Identify Depression Among ‘Perfect’ Colleagues
BY CYNTHIA BIRON LEISECA, RDH, EMT, MA
The dental hygiene job market is saturated in some areas and soon to be saturated in more areas. There are fewer full-time positions, and the part-time positions usually have no health insurance benefits. For many, this means paying for their own health insurance, and what is affordable has a high deductible and probably little or no prescription coverage.
Dental hygienists who are not practicing are working odd jobs in unrelated fields or are simply unemployed. Some have given up on the profession entirely, and are becoming educated in other professions. The financial strain and frustration can lead to anxiety and situational depression, even in those people who have never before experienced depression.
This article is dedicated to a dental hygienist who practiced for over 25 years, and due to the recent scarcity of jobs, could find only a part-time position. She had no benefits and only catastrophic medical insurance because that’s all she could afford. She suffered from depression, and the only treatment that seemed to help was a “specialty drug” (medical insurance term for brand name top tier) she could not afford, and her insurance would not pay for it. She described her severe anxiety and emotional pain as “unbearable.” Sadly, she took her own life.
In order to protect her identity, details about her are not included in this article. The personality trait that was a contributing factor to her severe anxiety and depression was called elevated perfectionism. Another factor that contributed to her depression was stress.
The objectives of this article are to promote an awareness of these factors and their association with general anxiety disorder (GAD) and major depressive disorder (MDD); discuss how the combination of anxiety and depression increases the chances of suicidal ideation; and to promote awareness and suicide prevention.
Striving for excellence is a healthy goal, but when people have unrealistic expectations of themselves and others, they create unhappiness in themselves and their relationships. Continuously functioning in this self-deprecating manner often leads to severe anxiety and depression. With perfectionism of this magnitude, there is often procrastination due to fear of failure, or even difficulty with decision making, as the choice may result in failure.1
Adjustment to life changes that do not align with lofty pursuits can result in extreme anxiety and profound sadness. For the elevated perfectionist, coping with day-to-day life is a challenge, but when a traumatic event occurs, coping can become nonexistent.1
Research has shown that elevated perfectionism not only makes certain individuals vulnerable to depression; it also makes them vulnerable to a variety of anxiety disorders, eating disorders, and obsessive-compulsive disorders. Many psychotherapists now use assessment scales to diagnose and treat perfectionism to reduce anxiety, depression, and associated disorders.3
Here is a link to the free electronic Multidimensional Perfectionism Scale: http://www.bbc.co.uk/science/humanbody/mind/surveys/perfectionism/
HEALTH-CARE PROVIDERS MUST STRIVE FOR PERFECTION
The accuracy and attention to detail required of dental hygienists make perfectionists ideal candidates for the profession.4 Ask any dental hygiene instructor about their daily dealings with students, and they’ll tell you that many insist on getting an “A” in every class or on every clinical exam. Perhaps we’ve recruited many perfectionists into the profession. You may remember being in dental hygiene school and hearing your instructors say, “Dental hygiene is not an exact science. Therefore, we call it ‘practice’ because we never get it perfect!”
Unfortunately, that expression falls on deaf ears of people with elevated perfectionism. She or he is the one who becomes anxious at patient checkout for fear the dentist will discover some minor omission in the dental hygiene patient exam. Then one day that hygienist may find something the dentist missed in his or her patient exam, and hopefully the hygienist will learn that “Perfection is unattainable.”
FROM STRESS TO ANXIETY AND DEPRESSION
Fear of failure, or just plain trying to survive, when there is insufficient income for living expenses is a daunting situation. The uncertainty of survival and lack of adequate medical care can keep someone in fight or flight mode. This is anxiety on a continuous level, the type that causes insomnia and physical symptoms common to general anxiety disorder (GAD).
Anxiety disorders include:
- Panic attacks — occur due to a sense of doom and lack of control.
- Obsessive compulsive disorders — obsessive thoughts or repeated behaviors of checking, counting, or hoarding, often paired with eating disorders, over-exercising, and a variety of routines that relieve anxiety.
