I've speculated elsewhere that dysthymia may sometimes reflect a manic with no power and no alliances. Rachel called several months ago for an appointment for her boyfriend, suspected of having ADHD. He refused to come. She called again two weeks later but to schedule an appointment for herself because she "was sick of going to support groups for 2 years and getting nowhere."
Rachel's family history had several domineering, critical, feuding characters, ones who expected the world to go their way. She had combative relationships with her sisters and brother who gave her orders and she tearfully complied. Her only ally was her mother who led a similar existence with Rachel's bossy father.
Her job was sorting office mail, sitting before a computer monitor for much of the day, and pushing the mouse and pretending to be busy. She described her boss as domineering, rude, and demeaning.
She had dated 3 abusive males, ones who hit or stalked her, who yelled, criticized, or failed to keep dates. Her current tyrant, Chuck, visited but only when his mother approved. His mother treated Chuck in a manner highly similar to the way Chuck treated Rachel.
I offered her some chats about alphas, about being number 1, and about sertraline's effects on self-esteem. She started on 25 mgs and got sick. We waited for her flu to pass and started her on 12.5 mgs and after a month, increased her to 12.5 mgs, bid.
Rachel started winning some things, initially with her guy (dropping him, a first for her), then her family: 1) accepting a holiday dinner from one sister who usually gave the orders and 2) refusing to collaborate in a family gift when the other sister failed to give her advance information about costs. Both events were also firsts. She no longer minded staying at home alone, preferring to sew rather than go to tap rooms or to shoot pool with male butts and dirty t-shirts.
Work was still unsatisfying even though she became more assertive, got her highest performance evaluation and the largest raise in the company. Her domineering boss was leaving; Rachel campaigned for a lateral reassignment but ignited when the slot went to an office socialite who, in turn, depended on Rachel daily for technical help. Rachel got a reassignment; she was told to work for the ditz. At this point, she moved her belongings out and called 6 temps agencies to "match my rate." She also commented that "I get so frustrated because I think I can win this one and it's not happening fast enough."
My phone rang a week later. A soft voice said, at 1:05 P.M., "I won, thanks for being there for me." She was given another assignment, at a higher rung than that occupied by the ditz.
My cautious interpretation is that sertraline kicked her into a mild hypomania. Some evolutionary talk about winning, about dominance, about alliances and hierarchies with respect to peers and to lovers helped target her energy. Meanwhile, Joe SixPack is back in her life but without sex. She thinks he's funny and, in order to be around her, now tolerates her talking to other guys. She comments, "I'm using him but I don't feel bad about it." She treats him just like his mother treats him and he meekly enjoys it.
Another interpretation is that sertraline made her less fearful of social rejection, her behavior variability increased, she was reinforced, and "winning" kicked her into the hypomania once she had some victories and found some alliances. I mention this possibility because some clients could respond poorly to medications due either to chemistry or because they still lose their social contests. Their Psych Adaptations continue to indicate a low position on the dominance scale, a position that discourages any of us.
She's consolidating her role at work, likes her new boss, and has signed up for a course. Rachel will likely do some dating, armed with information about Symons-Buss guidelines for mate selection. She's annoyed with Joe because she's smarter than he is and no longer wants him around. I think she's going to do fine. I have an eidetic recall of her phone message; I, too, feel like I won.
Of course I have some fears: a) I've only known her 6 months; it's far too early to be sure about the stability of her response. b) She may not be at asymptote in her trajectory. That is, she might eventually challenge Gore for office (maybe that's not so grandiose!). However, she spent only $300 on herself this past Christmas (an increase but money she can afford) and she seems to be making good decisions about the details of her life. She sleeps fine and her rate of speech is clearly WNL. She sometimes has a voice inside of her whispering that she's doing too well and getting "too big for her britches."
Things are usually not this easy and her example does not mean comparable results for the next client. There's substantial individual variability in the effects of sertraline or any other medication; however, I no longer believe the variance is entirely within chemistry's domain. They need some honest victories, not prattle about their self-esteem. I sometimes become annoyed with sertraline's being a prescription item; however, Rachel's sensitivity to it (25 mgs per day) reminds me that professional advice is a necessity and that such direction may not always be available from a family doc.