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Burnout – the face of modern depression

According to WHO experts, depressive disorders as a cause of temporary disability and in terms of the degree of economic damage caused will soon become one of the leading, if not the first. At the same time, psychiatrists, psychotherapists, doctors of other specialties are increasingly noticing that patients suffering from depression have for quite some time lost their classic, described by Jaspers. «outlook» and complain about anything, but not a low mood, a feeling of melancholy or lethargy. The so-called atypical, masked or larvae depression has become, perhaps, excuse the pun, the most common. This makes it difficult to identify and, of course, provide effective, timely assistance..
Patients spend months, and sometimes years, pounding the doorsteps of the offices of therapists, surgeons, neurologists, cardiologists, gastroenterologists, doing expensive research, «are experiencing» on yourself dozens of medicines. More and more often we have to observe when internists, desperate to help a patient with persistent arterial hypertension, arrhythmia, peptic ulcer or colitis, who does not have clear signs of a depressive disorder, add an antidepressant to therapy and achieve rapid improvement in the treatment of a seemingly purely somatic ailment.

What is the reason for such an obvious, fast, if not to say – catastrophic pathomorphosis?
The explanation lies in the abrupt changes in the living conditions of a modern person. Of us who have been in «sleepy stupor stagnation», and now forced by elbows, fists, other places and, fortunately, more and more often – brains to win a worthy place under the sun. But, as they say, there is no good without a thin layer, the ever-accelerating pace of modern life, all these informational and technological «explosions», The relentlessness of competition inevitably generates a veritable epidemic of chronic stress that grips virtually every segment of our society. However, stress, you say, is a well-known and well-studied problem, what does depression have to do with it? And despite the fact that it is stress that multiplies the number «depression of exhaustion», «vegetative», «somatized», «larvated» and other similar atypical depressions, which are based on special mechanisms that make the clinical picture of depressive disorders unique.
The history of such patients usually does not show hereditary burden or specific «fresh» psychotrauma, clearly defined «episodes» or «phases», and more often there is a roast «combustion» at work, turn «blows of fate», just unabated pain for the years spent aimlessly or in pursuit of a mirage, concern for children rushing about in vain in an attempt to get out «people» or, on the contrary, who have escaped, and are now reaping the fruits of success, which are very much like the apples from the famous tree in the Garden of Eden. In the behavior of these people, there is usually no «notorious» psychomotor retardation, at times they may even seem to be active, «lively», only sometimes the gaze fades or comes across the face «cloud», especially if you can find something really important for a given person, «sick» topic. The mood of such patients is characterized as «normal» or, in extreme cases, unstable. Only with a more careful questioning it turns out that periodically and over time they more often feel «tiredness of life», twitching, irritation, internal tension, anxiety, inability to relax. Often there is no feeling of rest after sleep, weekend or vacation, apathy rolls over, «laziness», or life loses its fullness and brightness, flows, as on «autopilot»; a person accidentally torn out of the daily hustle and bustle appears — he doesn’t know what to do, what to want.
In most cases, the complaints of such patients are of a purely somatic nature, and at the same time, there are often somatic diseases that explain these complaints, quite real, confirmed by paraclinical studies. Only sometimes experienced internists can notice that, for example, the severity and persistence of pain in osteochondrosis or gastritis or other symptoms seem to be exaggerated, that is, the impression of their aggravation is created, and they are usually resistant to treatment.
The symptoms of such depressive conditions are practically indistinguishable from the so-called «chronic fatigue syndrome», characteristic of long-term viral infections, and with this syndrome, depression should be differentiated in the first place. True, such differential diagnostics is quite complicated technically and requires high professionalism of specialists and modern laboratory and instrumental facilities..

