On Chronic Depression and Myth

One of the things that occurs a lot in the mentally ill, especially, thought not exclusively, in the mood disordered, is that a mood episode is treated with medication, and the cycling of moods is stopped, yet the person remains miserable, suicidal, even, and suffers a lingering handicap. In the world of psychiatry, this is the stage in which the doctor says, “There are personality factors at work,” which is code for, “This person is nuts and I have no fucking idea what to do.” The patient is then referred for long-term therapy, which rarely helps.

I know because I experienced this recently.  My acute episode ended – the heavy cardinal signs of depression and mania were gone, yet I remained miserable. The same pattern is readily apparent on many of the blogs on my sidebar (Exact Science, Coloured Mind, PWH). The thing that is last to fade, it seems, is the temptation of suicide.

The doctors never seem to understand this. “We fixed the chemical symptoms, why are you still fucked up? Why can’t you just go back to doing whatever it is that you were doing before you flipped out?”

My partner has been traveling to the Far East a lot lately, and has become interested in Buddhism. I got him a copy of Siddhartha, which I only read in high school and remember not liking that much. I thumbed through some of the coffee table books on Buddhism that he brought back, and one detail of the life of the Buddha struck me: that the hardest part of his journey was not leaving home to seek out new knowledge; it was not the reaching Nirvana, complete insight into the order of the universe, and not spreading his teachings to his disciples.

The hardest part was, after reaching Nirvana, reintegrating into the stream of life, caring about other living beings. He was presented the choice, upon seeing Nirvana, to either remain there for eternity, or to stay and spread his teaching on earth. The Brahma itself (God) had to come and convince him to continue on the path.

This struck me as the crux of the matter, as the reason I continued to be suicidal well after the depression had lifted. It is not the descent into symbolic death that is difficult, nor the ascent out of the underworld. Rather, the most painful and difficult part of the narrative journey is the return to the flow of everyday life after the threshold experience.

Myth studies and Jungian psychology are the types that most move me, interpretation through metaphor, myth, and poetry, seeing each individual as a Hero. It gives strength to people to realize that what they are facing is not mundane, not a result of skewed object relations or personality flaws, or dysfunctional families, but rather a part of what humans have faced since the dawn of time, and helps awaken them to the fact that they will have to call on their own mythic strength to prevail.

Mental illness in its life-threatening forms – suicidality, depression, mania, psychosis – is a liminal experience, one in which, unrequested, people are forced to face the boundaries of normal human experience. Symbolically, suicidal depression is a descent into the underworld, in which all of the trivia of normal life is stripped away.

During my last illness, I considered whether I would live or die, nearly each moment of each day. I made preparations for my death, and saw the world differently, knowing that I might not reside in it much longer. Trivia fell away; the world seemed quieter. Preoccupied with thoughts of high cliffs and nooses, the overwhelming unbearableness of life, other things seemed to fade.

When the episode was treated, under control even, I stayed on the edge of suicidal thoughts. They didn’t go away, even though the misery that had led to them did. And the shrinks never understand why.

But myth does. A classic stage in the monomyth is “the return threshold.” Dying is one threshold, and every hero has to face a symbolic death and descent. The hero is then saved and brought back to life with new understanding, either by his own prescience or a force from without. Though it seems like that should be a central plot moment, it is very short, albeit dramatic.

The true struggle comes after. It is not easy, once one has seen the void and been swallowed by it, to return. Everyday life seems trivial, bland, meaningless. When one has faced the pit, how is one supposed to return to preparing dinner, to cuddling in bed, to laughing? To getting up and going to work, to petting the cat, to doing the million small and seemingly meaningless things that make up life?

The road back is long and not terribly exciting. It is nothing like the symbolic death or the symbolic rebirth. It is arduous, in many ways more painful, and its outcome less certain than the simple death or rebirth. It is natural, easy even, to be faced with this journey and to wish to return to the underworld, where things appeared more certain, if darker, more essential, more stripped down to meaning-and-unmeaning. It may be a horrible place, but it least it is a final one, unlike the slow journey up the mountain to a destination – life – that one hardly remembers, that does not promise to be less frightening than the life that led one to the threshold of death in the first place.

And so we stay suicidal long after the depression has faded. We frustrate our doctors by continuing to talk about death and pain and our wish to be freed long after we have stopped waking up at 3 AM and being restless and wrestling with God.

This part of the journey is much longer and more arduous than crawling out of the grave. We, and our doctors, deceive ourselves by thinking that the gateway out of hell is the end of the struggle, the hardest part, when in fact it is the easiest and shortest part. The only way back, as the Buddha knew, is to immerse oneself in the river of life, and forget the rest, let the questions of life and death fade away, at least until they are back for good.

Yet another Shrink’s Line of the Day

Yesterday I decide that I feel bad about quitting the shrink all abruptly and in a rage. That I didn’t want to end like that, if just out of politeness. I really wanted to call and leave a message apologizing, and wishing him a happy holiday. I said that I was going to be the bigger man here, be the one to let my ego come down off the high horse first. Because, true, he shouldn’t have gotten sucked into the whole yelling and power struggle, but I participated too. I felt bad. I decided that, for the sake of my own dignity, that no matter what he said or did, that I wasn’t going to get into another knock-down-drag-out. I was going to be mature and in control, like my first therapist taught me.

