Matrix of Clinician Distress – Part 4

Mood Syndromes / Clinical Mood Disorders

(Part 4 of a 7 part series. You’ll see reference to this being a five part series. I was naive when I was writing it. It had to be expanded. The entire 7 part Matrix of Clinician Distress series is available in article and podcast format - see footnote for more explanation on how to find.)¹

Mood Syndromes / Clinical Mood Disorders

Depression (Major Depressive Episode)

“Just because you’re feeling depressed doesn’t mean you have depression.”

Huh?

Too frequently, the term “depression” is used to connote any sad affect that is sustained for a period of time.

So as to distinguish these more prominent depression experiences from ordinary situational sadness, criteria that include the duration of the disabling symptoms, the actual number of symptoms, and the fact of the syndrome having a detrimental impact on one’s life must be met. Otherwise, everybody who had an emotionally down day could be said to have a clinical mood disorder. A diagnosis that fits everybody refers to no one.

Like all diagnoses, the clinically significant depressive disorders are seen as having a characteristic cluster of symptoms, the number of separate symptoms and their duration determine whether a clinical syndrome of “depressive disorder” is present.

Mis-terming all sadness as depression creates the prospect of overdiagnosis of a depressive syndrome where none actually exists. Further, it medicalizes and pathologizes normal human experience.  And it leads to unnecessary treatment.

Now, it turns out that there are a lot of similarities between the occupational stress syndrome of burnout and the syndrome of Major Depressive Episode (capitalized because it’s an official diagnosis). Thus, many confuse the two and erroneously believe that burnout is just a form of depression that happens to occur in one's work life. This is a dangerous error that almost always leads to inappropriate treatment.

And this should be of little surprise. Any psychological stress when either acutely intense (like a high voltage surge) or prolonged in duration (like combat fatigue) is going to result in an array of manifestations. And these are often simply an intensification of the characteristic response we have to stress syndromes in general, whether it manifests more cognitively, affectively, bodily or behaviorally.

Over the course of my clinical and coaching career, I’ve found what’s helpful in distinguishing these are the following:

The syndrome of Major Depressive Episode has an array of symptoms, five of which need to be present for a sustained period, namely a minimum of two weeks. (You can have less but for a longer period, but such would suggest a different type of depression, such as chronic dysthymic disorder.)

Here are the clusters of manifestations that constitute the diagnostic criteria for Major Depressive Disorder:

Essential Symptoms - One or Both of These Must Be Present

Two main criteria that must be present for the full two-week duration criterion are depressed mood and anhedonia. A depressed mood has to do with sadness or “negative” emotions. Translated, this means that the person’s emotional state must be significantly sad and nearly unrelenting for at least a two-week period.

Anhedonia means that you no longer feel any pleasure or interest in the things you once enjoyed. What this means practically is that you can’t make the doldrums go away with the customary diversions that might have worked in lesser periods of low mood, such as going to a museum or out to dinner or socializing with friends. In fact, what I’ve seen most often accompanying these two is the state of social withdrawal.

You must have one and/or the other of these two main criteria to meet the diagnostic criteria for a Major Depressive Episode.

Secondary Symptoms

After you consider these two main criteria, you explore from the array of associated symptoms. These include somatic symptoms related to your physical body, as well as non-somatic symptoms that are related to thought and emotion. And yes, a diagnostician is running through these as they interact with their client.

Somatic Symptoms

You feel the somatic symptoms of depression in your body. And, you may notice that your body is changing while you’re depressed. The following are somatic or body-related symptoms mentioned in the DSM-5 depression criteria.

Sleep difficulties – If you’re depressed, you may have insomnia, restless sleep, or conversely sleep more than usual. Insomnia doesn’t just mean you can’t sleep at all. Rather, you may have trouble going to sleep or staying asleep. Sometimes people with depression wake up very early and can’t go back to sleep, despite a deficient duration or quality of sleep. Often, especially in younger people with depression, people sleep much more than usual. Excessive sleeping is called hypersomnia.

