WHOLE PSYCHIATRY

Imagine, if you can, that you are a 44-year-old married woman and mother of two grown children. You have had some marital difficulties over the past year or two and in your own mind you have associated this with the fact that your children are grown, out of the house, and your life is lacking a focus. Over the last several months, you have begun feeling that life has become meaningless and you have been feeling sluggish and depressed most of the time. You have become less tolerant and more irritable with your husband and, quite naturally, he has been spending less and less time at home with you. Things just seem to be spiraling down and you are worried about the marriage and the possibility that he may be having an affair. After all, you have not had sexual relations for seven months. You just feel very, very tired and have noted in the last several weeks the despite psychotherapy, which you have been engaged in for approximately 18 months, you are beginning to feel quite hopeless and even: suicidal. You just don't have any energy left for living; even the smallest chores, such as brushing your teeth, combing your hair, pulling on your boots in the winter, take enormous amounts of energy and are a sheer act of will. You have mentioned this to you internist, who did some routine blood testing but found no abnormalities. It was at his suggestion that you entered counseling to decide what you wanted to do with the rest of your life. At that time you had thought it was a good idea, but here you are, a year and half later, getting worse. Your therapist has been quite helpful, but the problems continue to escalate and you find yourself not knowing where to turn. Your life seems empty, only a shadow of what it once was. Ultimately, your therapist decides that perhaps medication would be of some help to you and reluctantly (you really don't want to start going through this all over again) you agree to see a psychiatrist for medication evaluation. In the psychiatrist's office, you realize that this is a different approach. The psychiatrist asks you what seems to be hundreds of questions. By the end of the evaluation, it becomes clear, at least in his mind, that your main complaint is fatigue, specifically muscle fatigue. This, the psychiatrist tells you, is preventing you from being active and leaving you feeling frustrated and helpless. He describes to you that this is a perfect paradigm for what he calls "learned helplessness." You are not sure exactly what he is talking about, but you follow his directions and get some additional blood work. This just seems like one more stress, yet you feel a certain sense of hope. Ultimately, a diagnosis of myasthenia gravis is made. (This is a disorder of the immune system in which the cells of the immune system actually attack parts of the muscle, leaving you in a very weakened state. It is not uncommon to have such profound weakness that combing your hair or walking up stairs would be very exhausting, if not nearly impossible.) As it turns out, you undergo treatment and begin to notice an improvement in your energy. A meeting with the psychiatrist and your husband, about one month after the diagnosis has been made, helps both of you to understand what had really happened: A medical disorder had robbed you of your strength. Not knowing what was going on, you began to feel helpless and spiraled into a depression. Your husband, also feeling helpless, began to work longer and longer hours and wondered about the possibility of separation. Now, with the diagnosis and treatment, there is renewed hope for your relationship and you feet quite relieved that your life, your marriage, and your self-esteem have been salvaged. This case indicates how what appeared to be a psychosocial problem causing consequent depression was actually a medical problem causing a psychosocial problem. Unfortunately, as clinicians, we are trained so strongly in the psychosocial arena that we often assign a causal role to psychosocial factors. It is always possible that psychosocial stresses might have taxed the physical organs, in this case the immune system, to the point of breakdown. However, it is clear that all aspects of the patient's life (biological, psychological, social) must be evaluated.