Unfortunately, he answered the phone, despite my best attempts at timing to get voicemail.

“Hi, this is Sara. I just wanted to say that I’m sorry for losing my temper, and I didn’t want to end on that note. So…I’m sorry for anything I said or did that was inappropriate – “

At this point he cut me off and said ominously, “Well, I’m sorry too that you’ve chosen to be like this and end things this way.”

My blood pressure immediately rose and all of a sudden I was almost ready for a fight again. I mean, even if I and my personality flaws are 90% at fault, there was at least some unprofessionalism on his part.

I took a deep, deep breath, and said, “Let’s not go into this again. I really just wanted to apologize for yelling, and wish you a happy holiday.”

He could hardly control his anger and snapped back at me, “Happy Holiday!” and hung up.

* * *

I promise, soon to get to the post on recurrent/long-standing mental illness and what the Buddha has to teach us. You know, something that might be of use to someone.

But since this is my journal, I can use it to think in writing. This incident raised so many questions for me.

Am I so crazy that I am imagining the anger/stubbornness/power struggles coming from him? Is that projection or some other psychological bullshit I am doing because I’m really as fucked up as he says?

Is there a legitimate therapeutic reason ever for being obscure or concealing the therapeutic mechanism? Is it ever right to say to a patient: I don’t think we can discuss your condition, how we are going to go about treating it? Is it ever ok to refuse to discuss the kind of therapy you do? Is it ok to say, “You just have to trust me” – and not at a given moment, but as a guiding policy? Especially when the patient is going through considerable distress as a result of the treatment? I mean, if I give a patient steroids for a serious disease, and they complain of side effects, I feel obligated to explain why I think that the benefit of the drug outweighs the side effects, what it is doing to them. Is psychiatry really so different?

Is it ever ok to refuse a patient their record, especially while refusing to give a reason? (Thanks to Jay for some perspective on this one.)

Is honesty on the part of the therapist always an important part of therapy? I mean, to me, it seems like that’s exactly what I’m paying for – someone else’s honest and trained opinion. But maybe I am understanding wrong – maybe I am supposed to just let him do whatever it is he is doing?

Is there a rule that therapists should never apologize? I mean, this whole thing would have been avoided (in retrospect), if he could have just said something like, “I’m sorry you feel hurt.” I wouldn’t even expect an apology for the content of what he said or anything – just some sort of acknowledgment that I was upset. Is there a rule in therapy that it undermines authority/transference/focus on the patient to apologize? I mean, my natural instinct in a similar situation with a patient – no matter how nuts they are – is always to say something like, “I’m sorry you’re so upset.” And when I’ve lost my temper or gotten annoyed with a patient, I always apologize – but maybe out of my own sense of guilt and remorse rather than concern for them?

The reaction I got was, “Why are you upset? There’s no reason for this to be upsetting to you. Why should this (being called both narcissistic and borderline in two sentences, one after the other) be a cause for concern?” This seemed so invalidating after I had said it was worrying to me to think that that might be the problem and asked what the treatment would be, what to do about it. I think I would have been ok if he had said something like, “Yeah, it’s hard to hear.” But a total failure to understand why I was upset – and then to tell me to “not be upset” was incredibly invalidating. It’s ok to tell a patient, I think, that their feelings are colored by their past experience or knowledge, that maybe they are taking offense or being hurt excessively – that, after all, might be part of what brings them to therapy. But to flat-out say that someone has “no right/reason to be upset” seems sort of anti-therapeutic to me – I mean, isn’t part of the idea of therapy recognizing and acknowledging feelings (even if one wishes to change them)?

Is any problem always the patient’s pathology?

And most importantly: Why do I keep seeking validation and understanding in a place where I so obviously am not going to get it? Why am I seemingly endlessly attracted to going back to someone who repeatedly hurts me, hoping for a different outcome the next time? What buttons is he pushing in me, or what screwed up need do I have that I keep running right back in for another round?

* * *

I’d like anyone, but especially therapists working in various schools, to respond to any question that catches your eye.

Anyway, if anything, that phone conversation should have cemented my position. From time to time, the situation catches me and I feel kind of bad. Not abandoned or whatever – I mean, I know if I’d just give in and stroke his ego a little, I’d be welcomed back and “forgiven.” It’s not like he’s kicking me out. I am, as he said, “choosing to end this way.” I think the choice is being made rationally, for sound reasons. I mean, I have to trust my own intuition and logic – it’s the only source I have. The real question is why I’ve been ignoring the signs for so long.

But still, I think it’s ok to feel a little sad. After all, even if he never did offer me much in the way of comfort, even if I’ve gone downhill under his care and felt worse for it…it still is, as Tony White would put it, an attachment, even if not the healthiest one in the world. I did like the guy as a person, if not as a therapist. And we’ve known each other a long time. And he did try to help me. Maybe I’m just unhelpable or unreasonable. So I think it’s ok to feel kind of bad, knowing that in the long run I’ll be better off. And I think I really do need to examine why, after so long and so much of my gut and brain telling me otherwise, I kept being pulled back.

Is a big part of it hope and regression? That he promised that, as deeply flawed as I am, that there was hope of a “cure” if I’d just keep coming and talking to him? (A lot of my frustration that brought up the conflict was that this therapy seemed to be going nowhere – that it was just like chitchat…with no change in anything.)

