CASE ‘I’m stuck’
Dr. D, age 48, an internist practicing general medicine who is a married mother of 2 teenagers, presents with emotional exhaustion. Her medical history is unremarkable other than hyperlipidemia controlled by diet. She describes an episode of reactive depressive symptoms and anxiety when in college, which was related to the stress of final exams, finances, and the dissolution of a long-standing relationship. Regardless, she functioned well and graduated summa cum laude. She says her current feelings of being “stuck” have gradually increased during the past 3 to 4 years. Although she describes being mildly anxious and dysphoric, she also said she feels like her “wheels are spinning” and that she doesn’t even seem to care. Dr. D had been a high achiever, yet says she feels like she isn’t getting anywhere at work or at home.
The authors’ observations
As psychiatrists in the business of diagnosis and treatment, we immediately considered common diagnoses, such as major depressive disorder and persistent depressive disorder. However, despite our training in pathology, we believe patients should be considered well until proven sick. This paradigm shift is in line with the definition of mental health per the World Health Organization: “A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”1
In Dr. D’s case, there was not enough information yet to fully support any of the diagnoses. She did not exhibit enough depressive symptoms to support a diagnosis of a depressive disorder. She said that she didn’t feel like she was getting anywhere at work or home. Yet there was no objective information that suggested impairment in functioning, which would preclude a diagnosis of adjustment disorder. At this point, we would support the “V code” diagnosis of phase of life problem, or even what is rarely seen in a psychiatric evaluation: “no diagnosis.”
EVALUATION Is work the problem?
We diligently conduct a thorough review of systems with Dr. D and confirm there is not enough information to diagnose a depressive disorder, anxiety disorder, or other psychiatric disorder. Collateral history suggests her teenagers are well-adjusted and doing well in high school, and she is well-respected at work with reportedly excellent performance ratings. We identify strongly with her and her situation.
Dr. D admits she is an idealist and half-jokingly says she entered into medicine “to save the world.” Yet she laments the long hours and finding herself mired in paperwork. She is barely making it to her kids’ school events and says she can’t believe her first child will be graduating within a year. She has had some particularly challenging patients recently, and although she is still diligent about their care, she is shocked she doesn’t seem to care as much about “solving the medical puzzle.” This came to light for her when a longtime patient observed that Dr. D didn’t seem herself and asked, “Are you all right, Doc?”
Dr. D is professionally dressed and has excellent grooming and hygiene. She looks tired, yet has a full affect, a witty conversational style, and responds appropriately to humor.
The authors’ observations
It can be difficult to know what to do next when there isn’t an established “playbook” for a problem without a diagnosis. We realized Dr. D was describing burnout, a syndrome of depersonalization (detached and not caring, to the point of viewing people as objects), emotional exhaustion, and low personal accomplishment that leads to decreased effectiveness at work.2 DSM-5 does not include “burnout” as a diagnosis3; however, if symptoms evolve to the point where they affect occupational or social functioning, burnout can be similar to adjustment disorder. Treatment with an antidepressant medication is not appropriate. It is possible that CBT might be helpful for many patients, yet there is no evidence that Dr. D has any cognitive distortions. Although we already had some collateral information, it is never wrong to gather additional collateral. However, because burnout is common, we may not need additional information. We could reassure her and send her on her way, but we want to add therapeutic value. We advocated exploring issues in her life and work related to meaning.
Continue to: Physician burnout