Vegetative Symptoms - Changes in appetite or weight – While you’re depressed, you may find that you don’t have much of an appetite for any food; it’s just gone. Conversely, you might feel like eating constantly. It’s the change in appetite from your baseline that’s significant to the diagnosis. The same is true for weight gain or weight loss. You may lose or gain weight during the depressive episode.

Poor concentration – Inability to stay focused happens during the depressive episode not because you have ADD (attention deficit disorder) but because your brain simply isn’t capable of focusing as well as it usually does. It shows up by not being able to focus on your work, daily chores, or even leisure activities like watching a movie or reading a book.

Diminished memory - Remembering is a complicated cognitive task requiring a series of discrete functions that route the brain’s circuits to retrieve information stored in temporary, short-term and longer-term storage. Memory packets essentially have to be “unpacked” before they’re brought forward. (They’re kind of like compressed digital “zip files.”)

Fatigue – The DSM somatic criteria for depression include physical fatigue and overall loss of energy. This grouping includes decreased activity, feeling tired, low energy, having decreased endurance, feeling weak, heavy, sluggish, or slow, having to put in more effort to do the same physical tasks, or frequently feeling sleepy.

Psychomotor agitation or retardation – Basically, this means a slowing down or speeding up of your physical and emotional reactions. Psychomotor retardation looks a lot like low thyroid: you find that you’re thinking and moving sluggishly. On the other hand, in a state of psychomotor agitation, you might feel restless, anxious, irritable, and tense. You may have racing thoughts or be unable to sit still.

Non-Somatic Symptoms

The non-somatic symptoms of depression include emotional states and the content of your thoughts. These are non-somatic symptoms of depression described in the DSM-5:

Depressed mood – Depressed mood is about emotion. It’s feeling sad or low.

Anhedonia – This is a loss of pleasure, interest, or enjoyment.

As noted above, at least one of these two symptoms must be present to conclude a diagnosis of Major Depressive Episode.

Feelings of worthlessness or guilt – This is the same as low self-esteem in which you feel there’s no worth or value in yourself as a person. Unwarranted feelings of guilt or shame are also frequently seen when someone is grappling with depression.

Thoughts of suicide or death – This is where you’re finding yourself having morbid, bleak thoughts, where you find yourself thinking about death, taking your own life, dwelling on others who have, how you might do it, how others would feel et al. These preoccupations are often unbidden and the person can’t shake them. When someone is manifesting these, it’s literally vital that they connect with someone who can help them address their depression. One of the biggest challenges in someone experiencing suicidal thinking is that, combined with the other symptoms, one is in a very dark place and can’t see their way out. And when you’re in pain, and feeling like there’s no hope, the disturbed “logic” of suicide becomes more compelling. That’s why it’s vital for those who pick up on suicidal thoughts of a distressed clinician need to get guidance immediately on how to most effectively direct that clinician to the most appropriate degree of care. Safety is paramount. The act of suicide doesn’t care about shoulda’s.

Conceptually, the syndrome of depression is not related to external situational causality. Rather, it more resembles that mental state that’s similar to what you feel like when you have a bad flu or bad PMS. It just sits there like a dense fog and all you breathe in are downer vapors.

Differentiating Major Depression From Burnout – Tips

If the syndrome began in the context of one’s worklife, and you’re in a people-work “high valence outcomes” line of work, and especially if you can more or less pin your low mood (“dysphoria”) to the work arena, then it’s likely situationally-induced and therefore more likely burnout.

If you take a break from work, get some rest, and are able to feel better, say after a week or two of vacation, it’s more likely work-related and thus burnout. In a Major Depressive episode, the mood remains mostly unchanged by environmental interventions.

However, this is not to say that external events don’t contribute to the development of depression. They certainly can. Burnout itself can’t morph into depression, as can intense grief. Rather, the removal of causality as a criterion for Major Depression ws simply to emphasize that the syndrome itself can be present and can be symptomatically evaluated independent of any consideration of causality.

Can One CAUSE the Other? Can They Occur Concurrently?

So, can burnout lead to depression? Most definitely, especially as the burnout syndrome progressively depletes one’s coping and “internal antidepressant hormones.”