* * *

About the comment on the last post about the colors and design of the blog being dark and depressing, well, true. But I rarely see them anyway – I just see the compose window and get the comments by email. I almost never look at the finished blog, so I forget the dark colors and photograph. I feel sort of like I do want to leave it, just because this is the place I can let the darkness out, my place to be the goth teenager I secretly always wanted to be. My other blog, the one about my real life and not my mental patient life looks nothing like this at all. Though it is a good point. I do take a lot of these kind of suggestions in real life – exposing myself to sun, to sunny people, exercising, keeping the Dali posters off my walls in favor of something warmer – definitely a good point.

Enough

I finally wrote what I thought was a reasonable letter to the shrink, since he never seemed to hear what I said…about how I can’t live in the dark about what is wrong with me or how to fix it, that I was deeply hurt and concerned about the borderline thing, etc. I hoped that we could work something out.

But today, we met. True, I knew I was in a bad mood going in. But on the other hand, he claimed I had nothing to be upset about, accused me of splitting between him and the GP (I knew from the minute they started “coordinating care” that sooner or later I would be accused of this and tried to be so careful not to say anything negative about either of them), said he couldn’t understand why I would be upset, that he was so sure I’m just trying to push away. It felt like always – I say and mean one thing, and he sees it through his filter. Refused to tell me why he thought I was borderline (and then later, when I was angry, said, “See – that’s classic borderline. You’re upset, so you’re trying to make me upset.”), what he thought my problems were, or how we planned to work on them together. (”Part of your problem is needing to just trust me.”) In short, it was the classic psychoanalytic bullshit – the shrink is always right and the patient is always crazy.

To top it off, I requested my medical records and was refused.

The whole scene was incredibly upsetting – to be so totally invalidated. But I had spelled out that I just am not interested in paternalistic care, where my problems and how they will be treated are hidden from me. That if this is the care he gives, I’m not interested…not interested in his diagnosis and not interested in buying a treatment that can’t even be explained to me. That I need collaboration, I want to change, but need the direction on how.

No good. “I can’t understand why you are so upset.”

I left, finally. It was sad, and it was scary. I’m now without a safety net and badly medicated, though I did meet a hippie clinical psychologist I sort of liked (woman).

I drove home and cried a little, felt like throwing up. It was so humiliating, invalidating. But – I also drew my lines in the sand. I can’t say I was totally calm; in fact, I was angry. But I spent months examining myself closely to see if what he said could be true, if there was justification in my anger. I decided there was, and that I needed some acknowledgment of that. I really didn’t expect not to get it at all. But I didn’t.

And that’s just not ok with me. No matter how sick I am, how bad I feel, how much I need help…I don’t need it that bad, bad enough to believe that I am so crazy that I am totally out of touch with reality.

So, through my tears on the way home, I reminded myself that I can save myself, that maybe only I can save myself, that I’ve done it before, and that I can do it again. That I’m somehow going to be ok. That I am a decent person, despite how broken I may or may not be.

I might go re-read The Color Purple. I think that is the message that I need to hear – remember Celie? Raped as a child, beaten, cast-away, unloved by anyone, half-literate…she knew somehow that she was a human being of intrinsic worth, one of God’s creations, one of the things that is included in the phrase “God love everything you love–and a mess of stuff you don’t.” That even if she was poor and ugly and a woman…the universe had created her with love. That God loved her, even if nothing and no one else did. That she existed, just as lovely as a wildflower.

I may suck at being happy. At being patient. At controlling my temper. I even may suck at loving the people I love. But I can do some things – I can comfort people and I, on a good day, can write words that mean something, that capture something real that happens to people. I can forgive. On a good day, I can be grateful, and on a great day I can pray, or at least I used to be able to. I can be part of the universe sometimes, and of the human race when I am not sick. I can overcome my fears. I can see the color purple. I can survive the dark night. I am a living, breathing part of the universe, and sometimes, that is enough.

I just need to remember that, to remind myself that during the moments when it seems like everyone is trying to tell me to the contrary.

• * *

Note to self for next post – remember to post the thoughts about chronic depression, the idea of depression as an addiction, why some people can’t seem to give it up, and the Buddha.

Still alive, beyond comfort of man or spirit

Thank you to everyone who left me comments or emails or anything. All much appreciated. Sorry I haven’t written back.

I am, indeed, still alive. In fact, the longer days are making some things easier. But I don’t feel better, am not getting better, am just biding time, this version of bardo, laced with apathy and terror. I started Wellbutrin intermittently again. The shrink has pretty much given up on me – tells me to just prescribe for myself and take whatever I want, because that’s what I’m going to do anyway. Not true, but it is very difficult to argue with a shrink.

Except when it isn’t, like the last time I was there, and ended up yelling at him for an hour straight. I feel bad, couldn’t have been very pleasant, but still, throwing psychodynamic interpretation shit at someone in my condition…well, seems like that’s asking for yelling. “Why are you so angry?”

Well, I guess I’m still angry about the borderline comment.

I wish my shrink weren’t so complicit with my self-punishment.

* * *

I woke up after a weekend of physical pain; unfortunately my GP is out until next week. I called the shrink  but then hung up on the answering machine.