- Posttraumatic stress disorder — anxiety and depression that occur within three months of a traumatic incident. Flashbacks replay the trauma as if it were occurring again.5
The following link includes a free anxiety assessment scale: Taylor Manifest Anxiety Scale (http://personality-testing.info/tests/TMA.php).
Major Depressive Disorder (MDD)
Major depressive disorder includes a variety of depressions that may or may not include all of the symptoms in the syndrome of generalized depression:
- Inability to function
- Inability to concentrate
- Lack of energy
- Feeling immobilized
- Sleeping too much
- Insomnia or sleep disturbance
- Loss of interest in daily activities
- Loss of interest in sex
- Overeating or lack of appetite
- Nervousness and agitation
- Persistent sadness, crying
- Anxiety and hopelessness
- Guilt and worthlessness
- Thoughts of death or suicide
Physical symptoms such as headaches, pain, and gastrointestinal disturbances that become chronic and resist treatment are often associated with major depression.6
Comorbid Anxiety and Depression
Current reviews of the literature show evidence of high risk of suicide in people with a combination of anxiety and depression.7 The largest percentage of people presenting with this combination are middle-aged women.8 There is an overlap in the symptoms of the two disorders, making it difficult to discern whether the anxiety is a symptom of the depression, or a separate disease entity that will not be relieved by antidepressants.
Comorbid anxiety and depression often require a combination of antidepressants such as selective serotonin reuptake inhibitors (SSRIs), or selective serotonin-norepinephrine inhibitors (SNRIs) and antianxiety drugs such as benzodiazepines. Examples of common antidepressants are fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), and desvenlafaxine (Pristiq). Common antianxiety drugs are alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin). If the patient’s condition still resists treatment, antidepressant augmentation with aripiprazole (Abilify) has shown complete remission in some patients with comorbid anxiety and depression, and pramipexole (Mirapex, Mirapexin, Sifrol) has shown complete remission in some patients with depression not combined with anxiety.9,10,11,12
Patients may not be diagnosed with comorbid anxiety and depression, but may be treated on symptoms. Most antidepressants do not relieve every symptom on the MDD list.13 The physician may treat various symptoms with additional drugs, e.g., benzodiazepines for anxiety, sedative-hypnotics for insomnia, and proton pump inhibitors for acid reflux. A patient may be on an array of medications for various symptoms and still not be in complete remission from depression. Could the profile of comorbid anxiety and depression be masked by the regimen? Does failure to diagnose comorbid anxiety and depression present a greater risk for suicide ideation? More research is needed to answer these questions.
Comorbid anxiety and depression require a multimodal therapy carefully planned by the physician who has conducted a comprehensive evaluation of the patient using all assessment scales and diagnostic methods to arrive at the accurate diagnosis. Psychotherapy as well as pharmacotherapy must be included in the treatment plan.13
Not everyone exhibits classic signs of depression or suicidal ideation. If they did, more lives would be spared. But if someone you know is depressed, it’s a good idea to ask that person if he or she is having thoughts of suicide. Suicide websites and training kits contain information stating that asking does not provoke someone who is not suicidal into becoming suicidal, and asking may be the key to getting someone to accept help.
NOW, you the reader — Do you have thoughts of suicide? If you answered yes, call the National Suicide Prevention Lifeline 800-273-TALK (8255).
For a complete guide to suicide awareness, go to www.suicide.org/index.html.
Local hotlines are also helpful for those with suicide ideation. Here is the National Suicide Prevention hotline link for finding a center categorized by country or state — http://www.suicide.org/suicide-hotlines.html.
Our fallen colleague was an elevated perfectionist, but out of the darkness of her quest for perfection, there was a crack of bright light filled with her love for friends and animals. She was an excellent caregiver to others. One could say she truly served the greater good, except she lacked self-love. She was perfect in many of her accomplishments, but not in her pursuit of happiness.
She is greatly missed and loved by many.