And can you have both? Most definitely. And when you see a person with both burnout and depression, it’s vital that you understand their conceptual difference and their different approaches to successful resolution. Missing the depression component in the combined syndrome makes resolution of burnout immensely more difficult. Missing the burnout component in a combined depression syndrome stymies resolution. This is especially so as burnout, as it is predominantly caused by a host of external situations depleting one’s coping, requires active identification and active alteration of those contributing issues for resolution. No matter how much Prozac you administer, the oppressive workload or hostile work culture or malpractice stress isn’t going to be alleviated one bit.

Anxiety (Generalized Anxiety Disorder)

Just as with depression, just because you feel worried doesn’t mean you have an anxiety disorder.

In today’s upside-down world awash in personal and communal threats affecting our daily existence, some degree of anxious apprehension would seem to be part of our psychic baseline existential constitution. I’d be inclined to argue that if you weren’t feeling some level of diffuse anxiety, there may be something amiss in your psychic apparatus. You may have blown out your fear module or something. (Yes, there is such a phenomenon - the almond-shaped structure known as the amygdala is the primary relay circuit orchestrating our fear response. Chronically high enough stress “voltage” and you can fry it.)

I suspect none of us is unfamiliar with that worried, keyed-up, preoccupied state of mind known as anxiety.

I’m going to keep my comments brief here as the tendency to go into greater details turns the article into a textbook and also tries the patience of the time-limited “just the facts, m’am” reader.

So briefly, with anxiety, you’re likely to manifest several of a set of characteristic manifestations that have been found to be associated with this syndrome. And interestingly, you’ll have your default stress response pattern - for some, it may be somatic, e.g. shortness of breath and increased heart rate; for others, it may be more cognitive, e.g. inability to focus or mental preoccupation such as obsessing and ruminating; and still for others it may manifest behaviorally, e.g. interpersonal irritability, or pacing.

Typically, anxiety leads to avoidance – of work, of social situations, and even close relationships – due to worry. With anxiety, it’s difficult to stay focused due to preoccupation with worry, sometimes being stuck in a state of obsessive worry where one keeps going over the same worry subject. This regurgitation is a mental process we commonly refer to as rumination. Worry commonly fatigues you. You lose interest in many activities – both work and leisure – as the worry keeps you emotionally tied-up. You may have a disturbance of your sleep pattern, whether too much, too little, or overall poor quality of sleep.

Characteristic Symptom Manifestation

There’s a host of physical symptoms you might experience such as:

• Restlessness, agitation, or tension

• Nervousness, irritability, or dread

• Feeling panicked, frightened, or in imminent danger

• Excessive sweating

• Rapid or shallow breathing

• Increased heart rate

• Muscle trembling or twitching (e.g. tremulousness)

• Inability to concentrate and remember

• Difficulty falling and staying asleep, or excessive sleeping

• Fatigue

• And a host of non-specific physical discomforts such as an upset stomach, diarrhea, constipation, bloating, various bodily pains or sensations

• And, like depression, a tendency to isolate and to avoid socializing with others

Except in the minority of people whose hard-wired circuits don’t transmit anxiety or fear, the vast majority of people have experienced occasions of significant worry.

Think for a moment of one of those times you’ve felt significantly worried. You’ll probably see every symptom you experienced amongst the array listed above.

Types of Anxiety Syndromes

For our very limited purposes here, let’s say that anxiety has two main flavors: situational and ongoing. And let’s also visualize that it comes in two sizes: ordinary and super-sized.

The situational one is not really a disorder. It’s simply a stress reaction of the anxiety or fear type. The stress reactions themselves are further characterized as non-disorder or disorder, the latter being designated when the anxiety stress response cascade is significantly more robust than the situation would call for.

When anxiety gets to be symptomatically problematic, i.e. interfering with one’s personal or professional life, and when stress management practices such as meditation, yoga, mindfulness and quiet breathing aren’t sufficiently managing it, that’s when anti-anxiety meds (and therapy) can be most helpful. Once you can get the syndrome under some degree of control, you can do the same exploration of causality as you would for the others. And you can fall back to relying on the host of “anti-anxiety” strategies that are great stress antidotes across the board., e.g. exercise, yoga, meditation etc.

