Saturday, January 13, 2007

Doctor as Patient II - Depression

It is best to begin at the beginning.

The aetiology of depression is loosely described as biopsychosocial.

There is certainly an hereditary element to depression. A genetic predisposition. A biological component, independent of circumstances good or bad. Exactly where and how and to what extent is not well understood. Suffice it to say that the degree to which depression is biological varies from person to person.

Much of the above paragraph can be reiterated with 'psychological' replacing 'biological'. the extent of causative contribution is quite variable. To simplify, one could say a pessimistic propensity is at play (Dr Dork never turns down an alliterative opportunity). Negative thinking patterns, whatever their genesis, are self-reinforcing.

One way Dr Dork conceptualizes this impact is that, for a given degree of depression, the extent to which it is impairing can partially relate to one's social circumstances. For example, someone socially isolated is more prone to a greater degree of social withdrawal when depression develops than is someone with a close, supportive family and social network. Social factors such as excessive work demands, interpersonal conflicts, bereavements and the like can precipitate or exacerbate depression.

Alcohol and other psychoactive drugs, licit or illicit, could be classed as both a social contributor and a biological contributor, Dr Dork thinks. Alcohol, for example, can be alluring to the depressed and/or anxious for it's transient elevation of mood and anxiolysis, yet alcohol is a depressant of the central nervous system, and is known to accelerate, exacerbate and possibly initiate depression.

This triumvirate, the biopsychosocial model, is a fundamental element of medical school teaching. Although most salient in psychiatry, every doctor is taught to consider healthcare for each patient within the context of their individual biopsychosocial milieu. A patient is more than a broken machine, and doctors are more than technicians.

Depression, for Dr Dork, has been aetiologically related to all three elements.
Depression, for Dr Dork, has also had ramifications biological, psychological, and social.

In the extended Dork family, depression is not uncommon. There is something in his families neurochemical makeup that lends a certain predisposition to this particular ailment. When depressed, all sorts of 'physical' aspects manifest directly, what psychiatrists refer to as physiological shift symptoms.

Psychologically, Dr Dork shares many traits common amongst doctors. Perfectionism, fear of failure, unforgiving of one's foibles, with a record of placing one's own needs for sleep, nutrition, exercise and rest a distant second to his vocational demands. Furthermore, Dr Dork is in many ways the typical Australian male: poor at openly discussing his emotional needs, in denial of his own distress, maintaining a resolute facade to all, and attempting to drown his demons at times.
Socially, the tendency to overload himself has been a contributory factor at times. For Dr Dork, this has been another method of 'escape', at times, which is also doomed to fail. And in his dark times, the costs to relationships, family, career and finances have been steep.

For these many reasons has the black dog lingered long, in the shadow of Dr Dork.

That is enough for today. This is a long tale to tell, and not altogether pleasant in the telling.

More another day.


Maderine said...

Hey, as an over-emotional American female, I share your pain.

scalpel said...

I hope you feel better.

You hit the nail on the head with the sleep, nutrition, exercise, and rest bit. Perhaps you should take your own advice.

Sid Schwab said...

I began to sweat as I read this. It's a familiar path, and I relate very acutely; a perfect template. I'm not sure I want to read what else you have to say, but I will. And I sympathize greatly.

Rob said...

A familiar eqation:
Anxiety (feeling of being out of control) + Professional that makes independent decisions and is used to being "in control" = incredible desire to escape*.

*Over-emphasis of work, overeating, negative relational behavior, alcohol, etc.

Far to familiar to me. I often say to my patients that one of the comforts of doing my job is that you get to see that everyone else is just as screwed up as you are.

I see "normal" people and they are all dealing with a lot of these things.

Your partner in crime,


Bo... said...

I sympathize--because a similar black dog has haunted me from a young age, chasing me for years, along with a penchant for ETOH (which I finally stopped, albeit with a few stumblings here and there). Right now I'm doing well, but the dratted black dog is like the tide---it comes in, it goes out, it comes in... (Which is somewhat comforting-- because if it comes in, then I know it has to subsequently "go out"...)

NeoNurseChic said...

Hmmm...I hear ya. Nothing more to say right now other than *hugs*. The topic is all too familiar and one that I struggle with constantly.

Hang in there and take care,

Dr Dork said...

Thanks for the kind words guys.

I am well. This is a retrospective.

If I practiced half of what I preached that would be twice as good for me.
The physician personality is but a pale imitation of the surgeon's! I mean that as a compliment.
I agree 100%. I spent time sublimating my own issues into training as a psychiatrist. Thankfully I realised this within just a (relatively) few years...

Bohemian RN, NeoNurseChic,
I've learnt to accept the dog. It can't be killed. It can't be banished. It can be known, and can be tamed.


Shiny Happy Person said...

I understand.

Barbados Butterfly said...

Hugs to you.

The MSILF said...

Thank you for posting about this. Maybe one day I'll be brave enough to too. This is one heavy taboo among docs (especially women) - the one, only thing ever that we cannot discuss with colleagues, the friends we train with who see us at every possible worst moment, even when we know that they have been there too.

You, DoctorMama, I thank everyone who has been open enough to write/talk about it. Wish I could.

Fallen Angels said...