Maybe, since I obviously am not going to work today, I should try writing something. I’ve thought of what I need to write, but haven’t been able to care enough, to drag up the energy, to do it. Which, in and of itself, is probably loaded with unconscious meaning that I also can’t quite seem to bring myself to care about.

* * *
Also, I have about 6 more weeks before finishing a certain stage in my training, after which I will have vacation. I have decided to try my hardest to avoid suicide until after that point, so that they can’t say that it was the pressure of the job or that I couldn’t take it or anything like that. Because, God knows, it isn’t that. It is me, all me.

Thanks for continuing to read

When a poster on a blog like this stops posting, usually one of two things has happened: either they’ve hit a significant remission and have somewhat lost interest in all things mental-health-related, or they have taken ill in a way that keeps them from writing, usually either a severe depression, hospitalization, apathy, or the black hole, in which there is nothing to say. And, I guess, sometimes they die.

Usually they come back to writing sooner or later, good for the second group, not so good for the first. As far as I know, there are no reports from anyone from the third group hasn’t returning to blogging.

I, unfortunately, belong to the second group, have had a tremendous crash-and-burn. I’m not sure why I’m writing now, and I apologize for the quality; it is written through a haze of legal psychiatric drugs that makes it difficult to stay conscious, let alone coherent or eloquent.

I just wanted to say that the other night, I went outside in a miserable state, where there was no peace to be found – not in drugs, not in music or poetry or adventure novels, not in trashy magazines, and not in sleep, which, anymore, is haunted by nightmares. I sat under the stars and smoked a cigarette. The moon was half full; soon, it will be full, and then, after that, the next time it will be full, it will be Passover.

And I thought: I really would have liked to see another Passover, that holiday I love so much, when I really do feel the holiness in the air, the meanings, the social and the mystical. The elision of time, when it is that same night as it was so long ago, in which we start out bound and by the end, hopefully, will be freed. And the merging of the physical and spiritual – the tastes of the bitter and the sweet.

I always loved Passover, the one time when my skepticism and atheism faded into a sentimental belief in magic. I would have liked to see this one. One more. One more full Nisan moon, one more race to bed before midnight. One more hope for Eliyahu to come and save us from this sorry world. To save me, on the wings of the Shechinah.

But I just know that it isn’t going to happen. That I won’t have one more Spring. I think it’s too late now. I’m too far lost, beyond a way back, beyond where I can even want one.

And finally, after all this time of numbness and dead souls, I sobbed. I could imagine something, anything, that I did want to see, would have liked to see, to be there for. Knowing that, I could sob. Not for missing the rest of my life and not for the gruesomeness of death or hopelessness or suffering, but for the simple, plain, yet cosmically significant idea that  I really would have liked to make it to Passover. One more time, I would have liked to feel that. And I most likely won’t.

Just that. I am beyond missing future adventures, past beauty, beloved books and books to come, future love, past love, present people and the spectacular world around me. I’m far beyond mourning any of that. Those things all have lost the hold they once had on me. I don’t love the things that I used to love anymore.

But I would have liked to see the Seder table, one more time, the poetry and ritual of it, the full moon, the sense of blurring of boundaries between present and past, the individual and the symbol, the present reality and the hope for a better day. I would have liked…to just be there this Passover. And oddly enough, when nothing else could, that was enough to make me cry. I was sort of surprised I still could.

I was so proud of her

I saw a patient the other night with a ton of psych meds in the ER for something unrelated. She was neither young nor old.

(Incidentally – definition of “a ton of psych meds” = more psych meds than me.)

And she was totally normal. If I hadn’t read the list of meds, I never would have known by how she looked, how she presented her pain, how she talked or reacted in conversation, how she was dressed, how she handled the interactions with everyone. No anger, no speech impairment, not slow through a drug haze, not hostile, not overly passive. Nice. Normal. I never would have known.

I always worry that psych patients are always so obvious to doctors after a few minutes, even if they function well or are only mildly ill, that I must be too, that it must be obvious to anyone who treats me. But she wasn’t. She gave me hope. And I was so proud of her.

But of course, I couldn’t say anything.

I did not see this coming

The latest in my escapades – no essays or deep thoughts or medical stuff here, just my personal update.

The anxious racing episode, naturally, crashed into a depression that hit hard and fast. Or maybe not so fast, but I didn’t feel it until it was out of control.

I think I am more and more becoming a burden. I haven’t had many normal conversations with any of my friends lately, it all revolves around my condition. I feel like a burden, and though they’d never say it, we are all doctors in training and under so much pressure that we are very limited in how much we can give to each other. It’s sad, but it is how things are. I also just sort of want everyone to go away and leave me alone, so they won’t see all this, and I can return to my life after I’m better without having done too much damage.

It is very hard for me to accept help, and I just want my partner and everyone else, well, I want them to help me and care for me, but I don’t want them to see me like this.

Since the depression got worse and worse, I went to my GP, who is very sympathetic to these kinds of problems, having had a son commit suicide, so he treats people with mental illness like people, not diseases. Actually, I didn’t want to go, but the psychiatrist wouldn’t treat me further unless I did because he wanted to be sure I wasn’t physically ill. I had attributed a lot of the physical symptoms to medication side effects and the depression effects.