Is there more to depression and anxiety that could be covered? Of course, volumes. But practically speaking, this should serve well as a travel guide to the main attractions.

Upcoming … the Stress Impact of Being Sued; Getting Caught in the MRTC Crosshairs; and the Hostile Bully Subculture in the Frat House of Medicine

In the last of our series of five articles, we’ll be wrapping up this overview of the clinician distress matrix by examining the stress syndromes resultant from malpractice litigation, from the administrative medical system referred to as the MRTC, and that which is seldom (if ever) written about - the immense continuous stress resultant from being discriminated against (in multiple forms) and trapped in hostile work cultures.²

While there are several notable experts in litigation stress, hardly anyone writes about these last two clusters. But I can tell you from my research (and personal experience), we’re way beyond overdue for examining their role in clinician distress.

Just to name one adverse impact, most physicians fear getting any sort of help with their so-called “mental health” issues, largely because of the menacing MRTC. That means clinicians don’t seek help. What’s deeply disturbing is not just that physicians suicide as a result of being afraid to get help, it’s that, still today, 30 years after the ADA was enacted, close to 50% of state medical boards - and likely credentialing applications at their hospitals – ask intrusive questions that are overtly impermissible under the Americans with Disabilities Act (ADA). Affirmative answers to these overtly illegal questions funnel one into the PHP system which then disabuses these newly diagnosed physicians of their rights and diagnoses them (also illegally) with an impairment they didn’t have, and sentences them to forced and extremely costly treatment, and marks them as damaged goods for the rest of their lives.

It should beg a larger question – why do state and national medical societies and the medical boards’ national trade group, the Federation of State Medical Boards, permit this?

I suspect you’ll find it an intriguing if not unsettling read. If you haven’t yet subscribed to our free Physician Interrupted newsletter here on Substack, doing so (see blood-red box, end of article) will automatically send you that next provocative article as soon as it’s posted. (And I assure you, you’re not going to get a lot of detritus in your inbox. Not just because it’s against the rules and irks intelligent people, but also because I don’t believe in wasting people’s time with a lot of yada yada.)

I’d really love for you to comment on this or any of the Clinician Distress Matrix articles so as to foster dialog. And please share this series widely, especially if you agree we’ve got some problems and we - specifically the medical community - need to talk.

Till then. Stay / get well. Heartfelt appreciation for our colleague clinicians’ heroic work.

And now, on to part 5, Medico-Legal-Regulatory Stress.

1. When you click at the very top of the page on the Physician Interrupted title, it’ll take you to Physician Interrupted’s table of contents page which lists all the articles and podcasts published. You can sort them in a variety of ways. As some of the articles were longish, I broke up the corresponding podcasts into more manageable parts, e.g. 6A, 6B etc.

The articles’ titles aren’t exactly descriptive - I’ve put the topic covered in the subtitle which, space permitting, may or may not show up in the TOC.

The podcasts are all identifiable as they have a headphones icon. The content of the podcasts is mostly the same as the article. While I read aloud the content of the corresponding article, occasionally I improv’d a bit. Nothing substantial. Some people prefer the written word; others enjoy a podcast; still others like having both. Some have some cover art; some don’t. I’m still getting the hang of this. I’ll likely go back and prettify things some time hence.

2. MRTC = the Medical Regulatory Therapeutic Complex. This is a powerful collection of entities that have life and death power over your career – worldwide. It includes state medical licensing boards, so-called physician health programs (PHPs), credentialing entities such as healthcare institutions and others. It operates virtually free of oversight, regulation or accountability.

You can read more about it here: Systematic Abuse and Misuse of Psychiatry in the Medical Regulatory-Therapeutic Complex. Robert S. Emmons, M.D. Kernan Manion, M.D. Louise B. Andrew, M.D., J.D.  Journal of American Physicians and Surgeons Volume 23 Number 4 Winter 2018. pp 110-114. link: http://www.jpands.org/vol23no4/emmons.pdf