From the lyrics of the song “Anthem” by Leonard Cohen:
Ring the bells that still can ring
Forget your perfect offering
There is a crack in everything
That’s how the light gets in.14RDH
Top 10 Signs Your a Perfectionist
- You cannot stop thinking about a mistake you made.
- You are intensely competitive and can’t stand doing worse than others.
- You either want to do something “just right” or not at all.
- You demand perfection from others.
- You will not ask for help if asking can be perceived as a flaw or weakness.
- You will persist at a task long after other people have quit.
- You are a fault-finder who must correct other people when they are wrong.
- You are highly aware of other people’s demands and expectations.
- You are very self-conscious about making mistakes in front of other people.
- You noticed the error in the title of this list3
Source: Gordon Flett, PhD
1. Flett GL, Stainton M, Hewitt PL, Sherry SB, Lay C. (in press) Procrastination automatic thoughts as a personality construct: An analysis of the Procrastinatory Cognitions Inventory. Journal of Rational-Emotive and Cognitive-Behavior Therapy.
2. Flett G. “York researcher finds that perfectionism can lead to imperfect health” York’s Daily Bulletin, York University, Toronto, Canada, June 2004.
3. Egan SJ, Wade TD, Shafran R. “Perfectionism as a transdiagnostic process: a clinical review. Clin Psychol Rev. 2011 Mar; 31(2):203-12. Epub 2010 May 5. Source: School of Psychology and Speech Pathology Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia. firstname.lastname@example.org.
4. Henning K, Ey S, Shaw D. “Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students” Medical Education article first published online 4 Jan 2002 DOI: 10.1046/j.1365-2923.1998.00234.x.
5. Stein MB. Attending to anxiety disorders in primary care. J Clin Psychiatry 2003;64 (suppl 15):35-39.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR) Washington DC, American Psychiatric Publishing, Inc. 2000.
7. Cyranowski JM, Schott LL, Kravitz HM, et al. Depress Anxiety. 2012 Aug 28. doi: 10.1002/da.21990. Psychosocial features associated with lifetime comorbidity of major depression and anxiety disorders among a community sample of midlife women: The Swan Mental Health Study. Source: Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
8. Joffe H, Chang Y, Dhaliwal S, et al. Arch Gen Psychiatry. 2012 May;69(5):484-92. Lifetime history of depression and anxiety disorders as a predictor of quality of life in midlife women in the absence of current illness episodes. Source: Department of Psychiatry, Center for Women’s Mental Health, Massachusetts General Hospital, Harvard Medical School, Simches Research Bldg, 185 Cambridge St, Ste 2000, Boston, MA 02114, USA.
9. Hori H, Kunugi H. The efficacy of pramipexole, a dopamine receptor agonist, as an adjunctive treatment in treatment-resistant depression: an open-label trial. ScientificWorldJournal. 2012;2012:372474. Epub 2012 Aug 1.
10. Dold M, Aigner M, Lanzenberger R, Kasper S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials. Int J Neuropsychopharmacol. 2012 Aug 29:1-18.
11. Yoshimura R, Kishi T, Hori H, Ikenouchi-Sugita A, Katsuki A, Umene-Nakano W, Iwata N, Nakamura J. Comparison of the efficacy between paroxetine and sertraline augmented with aripiprazole in patients with refractory major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2012 Jul 17.
12. Maher AR, Theodore G. Summary of the comparative effectiveness review on off-label use of atypical antipsychotics. J Manag Care Pharm. 2012 Jun;18(5 Suppl B):1-20.
13. Dunlop BW, Davis PG. Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review. Prim Care Companion J Clin Psychiatry. 2008;10(3):222-8.
14. Pychyl TA. Words of Healing for Perfectionists: Forget Your Perfect Offering. Psychology Today 2010 Nov 19.
CYNTHIA BIRON LEISECA is president of DH Methods of Education, Inc., Home of Boot Camp for Dental Hygiene Educators. She is also the producer of two DVDs, “Precision in Periodontal Instrumentation,” and “A Focus on Fulcrums.” Cynthia is the distributor of “The Sharpening Horse Kit,” www.DHmethEd.com.