I hope you are able to keep the black dog tamed and at bay. He visits me far too often, so I understand.


Dr Dork said...

Siny, Barb, AMSILF, FA,

Thanks for the kind words. The dog is well behaved nowadays. One of the hardest things for me was accepting he will always be around, to some extent, and the first step to keeping him at bay is accepting and understanding the dastardly mutt.

Doesn't mean you have to like him.


Health Psych said...

Glad the black dog is currently on the leash.

Kudos to you, Dr. Dork, for sharing your experiences with living with and taming the mutt..more people struggle with this than many realise...

Deb S. said...

I'm glad you wrote this post. I am not a doctor, but because my profession shares similar traits with yours, I understand how things such as perfectionism and sleep deprivation impact one's personal life. I also know all too well how one can be genetically predispostioned for depression.

Some of the most creative people I know wrestle with some of the issues that you have had to face. When it comes to creativity and compelling writing, you go to the top of the class!

Sheila said...

I am medicating my dog into submission. Can doctors do that, or does it become a liability issue and/or impair your ability to do your job?

And now I have "Who let the dogs out?? Who? Who?" stuck in my head. Oh well, better than SI, I guess.

Zoe Brain said...

Consider yourself Hugged.

Dr Dork said...

Hi healthpsych,Zoe,
Yup, darn mutts are everywhere.

Flattery will get you everywhere, my dear. Ha!

Doctors are required to not be cognitively impaired, whether this be due to illness or psychotropic medication, for obvious reasons. Fortunately, most antidepressants used nowadays don't cause any problems with sedation or cognitive impairment - they tend to have the opposite effect, by virtue of resolving the impact of the depression itself on these functions.

Kind regards

Now I've got that song in my head...

Tiny Shrink said...

Always comforting to hear from someone else with the 'black dog' problem, especially when that person has dealt with the problem for so long and has thrived. Thanks for a morning's inspiration!

Kim said...

I am indebted to Zoloft for helping me with the "black dog" in my life - who, as mentioned above comes and goes.

I think the hardest part was dealing with feeling guilty for feeling depressed! Good marriage, healthy children, great job, much faith....feeling like I had no "excuse" to be depressed!

It's an interesting phenomenon, especially when looking at it from the inside out.

Godwhacker said...

I think philisophy plays a role as well. Is life "knowable" and "doable", or does destiny have us in a vice of misery and constant control? Do we believe that we deserve to be happy, or do we harbor guilt for which we believe we should suffer? Do we have free-will, or does fate (god) have us as part of a master plan.

Also, there are a lot of negatives associated with depression. Certainly it is not good to be depressed for lengthy periods. But can we be justly and healthily depressed for valid reasons - as in empathy for the suffering of others or because of awareness of the many wrongs of the world that have yet to be made right?

Yes ~ I think.

Patient Anonymous said...

Just wanted to pop in and let you know that I understand. It sounds like you're doing a bit better now so that is good. Your post completely resonated, however.

Take care.

Dr Dork said...

You're welcome. There were times when the "light at the end of the tunnel" was definitely an oncoming train, as they say...and you'd be surprised how many travel thorugh life with a little canine friend.

I understand 100% - I spent a long time in denial of being unwell, guilty over being unwell, and using the "manic defence" common in docs. I plan to elaborate on this in a post.

Good point...but you're giving me a headache..ouch

no worries..a misery shared is a misery halved...Ha!

Kind regards

Godwhacker said...

Sorry doc. I believe we can change the future.

Mother Jones RN said...

Doc, D.

I'm very sorry to hear of your pain. Mental pain is worse than physical pain. It cuts into the soul.
Stay strong.


Dr Dork said...

I was being a tad apologies. I think clinical depression and sadness are very different entities. Personally, I believe in free will - for the most part. Scott Adams (the writer of Dilbert - see the link to Dilbert Blog in my sidebar) is fascinated by the notion of free will, or lack thereof, and expounds upon it regularly. His blog is hugely popular, and the comments and discussion ensuing when he frequently posts on the topic of free will (or lack thereof, as he proposes) make for fascinating reading.

Mother Jones,

Thanks for the kind words - but I am just fine - see above - this is retrospective.

Kind regards

Moof said...

Dr. Dork, this was quite a difficult - and enlightening - read. Thank you for having the courage to write it. Like Dr. Schwab ... I'm going to have to steel myself in order to read whatever follows along the same lines, but read I will ...

Thank you again for your courage, Dr. Dork ...

Anonymous said...

I resonate with the common threads mentioned in your blog and the comments that followed. I haven't heard anyone talk about dreams. Since my onset of depression over 15 yrs ago I have had nights of incessant dreams - I wake up exausted.

Anonymous said...

Hey Doc!

I am going through that phase right now... im seeing a psychiatrist

Dr Dork said...

sorry for the delay

better late than never

Sid is a much more appealing and talented writer. Thanks for your input, it is always valued.

I am fascinated by, but do not really understand, dreams. It is my opinion that no-one really does. Not even the dreamer. Sometimes, they are revealing, though.

Nothing wrong with seeing a shrink! Heart feels funny..see the cardiologist. Thoughts seem funny, see the psychiatrist.

Avoidance and denial are unevolved defences.

Kind regards

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