I went to the GP and told him to just sign off, send some basic blood tests etc, and to give the shrink a green light to continue treating me. I told him I was not alright, but I couldn’t tell him about the suicidal thoughts. He knows about the depression, not sure how much about the whole bipolar story. He said I looked bad, and asked if I had ever been this bad before – I had, twice.

He started to do a brief physical exam, like, put a stethoscope on me while I was just sitting in the chair, but once he heard my heart, he told me to get up on the table, and did a full exam. He started yelling at me (well, not “yelling at me” but he got surprised and upset) that I was in horrible physical condition – apparently malnourished and dehydrated almost to the point of shock – racing pulse, minimal blood pressure, gray, the whole textbook version.

I had been feeling dizzy and horrible, but thought it was some central effect of some drug so I didn’t really pay attention. I was surprised because I’d been working as usual. I knew I hadn’t been eating because the depression sort of took away my appetite and one of the medications or another was making me either unable to eat or throw up often. But I didn’t think it was so much. I had been trying to eat a lot of calories in whatever I did eat – adding butter and honey and always juice with lots of sugar. It’s my “depression diet” because I know that sometimes I lose a lot of weight fast when I get like this, so I try to pack as many calories as possible into what I do eat. I guess I didn’t start early enough this time.

He called the psychiatrist from the office right then and there. This felt really bad, like I was this wayward child who needed to be taken care of – all of the sudden I was the ward of these two doctors, playing ping-pong about what to “do with me.” I only heard the GP’s side of the conversation, but he said at the end, “Look, I really think we’re getting to the limits of what can be treated outpatient.” No idea if he was referring to mental or physical state.

He sort of vaguely asked me about suicide, asked if I could or would talk to the psychiatrist about that. I said, “Probably not.” But it got the idea in my mind that maybe I should say something.

I walked out of his office and I remember sitting down at a bus stop just to rest and catch my breath for a few minutes before going to the car. It was freezing. But I was so tired, two hours passed while I sat there, watching people and buses come and go, waiting for the energy to get up and leave.

I did the blood test and the H. pylori test, and then went to meet a close friend (also a doctor), and told him how scary facing hospitalization was (for either the medical or mental stuff, I wasn’t even sure which anymore). He told me, “You look terrible. I’m a friend, not your doctor, so I’m not going to tell you what to do, but maybe you should go to the fucking hospital.”

The next day, I went to the shrink and confessed the suicide stuff, even though it was hard. It seemed like the responsible thing to do. I think I was actually looking a little less depressed by then because going to his office makes me so nervous that it gives me a little energy. He basically didn’t react. Nothing. I asked what to do. Nothing. I felt ridiculous, like some drama queen. He didn’t ask any of the suicide questions that even I know to ask (Do you have a method? Plans? What do you think will happen if you do? What stops you?).

Finally I asked, “Do you think this is some sort of manipulative thing, just to get attention, or something?”

His answer was, “It would only be manipulative if you were doing it consciously.” (I guess that qualifies as a Shrink’s Line of the Day.)

Then he said he wanted to give me Zyprexa “as it recently got approval as a mood stabilizer.” He sounded like a fucking Lilly commercial. I absolutely refused. Then he got angry at me. “You just can’t work with you! You say you want help, but then you refuse the help anyone offers!”

I asked him if he would take a pill of that. He said that that wasn’t a fair question. I said I ask myself that every time I prescribe something for someone (true). At the same time, he told me to stop the antidepressant that he started a week ago – just as I had started to get over the nausea from it, way before anyone has any idea as to if it will work or not.

As usual, I left there feeling worse than when I went in. Maybe he was right, who knows? Maybe not reacting will discourage me from threatening suicide again. He’s a nice guy. He did call today to suggest maybe somehow finding some derm specialist who can solve the side effect problem of the old drug (or possibly that was the subtext for calling to make sure that he didn’t kill me after all), that he had searched around the area and there was some guy a few towns away who specializes in drug reactions in the skin.

I said I was sorry for being such a horrible patient.

The next morning I went back to the GP for the test results and because he had said he wanted to see me again the next day. To make sure I was still alive, I guess. I told him what happened. I asked him if he thought I was being unreasonable to refuse the Zyprexa. He did the screening for psychosis (of which I have never had any symptoms). Then he said that Zyprexa seemed a little excessive (”an atomic bomb drug”), but that he didn’t know why a psychiatrist would suggest that or what psychiatrists consider.

You see so many psych patients who come in with lists of maybe 5 or 7 psych meds, from all different categories, and they look horrible, like zombies, and you have to think that whatever their illness, it can’t be as bad as that, and that there is no rhyme or reason to treatment, they just keep throwing more drugs at them, one on top of the other. That poor girl I wrote about was on something like two antidepressants, and old and a new antipsychotic, a benzo, valproate, and a sleep aid. No wonder she could hardly speak.

I felt like I was slowly turning into that. I was on a lot of peripheral shit at the time. The psychiatrists, including mine, mean well, but it’s such a strange field, no one knows anything, and they just keep throwing more and more drugs on people until they are just shells. I feel bad, so he gives me a med, and I still feel bad, so he gives me another – it’s all well-intentioned, trying to relieve my misery. But I got the feeling that that was what was happening to me – I was being made sicker.

