Lawyers, Stress, Depression and Burnout:

Work Addiction ? Addiction?

Ray Baker MD www.healthquest.ca rbaker@interchange.ubc.ca

Objectives
Stress, depression, compulsive

work, addiction Some neurobiology Common symptoms Getting help

Acute Stress as a Mood Elevating Experience

Norepinephrine surge, locus ceruleus Dopamine release from reward centre Cortisol release from adrenal cortex Adrenaline release from adrenal medulla

Neurobiology of Chronic Stress

Endorphin depletion (pain tolerance) Serotonin depletion (Sleep, mood) Dopamine depletion (hedonic tone)

Locus ceruleus overactivity (fight-flight)

Stress ACUTE
Elevated

CHRONIC
Decreased

endorphins, dopamine, adrenaline Cardiovascular Emotional Fight-flight

endorphins dopamine serotonin Sleep disturbance Cardiovascular Gastronitestinal Immunological Psychiatric

Stress: great imposter

Interpersonal problems at work

(supervisor) at home Substance use disorders Depression Unresolved emotional issues Medicalization of non-medical issue

Top 10 Sources of Workplace Stress

Feeling of not-contributing, having no influence Lack of 2-way communication Being unappreciated Inconsistent/illogical management Career and job ambiguity: whats going on? Unclear company direction and policies Mistrust: office politics, gossip Doubt: not sure of rules, who handles what Random interruptions Treadmill: too much to do, too little time

Wilson/Wilkerson Unheralded Business Crisis in Canada

Addictions: What Are they

A pathological relationship with

a mood altering activity with lifedamaging consequences Disease of brain with psychosocial factors in etiology and expression

Addiction: a disease of the brain

An inborn or acquired relative

underfunction of the circuitry of the mesolimbic system responsible for reward, pleasure and hedonic tone Resulting in the inability to comfort or soothe oneself, increased dysphoria, a deficit in hedonic tone

How Do Drugs Work?

Mesolimbic Dopamine system (craving, reward, pleasure) Locus Ceruleus (withdrawal: frustration, anxiety)

Dopamine Release
Nucleus Accumbens goes Squirt

Addictions, depression, chronic pain syndromes, chronic unrelieved stress share: lack of serotonin, endorphins, dopamine disturbance in brain centres responsible for sleep regulation, stress modulation, emotions, fight-flight, rewardreinforcement

The Invisible Disabilities: a common etiology

Compulsive Work
Behavioural syndrome manifesting as self-imposed demands, inability to regulate ones work habits, overindulgence in work to the exclusion of most other lifes activities
Robinson

Addiction Hierarchy

m s i l y n o o e t t g u r l h u G P o e g n c l Bi ng i A t a E

Com Prescription Drugs pul siv eE xer cise

SE X Ad UAL dic tion

r C / n on i o ti r e c i H d d A k c a

Work aholis m

ive uls mp Co nding Spe se nt Abu Solve

Symptoms of Work Addiction

Time pressure - hurry sickness Need for control - others wont get it right Perfectionism - no room for mistakes

self/others
Relationships strained - fail because of

work
Binge work pattern - self-inflicted deadlines Robinson 98

Symptoms of Work Addiction

Restless, irritable, discontented - if not

working Blackouts - D.W.W., even when hes home, hes not Impatience - might cause mistakes bc going off half-cocked Human Doing - only as good as my last achievement Neglect self-care - never enough time
Robinson 98

Burnout
Irritability Fatigue Sleep disturbance Poor concentration Memory loss Loss of motivation

Diagnosis of Presenting Clinical Picture of Depression Substance Dependence

Depressed mood/ irritability Apathy, loss of interest Weight loss/wt. gain Insomnia/hypersomnia Psychomotor agitation/retardation Fatigue Worthlessness/guilt Loss of ability to think/concentrate/decide Suicidal ideation

Addicted (dysfunctional) Family

Addict Somatization of feelings Chief Enabler Dont Trust Talk Feel

Hero Scapegoat Lost Mascot

Children from Addicted Family Systems: Core Issues

Control Trust Feelings: alexithymia Dependence Ungrieved losses Fear of abandonment All or nothing thinking High tolerance for inappropriate behaviour Over-responsibility for others Neglecting own needs Difficulty resolving conflict Problems maintaining intimacy

T. Cermak 93

Cognitive Distortions of the Workaholic Lawyer

Perfectionistic thinking: anything less

than perfect is unacceptable All-or-nothing thinking, overgeneralization, black and white thinking Magnification of the negative Blurred boundaries around work: roles spill over
Robinson 98

Cognitive Distortions of the Workaholic Lawyer

People-pleasing thinking Pessimistic thinking: world is hostile Helplessness thinking, victim thinking Serious thinking: no place or time for

humor Externalized thinking: if I get the outside stuff right, Ill feel OK
Robinson 98

The emotions of the Workaholic

Emptiness Low self-esteem Shame Anger Confusion Numbness

The problem is. Because of alexithymia they neither recognize nor express these feelings

IAMNOWHERE

Baseline Assessment
Biomedical
Medical Hx & Px Lab and Ixs Pharmanet Pain Hx Addiction Hx Psychiatric Hx Psychosocial Hx Mental Status Collateral Interviews l Self-Administered a i c Questionnaires o

Ps yc hia tric

s o h c y s P

Recovery Checklist
Coping skills Accountability to others Responsibility for self Education about illness and recovery Social support network Spiritual health
Adapted from Baker, 2002

CARESS

Take responsibility for change:

Be proactive Stop rationalizing, blaming,

intellectualizing, denying, being a victim You are responsible for your own recovery

Recovery Suggestions
Learn to identify emotions, ways to

deal with them Work on cognitive distortions Stress management: quit a committee, phantom clients, throwaway journals Practice saying NO nicely

Changing
Share plans with friend, family

member Join a group (Al-Anon, ACOA, CODA, church/temple/synagogue) Join a lawyers-in-recovery group Get a sponsor/mentor

Changing
Learn prayer and meditation Set a weekly date with your honey Do something fun, funny, silly Take up that hobby/skill/craft you

always secretly wanted to do (but never had time)

Bibliotherapy for Stressed Out Lawyers (and their families)

Chained to your desk - Robinson 1998, New York Univ. Press Feeling Good - Burns, 1992, Avon Your money or Your Life - Dominquez & Robin, 1992, Penguin 7 Habits of Highly Effective People - Covey, 1989, Simon & Schuster Margins - Swenson, 1992, Navpress

STUMP THE DOC

Questions?

Summary
Compulsive work as an addictive disorder endemic

amongst lawyers Stress is a symptom, not a disease Similar neurobiology in chronic stress, depression, addiction Family system perpetuation Effective therapy includes cognitive changes, balance, practice

Ray Baker MD FCPF FASAM Medical Director HealthQuest 604-808-4619 rbaker@interchange.ubc.ca www.healthquest.com