1 year 10 months back. Two years back client was pregnant but after 5 months she had continues vaginal bleeding with pain for which she consulted to doctor and then she found to have miscarriage and had to do abortion. After few days of abortion client started having pain in her lower back which began suddenly. Sharp pain shoots down in her legs and sometimes in her abdomen also. She also reported having sensations of numbness and feels as if something is tightly wrapping the skin of her abdomen and legs. Gradually client had paralysis of the lower body part in which she was unable to move her lower body parts. Later she was diagnosed with Transverse Myelitis (TM) for which she consulted different treatments such as Ayurveda, allopathic and her family members went to traditional healers also. But nothing worked and her condition worsen then she visited government hospital from where she was refer red for physiotherapy. After that client joined physiotherapy at LGBRIMH, Tezpur. During this period client had low mood, worry about future. Her confidence level was low as she was not able to walk. Because of continuously thinking about her illness her sleep and appetite also got decreased. She was not showing interest speaking with people also.

Therefore she was referred to psychiatric social worker for psychosocial intervention. Clinical interview reveals gradual onset, continuous course and deteriorating progress of present illness with total 1 year 10 months of duration ,with precipitating factor of abortion in 5th month of pregnancy, nil significant past history, no family history of mental illness, with nil contributory personal history, with well-adjusted premorbid personality. MSE finding reveals well groomed, unable to walk, eye contact maintained, cooperative, low speech tone, anxious affect, worries regarding future. Grade V insight.

FAMILY COMPOSITION
This is a joint family with upper socioeconomic status from rural background wherein client stays with her mother-in-law, father-in-law, husband and her son. They have own family business. Client’s father-inlaw was 80 year old, studied till 9th Std., businessman. He was responsible person had cordial relat ionship wi th other family members. Client’s mother-in-law was 65 years old, studied up to 7th Std., housewife. Emotional in nature. Client’s husband was 37 year old, 10th pass, businessman. He runs bakery and sweet shop along with his father. He is introvert by nature but he is very supportive towards client. Client’s son was 8 year old and studying.

Family Dynamics
The interaction pattern in the family was cordial, the parental subsystem, parent-child subsystem interact directly and having verbal and non-verbal communication. Both Internal and external boundaries are open and clear as they maintain healthy relationship among themselves and with outside system. Family members were allowed to carry out their functions without undue interferences. Client’s father-in-law was the nominal head and democratic decision making being followed. Adequate role functioning is been perceived in the family. Both positive and negative reinforcement are present in the family. Family members resolve their conflict by mutual understanding and discussions. Primary, secondary and tertiary social support has been observed adequate in this family.

Personal History
Client was born out of full-term normal vaginal del ivery at home f rom a nonconsanguineous parentage. Home situation in childhood and adolescence was congenial. Client started schooling at 4 years of age she was average in studies. Client attended menarche at the age of 12 years since then it was regular and no complications were there. Client has adequate knowledge about sex and reproduction which she gained through her friends, mother and books. During her illness client has sexual dysfunction, which is a common complication of her illness. She had difficulty reaching orgasm. Client married at the age of 18 and the age of her husband was28 years old. It was a arrange marriage with consent of both family members and they led a satisfactory marital life. Client follows non vegetarian diet. She likes to eat homemade food, fish and meat. Her sleep pattern is nocturnal . Like to draw mehndi and interested in watching TV. Client’s family reported client had well-adjusted pre-morbid personality.