So a few days before, I had also stopped taking all kinds of benzos and sedatives and phenergan and shit that the shrink had put me on, and only left the antidepressants, so I think I had a little more affect when I walked in to the GP, looked a little better, even if I didn’t feel better. I wasn’t like the walking dead.

The clinic was very busy so I didn’t want to take up a lot of his time. But it took me a minute or two while I asked him to wait so I could get up the courage to tell him that I had been checking my life insurances, making sure everything was in order. I didn’t tell him the rest. But he took me seriously, told me to go home, go to sleep, and come back in the morning again.

I was supposed to go with my partner to his parents’ for a few days, but when he got home from work it was late, and I had showered for hours and gotten minimally dressed to leave. But I was so weak and lying in bed, thirsty, sort of hungry. I couldn’t move (as had happened most of the week, lying down with no willpower to physically move my muscles). I just couldn’t get up and pack a bag and get in the car. The wind was howling outside, and the bed was warm and soft, and I was so tired, and thought of the uncomfortable bed at his parents’, and their yapping dog and the noise there…when I finally felt sleepy and warm and safe at home. I just told him to leave me a glass of water and go without me.

The prospect of a silent weekend alone was so tempting. I slept. Woke at 3 AM again, but not as restless as usual. Just relaxed in bed and listened to the wind until I fell asleep again at dawn. I got up in the morning at 9. I wanted to go back to sleep, but I figured that since the GP had been so decent, the least I could do was show up. (Friday is a half day for him at that clinic.) So I went in there, and sat down to wait, and started to feel faint so I went and bought some juice. I didn’t want to pass out and make a scene, or worse, be sent to the emergency room of my own hospital.

I told him that I thought all the drugs had really knocked me down and out, taken away the last bit of energy I had to cope with anything, including the depression, that they were slowly working their way out of my system. I kept taking the antidepressants but stopped all the heavy shit. And suddenly I could move again.

He asked me about my plans for the weekend, and I told him honestly…that I just really wanted to be alone at home. He said I deserved some rest. I was glad he didn’t try to insist I be around someone, that my partner be home or that I go with him. I thanked him and apologized for making such a mess and scaring him, and he hugged me and told me to come back sometime next week.

Then I went across the street and bought a newspaper and some bread and light food and went home and, for once, instead of dropping it all on the floor to deal with later, put the things away. I took out the garbage and minimally cleaned the floor. I drank and ate a little bit, then went back to sleep until the afternoon. Then I moved to the sofa and watched bad 80s movies. The quiet day, no one at home but me, the big bed all to myself…the sleep, for God’s sake. It was all so sweet.

I hate to say I’m getting better because every time I say that something horrible happens, but I wish this quiet could never end. I am just going to try to enjoy the rest of the evening, watch bad sitcoms. Try to sleep off the rest of these drugs. Not to worry about all the things that got me to this point or when I will go down again. Not to fantasize about suicide. To eat long enough before taking the meds that I will gain some calories from it. To drink. To try to orally fix the electrolyte mess that came back in the bloodwork.

* * *

I’m not sure if I learned anything from all of this or what the point of writing it down was. No profound insights. I didn’t suddenly find purpose in life, and I don’t know how long I will remain ok. I have to go back to the race shortly and I am terrified and still exhausted. It’s not a big happy ending. I don’t “know that I have more of a safety net than I thought” or that “people really care about me” (they do, but I already knew that and it doesn’t really matter when I’m in that place). And it seems like I have made a real mess of my body that will need some straightening out. I guess that there are probably some readers who read for the personal stuff, the same kind of stories as they go through. So that is why I am trying to be honest here for you.

I may go back and remove or edit this. It feels very raw and exposed. But for now, this is my story.

Here we go again

New appointment.

New level of truth telling by me.

New drug.

One (low) dose of fluvoxamine down.

Hours later: paralytic sleep, the kind where you know you are asleep but can’t move and can’t wake up.

Woken up by nausea. At the same time, phone call from work.

Vomit for 15 minutes, not very successfully. Do not feel better. (It’s central nausea, of course not.) Wonder vaguely how the eating disordered do it.

God, will this ever stop? I just don’t know how much longer I can do it.

Crying at the shrink

I did cry at the shrink’s the other day, and that was strange, because I’m usually so hard and in control. But I was so strung out by anxiety and three days of no sleep from the bupropion that it took me a few minutes to even calm down enough to talk (this kind of hysterical shit is very unlike me). In an ominous tone, from him, “You NEED a mood stabilizer.”

He wanted to send me home then and there with an injection of phenergan so that I would sleep a few hours before being on call; I declined. Not a fan of the sleep aids. Last time I took zolpidem, I was fine and awake in the morning, but almost got in a car accident, which had never happened to me before. (And while on call, I saw yet another acute dystonic reaction, so there about the phenergan.)

But at least the massive anxiety from this drug, as well as the calming of the affective storm, for once made me feel both stable enough and uninhibited enough to actually talk to the guy about something that happened in my life that was very meaningful to me, that happened a long time ago, advice that someone gave me that let me move on from grief and heal tremendously from a big wound.

Without going into a long and sort of irrelevant story, the gist of it was that an older woman knew me well, and gave me permission to grieve about something when I was a teenager, to acknowledge a severe loss and hurt. She was one of my mother’s friends, artist-spiritual type, and gave me a concrete ritual to do to give myself permission to grieve, and maybe open doors to a grief I didn’t fully realize I had, or was entitled to. I remember thinking the idea was silly at first, but I went home and tried it (starting by looking at old pictures and just thinking about the people in them), and it unleashed a tremendous flood of tears.

