part0014

I had not seen 30-year-old Sanjay for some time. A healthy young man, he rarely came to the office, and when he did, it was normally for some minor problem. A wart. A flu shot. An ingrown toenail.

Sanjay’s demeanor at this visit surprised me. His affect was flat and his frustration readily apparent. “Everything I try to do to remedy the situation just leaves me more tired. Like I played golf and met my friends for several games of tennis but nothing seems to help,„ he said with an exasperated tone in his voice. Sanjay went on to explain, “I have even given up fast foods and takeout, but even eating good wholesome meals is not helping.„ Sanjay strained to put on a smile about how good his life was despite his fatigue.

While I had seen Sanjay infrequently over the four years he had been my patient, I had come to know a few details about his life. After finishing high school, Sanjay had various jobs until he studied to become a realtor. He always saw himself as a high achiever. Sanjay enjoyed the challenge of “selling the most homes in a month„ and often appeared in the gold category of his company, competing with national realtors. He felt pride in his accomplishments and being acclaimed as “a rising star„ in the industry.

Thus as a realtor in a competitive market, Sanjay felt personal defeat at not being able to give 110% of himself all the time. He had worked hard to become “one of the best in the field„ and now became anxious when the overwhelming sensation of tiredness engulfed him. Waking up each morning was a strain. “I am usually outgoing, love life and can work till I drop,„ Sanjay said wearily. He spoke with pride about carrying his beeper 24 hours a day. But Sanjay also wondered, “Maybe I should give the beeper up and take a night off. What do you think, Doc?„ his eyes almost begging for permission.

When I asked if he had experienced anything like this before, Sanjay vaguely described an episode of “feeling down„ several years ago. But just as I began to inquire further about the “episode,„ Sanjay’s beeper sounded loudly. “Sorry Doc,„ he said quickly, “Gotta go. There’s an offer coming in on my million-dollar listing. Guess you can’t fix me today.„ Sanjay stood abruptly and as he exited the examining room, stated bluntly, “I’ll be back.„

It was several weeks before Sanjay returned and in interim I had been quietly concerned about the well-being of this normally gregarious young man. Something was wrong. When I entered the examination room my worst fears were realized. Sanjay had clearly lost more weight. He was unshaven and his eyes appeared bloodshot and puffy – almost as if he’d been crying. “I lost the million-dollar deal,„ he said mournfully, “and two other mega sales. What’s happening to me, Doc? My life is falling apart big time.„ He sunk further into the chair. After a brief moment, Sanjay suddenly straightened up and, looking me in the eye, demanded, “You gotta give me something to fix me up and fast.„ I suspected there would be no quick fix and began to try and comprehend what was happening to Sanjay.

An inquiry of his illness experience revealed a six month history of fatigue and loss of interest in activities Sanjay had enjoyed in the past. He liked to go south to play golf with his friends and did so once a year. Sanjay played the stock market and was always on the lookout for a good investment. He talked about losing close to 80,000 dollars once and said it was part of the game. When asked if he had any close friends, Sanjay said, “I have many friends that I play golf and tennis with,„ but then sadly replied, “I don’t have any close friends. Too busy.„ In addition, his girlfriend for the last two years had suddenly ended their relationship, claiming he loved his work more than her. Sanjay solemnly agreed, “I did love my work more than her. My work is my life.„ His eyes welled up with tears of shame.

Sanjay’s appetite was down. “Geez Doc, I had to get all my pants altered, ’cause I’ve lost so much weight,„ Sanjay explained. He had periods when feelings of sadness flooded him. Fantasies of death came to him frequently, but Sanjay denied any fixed thoughts or plans to commit suicide. He worried more and more about how his work was affected and the potential loss of more clients. His sales had plummeted. Sanjay had overextended himself on his mortgage and a lavish automobile to impress his clients. His debts were rapidly accumulating.

Sanjay’s despair permeated the room as his story unfolded. After some probing, Sanjay described a similar depressive episode following the breakup with his high school sweetheart when he was 22. His depression resolved after being treated with medication. He denied any other psychiatric illnesses such as mania or psychosis. Sanjay flatly denied alcohol or drug abuse. “Can’t do that kind of stuff and work 18 hours a day. No way!„ Sanjay was adamant in his response.

When asked about how he was feeling, Sanjay appeared guarded, as if not wanting to appear weak or inadequate. He struggled to preserve his persona of success. When asked to use more concrete words to describe his mood, Sanjay became tearful. These difficult moments were quickly coupled with tales of his many accomplishments. He clearly felt uncomfortable talking about the deeper issues affecting his life.

Over time, I learned that Sanjay was the eldest one of two siblings. His mother was alive and his father had died several years ago after a violent suicide. Sanjay had never forgiven his father and his anger ran deep. He did not spend much time with his brother and viewed him as a loser. “My brother has no ambition. You gotta have ambition to make it in this world,„ explained Sanjay – a man who was fighting desperately to maintain this long-held belief. His mother was needy and required much of Sanjay’s attention, both financially and for many daily activities. It was wearing him down.

Whether Sanjay’s current experience of depression was situational or hereditary appeared somewhat irrelevant. In order to help him, it was key to recognize this man’s unique illness experience. In brief, Sanjay was terrified that his depression was eclipsing his life. He fought desperately to deny that his depression was his father’s final legacy. His extremely successful career was in tatters. Sanjay often stated in desperation, “I am now a falling star.„ With many of his relationships on tenuous ground, he felt adrift as a worker, son and albeit “dumped„ lover.

In time Sanjay came to realize that there would be no “quick fix„ . Working up to 18 hours per day and being reluctant to acknowledge the need for rest, Sanjay could only take small steps towards healing. During many moments when painful issues were discussed, Sanjay attempted to divert the conversation to more neutral territory. Eventually, Sanjay came to accept his depression. He agreed to try a course of medication. With careful monitoring, his mood stabilized and Sanjay overcame this episode of depression.

My therapeutic energy was directed at helping Sanjay achieve the ability to become more self-aware and to learn to prioritize and value his own needs. He became more comfortable in recognizing and accepting his needs as valid and worthy of attention. Sanjay continues to this day to “give the beeper up … sometimes for a whole weekend!„ Perhaps as importantly, I came to value this patient’s unique illness experience.