Many 'problem' patients seen in primary care settings cannot be easily classified as 'masked depressives' or seekers of secondary gain. Rather, they fit into a third category - those with the 'tired person' syndrome. The essential feature of this syndrome is the decrease in self-esteem that follows the real or perceived loss of the ability to work productively. The decrease in self-esteem triggers anxiety, which may be so severe as to approach a panic state. The patient then becomes increasingly disabled or has increasing physical symptoms and enters a vicious cycle culminating in debility. Treatment is aimed at the physician's accepting and legitimizing the very real loss that the patient perceives in order to help him or her become comfortably dependent.
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