Let me state that the “ritual” she recommended wasn’t an exorcism or supposed to work on some bullshit supernatural plane; I think it was pretty sound psychological advice, if phrased in terms of spirituality. It allowed me to realize a loss I hadn’t acknowledged because it came at such a horrible time in my life anyway, and to free me from the past by letting me discover various feelings of anger, injustice, and ultimately, mourning. It was not “out there” by any means. It wasn’t like she told me to draw a crop circle so aliens could come heal me. It was just something to formally mark a loss, which gave me the opening to feeling it.

And sometimes even today, years later, maybe once every couple of years, I revisit those photos and what she told me, and I cry again, hard. But it is different now, in the way that grief changes. I look at the pictures, and it’s not this raw gaping wound, it’s just sort of a nostalgia, a sense of being sorry that things didn’t go the way that they would have in a perfect world. A love for times and people past, with all the imperfections.

She gave me the gift of being free from something that could have torn me down, destroyed any potential I had to be other than numb or in shock for the rest of my life. She gave me the gift of healing.

When I think about it…no, that’s not right, when I feel it, really let myself remember and feel, I can’t help but cry. And that’s what happened at the shrink. It wasn’t like I was sobbing hysterically and out of control. It’s just that the story opens in me some very bittersweet emotions – of the loss, of the gratitude of being able to let go, of the magic of healing, and of a million other things, too.

I noticed also that for the first time with the shrink, I was talking in terms of how I really think, how I used to be, because it took me back to so long ago, to a time when I was in my core state, when I was really ok. I spoke in terms of ritual and feelings and symbols, which is a reflection of how I see the world, how I grew up, in a world of artists.

I think I concluded the story by saying something like, “That’s what I think I need now…a priestess. An older woman who knows what happens to women, how they get so hard and cold, the way I’ve gotten to be. I wasn’t like this then. I was warm, and loved everyone, and was so idealistic and compassionate and forgiving. I wasn’t ice like I am now. I need someone who understands how that happens to women’s spirits, how they get lost in the woods and meet so many monsters that they start building up armor, and how to set me free again.”

I’ve said to the shrink many times, “We don’t speak the same language.” I don’t think he ever quite got what I meant. It became clear to me. I have always spoken to him in medical language, the language I’ve learned, the language of pathology and death. But that isn’t my real language. I think that I had forgotten my real language a bit, and speaking in it, of ritual, magic, symbols and signs.

After I said all this, the contempt was all over his face. Then he said, “Sure, she just gave you a magic solution.” Obviously he also wanted to say that he thought that she had probably done me psychological harm. But it wasn’t a “magical solution” and it didn’t solve anything overnight.

He thinks that at the core, there is something wrong with me that it will take expert reparenting or whatever (naturally, by my submission to his worldview and acceptance of it, by letting him be daddy). I think that at the core, I am actually healthy, and just need to be freed from a lot of things that happened to me along the way. I need to find my way again.

And that is what became so clear to me sitting in front of him. For once, I didn’t give a shit that he was so dismissive, so utterly un-understanding, because I know what is wrong now. I need my language back, my self back. I need to get rid of the chains that medicine has wrapped around my soul and return to the path. I don’t need to fix what is broken; I need to find what is whole.

Suddenly I could see a chain of events, a period of time, in which I became hard, and cold, and unrelenting, began to speak in a foreign and cruel tongue.

I saw that he didn’t get it. So I started to say something like, I just think I need to see a woman…because I just hate men too much. It was my way of letting him off the hook. It isn’t his fault he’s a man. It’s easier and kinder to say that than to say that it is his fault that he hasn’t seen me, not really, not once, in all these years. That managed to set off a huge argument over whether it is normal or not to hate men. Which was missing the point, but that’s ok. I finally see it: he’s just not going to get the point.

But I do. And that’s a start.

* * *

When I asked her what I/we could/should do, she took up her walking stick and walked expressively and purposefully across the room. Dipping a bit from side to side.

She said: Live by the Word and keep walking.

- Alice Walker

The Rest of My Life

I’ve been writing kind of heavy stuff lately, and I think it has skewed what this started out to be, which was a chronicle of how people who are crazy live in the normal world, how we are mostly invisible to everyone. Lately, you’d think that all I ever am is crazy.

Which is understandable. This last year my mental health has been perhaps the worst in my life (or second worst). And the Wellbutrin is making me anxious which makes me write. (Student loan panic set in tonight, which is always a symptom.) And I have been thinking a lot about my mental health, which I don’t usually do when I am well. It is the main thing on my mind, sad to say. I’m afraid many more important things have been forgotten in the mess, like the people I love.

So I thought I’d put in some balance of the perspective. Despite having an awful morning due to various symptoms, I pulled it together and worked a night shift last night that was perfectly fine. While working, or writing, or engaged in conversation, I am able to selectively ignore a lot of symptoms, just feel them less. I think it’s like sometimes when you have a flu or something, you really do feel better when you are up and moving around rather than lying around thinking about what hurts.

I thought I’d make a scattery list of things that happen in my average life, which are far underrepresented here.

