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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
I need to know what I am suffering from. I was abused for 9 yrs by two different men who were related to me and didn’t know about the other. My children were molested by their birth father who is now incarcerated for it. I can’t hold a job, I take antidepressants, I am always tired, I have two failed marriages. I can’t help but worry about the safety of my children. I worry about myself and the anxiety that I feel all the time. Please help me help myself and start to heal. My family doesn’t understand me and just think I keep making stupid selfish mistakes. I try to be a good person and I know that I am a good Mom, that is my strongest attribute. I really look forward to your reply. I can’t do this by myself and I need to start healing. Cindy F.

Answer:

Thank you for your courage and honesty in sharing the painful experiences that have led to your suffering. I will comment on what you have described and offer you some information that I hope will be helpful, although I will not offer a specific diagnosis for you. Let me clarify for you and other readers why I will not offer a specific diagnosis to you, or to others in my responses to their questions: I think that an accurate diagnosis requires either an extended interview, preferably face-to-face, or the use of proven diagnostic tests and questionnaires administered by people trained in their use. In my experience treating abuse survivors, I find that observing a person’s non-verbal communications and how they interact during the interview is critical to both making an accurate diagnosis and understanding the person’s individual versions of the human dilemmas everyone must face.

One of the key points that I want to address here is that childhood sexual abuse predisposes abuse survivors to increased risks of developing, during their lifetimes, all mood disorders, all anxiety disorders, and several substance abuse disorders. In particular, childhood sexual abuse results, in female survivors, in about twice the rates of depression, panic disorder, and generalized anxiety disorder, and about six times the rate of subsequent post traumatic stress disorder, compared to women who were not abused as children. The evidence also comfirms that repeated rapes cause more severe consequences than molestation without rape, and that rape by relatives, step-relatives, and acquaintances had more severe consequences than rape by strangers, presumably because rape by a relative, step-relative, or acquaintance also undermines the development of trust in relationships.

Being abused as a child increases the lifetime prevalence of depression in women from about 19% to about 39%, which is a significant increase in a person’s vulnerability to become depressed. I do not know whether your fatigue is a symptom of depression or some other disorder, but depression can certainly cause fatigue and impaired concentration to the degree that it will interfere with a person’s ability to work. Childhood sexual abuse also increase the lifetime prevalence of generalized anxiety disorder in women, and this disorder also can cause fatigue and impaired concentration.

Thus, although I cannot say what you are suffering from beyond severe childhood sexual abuse and its after-effects, you need to know that the abuse you suffered makes you significantly more vulnerable to depression and anxiety disorders. Because antidepressant medications are used to treat both depression and generalized anxiety disorder, as well as panic disorder and post traumatic stress disorder, the fact that you have been given antidepressants also does not clarify your diagnosis. What is clear is that you are still struggling and experiencing severe symptoms.

Reviewing fully whether medications could provide you more benefit than they do at present would require knowing more about the full list of your symptoms, your current medication and its dosage. Let me say, however, that for antidepressants to be of benefit they must be at an adequated dosage for at least several weeks. In the treatment of depression, many of the commonly prescribed newer antidepressants called Selective Serotonin Reuptake Inhibitors (SSRI’s), such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox) seem to help about 60% of the people who try them, in terms of reducing depression symptoms of sadness, impaired concentration, inability to enjoy things, sleep disturbance, appetite disturbance, hopelessness, helplessness, and preoccupation with death. Interestingly, in the studies of these drugs, about 30-35% of people respond to placebo, so skeptics will argue that these antidepressants “really” only work 25-30% of the time. Working with patients to help them get some benefit from medications requires trying also other new antidepressants that help both depression and anxiety, such as venlafaxine (Effexor) and mirtazepine (Remeron), which may have higher rates of response in people with severe depression, or higher rates of helping people get back to an asymptomatic state. Some people who do not respond to drugs that work primarily on serotonin benefit from Wellbutrin, which works on the brain chemicals dopamine and norepinephrine. Still other patients require combinations of more than one antidepressant, or combinations of antidepressants with other drugs called augmenting agents, which can increase the effect of the antidepressants. Drugs used to augment antidepressant effect include lithium, forms of thyroid hormone, stimulants, buspirone, atypical antipsychotic drugs, estrogen (in menopausal women), and a variety of other drugs. Still other patients respond best to older antidepressants (tricyclic antidepressants or monoamine oxidase inhibitors). Because this rapidly becomes complex if a person does not have a good response to an antidepressant, treatment of so-called “treatment resistant” depressions should be under the supervision of a psychiatrist.

Antidepressants are helpful with a number of depression and anxiety symptoms, but they are no substitute for learning better skills for solving problems and tolerating stress and distress. Thus, it is important to consider whether your abuse history has resulted in a very negative self image and difficulties in relationships. From your brief statement, it is possible that difficulties in relationships have affected your marriages, and difficulties in relationships with co-workers may have contributed to your inability to hold a job. It is not uncommon for women who were repeatedly sexually abused as children to have later problems with relationships for several reasons. The experience of repeated abuse as a child includes being treated like an object or thing, not a person, and also severely violates the child’s developing boundaries of body and self. These experiences undermine self esteem (being treated like an object or thing) and can take away the feeling of having any rights in a relationship. At the same time, the child has a tremendous need to be comforted. There are many variations on how these factors interact, but they can result in later difficulties in negotiating boundaries and give-and-take in relationships. These difficulties can result in poor partner choices (feeling you must give in to the other, or trying to “fix” the other) and impaired ability to communicate out of fear of retaliation or not believing you have a right to a “say” about the relationship. These relationship problems can also affect relationships in the workplace, because abuse leads to an understandable distrust of people who have power over you, and rapid escalation of anxiety if you think someone is upset at you.

Healing from the abuse you have suffered and its after-effects will take a lot of courage and the assistance of a therapist who can help you learn more effective ways to solve problems, tolerate the distress that you feel, and cope with stressful situations. Being a “good Mom” is a positive attribute that includes many skills (anticipation, patience, planning, ability to comfort, ability to love) you may be able to learn to use to help yourself in other situations. For example, could you find a way to use some of the “good Mom” skills in the workplace, to better keep track of priorities and avoid being distracted by things that are not as important, or could you use the advice of the “good Mom” to get along better with co-workers? Similarly, it may be possible to use some of the “good Mom” comforting skills of redirecting a child’s attention and changing their focus to something that is positive to comfort yourself when you are anxious. These examples and many others would be worth exploring in therapy, to learn to better use the skills you already have.

You should not have to settle for the present “status quo” in your life. I believe that with help you can feel better, make better choices in relationships, and regain the ability to make it in the workplace. Good luck!

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Do you have a question relating to a mental health issue? Do you have a question relating to abuse or multiplicity? Do you have a question about medication? Once a month a new question will be answered and posted on this column. A special thanks to Dr. Yank for donating his time to answer the questions.

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Disclaimer: The information contained here is not intended nor implied to be a substitute for professional advice relative to your specific medical or mental health condition or question. ALWAYS seek the advice of your physician or other health provider for any questions you may have regarding your medical or mental health condition. Information provided here DOES NOT constitute a doctor-patient relationship between you and the column author.

© Copyright 2003-2005. All rights reserved. Contact: ShrinkTime Last edited: 06/28/03.