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    Not Getting Better? Insist Upon The Biopsychosocial Model (Part 2)

    Sandra’s Story

    Last week I introduced you to The Biopsychosocial Model and Sandra, a young physician suffering from depression and anxiety over the death of her mother and persisting problems with her future mother-in-law. Let’s continue with her story. Initially we began treating her with Zoloft, a commonly used serotonin specific reuptake inhibitor (SSRI) antidepressant medication and her symptoms began to respond. The psychotherapy helped Sandra begin to grieve the loss of her Mom, and then develop options in dealing with a difficult, cold and narcissistic future mother-in-law. As she felt more in control of her personal life she began to feel better, and soon thereafter she and Sam got married and went on their honeymoon, touring and climbing mountains in Patagonia, Chile.

    After they returned from the wedding and honeymoon, I received a full report from Sandra – the good, the bad and the ugly. Her mother-in-law had behaved egregiously at the wedding in a way that had embarrassed both Sandra and Sam, and as they were both distressed by her behavior and how it would impact their marriage going forward, I invited Sam to join our next session, as he didn’t understand Sandra’s need to have the two of them keep a distance from his mother’s destructive behaviors, to support her recovery.

    As we explored this in session Sam recognized how difficult his mother could be, yet was afraid to confront her for fear of losing his relationship with his father, who always seemed to take his mother’s side in any conflict, yet was the only family member with whom Sam had a somewhat gratifying relationship. After several sessions Sam reluctantly agreed to speak with his father regarding this dilemma, and as predicted his father was unsupportive, leaving the couple in an uncomfortable place. They decided that Sam would continue to see his father at occasional weekend fishing outings, yet as a couple they would limit their exposure to his mother to a few hours around each of the major holidays.

    “Sam, it is important that Sandra become your first priority, your number one commitment in your life, and that Sandra comes to believe that you have her back when it comes to your mother. She needs to come to feel that you will protect her, and your parents need to adjust to this new reality – that your relationship with Sandra is your first priority. What do you think of this point of view?” It made a great deal of sense to him, but could he be firm with his parents? He felt extremely anxious about the prospect. Just thinking about it filled him with dread. Time would tell…

    This imbued Sandra with newfound esteem for Sam as he firmly committed to taking this approach to his family. All seemed well until he took a new position at a think tank specializing in Middle Eastern affairs, which required his working well into the evening during weekdays, and frequent weekend assignments. Sandra began to feel more alone in the marriage, but consoled herself with nights out bar-hopping with friends, and throwing herself into her research studies and clinical care at the hospital. This coping mechanism began to fail.

    In addition, as we worked together to further optimize her functioning, she described longstanding difficulties sustaining a focus, and becoming easily distracted. Psychological testing confirmed that probably since childhood Sandra had been suffering from Attention Deficit Hyperactivity Disorder (ADHD), predominantly inattentive type, which had led to increased mental exhaustion at work. While she had suffered from ADHD since she was a child, because of her high intelligence, and the absence of symptoms of hyperactivity, it had not been diagnosed until now. We began to treat her ADHD with Vyvanse, combining it with the Zoloft.

    She also reported deep feelings of loneliness in the marriage, and worsening symptoms of depression, as Sam was working 70 hours or more per week. I was worried about her decline, which seemed almost inexorable, and said to her, “Sandra, something has to give here. You are depleting yourself at work, drinking too much alcohol on your nights out, and feeling unloved by Sam. It is vital that you protect yourself by cutting back at work and really limit hanging out at bars, and focus on your relationship with Sam by letting him know how lonely you are feeling, and that you need more of an emotional connection with him.” Believing my comments to be somewhat helpful, nonetheless I sensed that something else was going on, something unconscious and more insidious was also depressing her. But what was it…?

    Sandra reached out to Sam for emotional support by asking him to cut back his work hours to spend more time with her. And she agreed to do the same by reducing her teaching load and time spent in the clinic. While Sam paid lip service to Sandra’s request by coming home for dinner, he would respond to e-mails at the dinner table while she was talking, and created a home office in which he worked into the early morning hours. On weekends, he would also visit his family without her, dismissively commenting, “I know that you don’t like them or want to be with them, so I am going by myself.”

    As a result, Sandra became more and more desperate, and eventually “hit a wall,” becoming profoundly depressed and suicidal. We were both afraid that she was having nearly uncontrollable impulses to drive her car off the road into a tree, and so we admitted her into a hospital for safety and stabilization. This would also enable Sandra to work more intensively with Sam on their marital issues. The hospital psychiatrist and I discussed how we might provide Sandra more symptom relief through augmenting her antidepressant and ADHD medications with Abilify (aripiprazole)[ii], to help stabilize the frightening downward mood swings that brought out her self-destructive impulses. She began to feel somewhat better.

    Please observe that helping Sandra achieve a full recovery is requiring a thoughtful, stepwise, and increasingly complex regimen. Next week you will learn how genetic testing provided additional valuable information to help her feel better still.

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