What are the pathogenetic mechanisms of the discussed type of depression?
To explain their development, the concept of nonspecific protective-adaptive reactions of the nervous system proposed by Yu.L. Nuller. When, as a result of prolonged depleting influences (chronic stress), a general deficiency of the body’s energy resources develops (primarily – resources of the nervous system) a nonspecific anxiety reaction is triggered through the feedback loop (sometimes patients feel this physically – complain of poor sleep, internal tremors, muscle tension, symptoms appear that are considered to be «neurotic», — persistent cephalalgia in the form «helmets» on the head, «lump» throat or difficulty swallowing, feeling short of breath or heartbeat). In parallel, according to the law of locus minoris resistencia, old or dormant somatic diseases are exacerbated, which also does not contribute in any way to identifying the true triggers of health disorders. Since the anxiety reaction (nonspecific activation) does not solve the problem, and the depletion of the nervous system continues, a second, deeper «echelon» protection — depression, which, within the framework of this concept, is not a disease, but a special mechanism of protective inhibition developed by evolution, which does not allow the latter to be wasted, «inviolable» reserve of strength. But for a reasonable person living in society, this mechanism loses its protective value – he can not «hide away» from life, driven by a sense of duty, responsibility, obeying generally accepted rules and social laws, finally, simply by inertia, he continues to fuss and at the same time constantly receives signals from his nervous system about the approaching inner «bankruptcy». Possessing the ability to predict, such a person, on a conscious or subconscious level, seems to constantly ask the question: «How to live on, being in a state of squeezed lemon?». And vaguely anticipates or represents the possibility of a complete collapse in all directions. This gives rise to an increase in anxiety, periodically reaching a degree of despair or panic. The latter is often accompanied by vegetative «storms» (in the form of fluctuations in blood pressure, arrhythmias, dyskinesias of the gastrointestinal tract), which were previously usually attributed to vegetative-vascular dystonia or diencephalic (hypothalamic) crises, and now are increasingly referred to as «panic attacks».

With the repetition of such crises or attacks, obsessive-phobic mechanisms are activated, which, along with the above-described protective-adaptive reactions, form a vicious circle of self-maintenance of depression. And when all these mechanisms, acting not only at the psychological, but also at the biological level, are turned on, the patient, unfortunately, is often no longer able to help either full rest or the most sophisticated psychotherapeutic techniques. Means are needed to reliably break the vicious circle «exhaustion – anxiety – emaciation» and blocking adaptive reactions of the nervous system, which have lost their protective meaning in humans and only maintain the state of the disease.

So far, only tranquilizers and antidepressants can claim the role of such funds..

In addition, depression therapy always requires an integrated approach. Along with a comprehensive examination (due to the above difficulties in distinguishing between somatic and «depressogenic» symptoms), antidepressant treatment should be combined with psychotherapy and psychological counseling. At the same time, psychotherapy and the work of a psychologist, regardless of the methods used, are designed to ensure the solution of the following fundamentally important tasks.

  1. Description (in a form accessible to the patient) of the nature, mechanisms of development and, most importantly, the reversible nature of depressive disorders.
  2. Familiarization of the patient with the peculiarities of the effects of the drugs used and the need to strictly follow the recommendations given by the doctor!
  3. Identifying major debilitating factors – overloads, external and internal conflicts, dependencies, «dysfunctional» relationships and cognitive processes, and in the longer term – the formation of a new, less «cruel» in relation to the nervous system and to the body as a whole lifestyle. The process is complex, time-consuming and leads to success only if started on time – when the patient already has the desire and strength to change something, and he himself is looking for «new ways», and the psychotherapist, as required by one of the basic laws of this profession, plays not directive, indicating, but accompanying («facilitating») role. At the same time, we must help the patient to understand that otherwise (if such searches are abandoned), the risk of at least repeated courses of antidepressant treatment remains..

Therapy for modern depression – the process is usually effective, but far from simple and cloudless, relapses are quite frequent, often there is a tendency to chronic depressive disorders.

An ideal antidepressant that combines high potency has not yet been proposed, «force», broad spectrum of action with no side effects.