1. I usually meet friends a few times a day. Having stayed more or less in the same medical system where I went to medical school, there is no shortage of acquantances and a few very close friends around all the time. Sometimes when it is very hard for me to go to work, knowing that they are there helps a lot.

My best friend is a friend from medical school who also stayed on at the hospital. We can often catch a few minutes to chat outside the building while he smokes. He’s tried SO hard to quit, and even tried taking the bupropion for that, but guess what – it gave him panic attacks and made him paranoid! He can’t believe I’m sticking with it. It does give me panic attacks (witness yesterday morning) but I find them infinitely preferable to depression.

He has a new baby and is utterly in love with her and shows me pictures on his cell phone. I haven’t been good about going to see her; haven’t given her the baby gift (partly because I can never find anything quite special enough). I am happy that he is so happy.

I’m afraid I haven’t been a very good friend lately, since all I can think or worry about is how crazy I am…and no one wants to hear about someone’s mental health, shrink problems, med problems etc forever. He has been very good about always coming to talk if I need to, though. And sometimes we just talk about normal stuff, laugh at ridiculous senior doctors, the fucked-up system we are in, and so on. If another friend joins us, it’s better sometimes because I can’t talk about crazy and it just rolls over into small talk.

2. My partner and I spend domestic time together, which is very quiet and pleasant. I tend to be something of a homebody, and he humors me. We spend a lot of nights watching DVDs of comedies (I can’t stand to watch anything sad or serious on TV. If I wanted reality, I could go to work.) We laugh a lot. We curl up and read. We are both nerds. Sometimes we talk about physics or other science topics one of us has read about. We had this weird discussion of Descartes and Maxwell after something he read a few days ago, lasted late into the night. We got into this discussion about whether mathematics is something that exists intrinsically, or something we made up.

3. I love my house. It isn’t anything fancy, and is really a rented apartment, and nothing in it is expensive, but it has my things in it, and I have set it up to be a shelter for me, a quiet place with warm colors. I think that sometimes this isn’t so good because I don’t invite people over much. But sometimes I curl up on the sofa with a book or a blanket and feel overwhelmingly content. I am surprised at how nice this feels. I guess when you grow up in a stormy, violent place, the thought of home is a strange pleasure. I’m surprised to have found one. I am overwhelmingly grateful to live so comfortably, to be safe and warm and sheltered.

Of course, because I am crazy, this can lead to worry that it will all be taken away from me somehow. But I know I can survive that too. I have been in very bad places, poor places, alone in life, and that taught me that really a human being needs very little to survive. You don’t need a bed, or a roof, or a change of clothes, or internet. You need food, and that is about it. I can be thankful for what I have now while still knowing that I could survive without it, have survived in scarcity, in violence, not knowing where I would lay my head. I love what I have and would hate to give it up, but I wouldn’t die from that.

4. Though it stretches my budget immensely, is my single biggest expense after rent, I can pay for my mental health care, for what I need to keep a job, to avoid the “bottom of the barrel” public mental health system. This makes me luckier than people thrown at the mercy of the public system. Unfortunately, this is also self-perpetuating: I am able to work because I can afford at least partial medical treatment for my condition, which is not covered by insurance. People who can’t will never get the quality of care they need to get better.

5. When I work in the emergency room, I sometimes pass through the pediatric ER just to see what is going on. Pediatricians are the nicest people in the world and I’m always able to say hi and smile. There are sometimes funny kids in there too, and they make me smile too, even though kids aren’t my thing. The best break room in the whole ER complex is in the pediatric ER and when I eat I go in there and make tea (they have the water cooler) and see nurses and staff I haven’t seen since I stopped working there. The hardest work I did was there, but also the nicest environment. And everyone there always says hello to me and smiles.

For someone as shy and introverted as I am, it is wonderful to know I have a place like that, a place where “everybody knows my name.” And not in the way the internal med docs or ER docs do – as the freak one who always was in a rage and never got along (last time I worked with them I was in a very bad state). The pediatricians know I didn’t like pediatrics and didn’t like working there much, but they like me anyway. For someone like me, it is very nice to have people who are happy to see me. Especially after this bad year, when I ruined so many working relationships.

6. Since I’ve lived in the same place since med school, the local businesses know me. I can walk in to grab quick take-out food, and see familiar faces. The nearest neighborhood with amenities is of a lower middle class to working poor area, and people haven’t gotten into the ideas of having cars for everything, so they walk and use local business. There is a sense of community that people don’t have in wealthier areas. And they know me by sight when I walk in, too.

7. I always can call someone on the phone from my cave. (Not that I usually would, but that’s a different issue altogether.) Somehow, I don’t know how it happened, I ended up having friends. I’m afraid I haven’t been as good a friend as I should always, but I am fortunate to say that I’ve never felt truly lonely. Alone, certainly, but I have received far more love in this life than I ever deserved. We don’t get together that often, but we chat, we see each other at work. Sometimes I feel guilty that I’m sick, sometimes I can’t love them back as well as I’d like. But I know that for a lot of the mentally ill, they drift out of society into increasing isolation and that loneliness is a huge factor in suicide. I think that I may have spread a lot of pain amongst the people who have loved me, but I never meant it, and I was never really left alone.

Last time I was really depressed, it was last spring. One friend, I didn’t tell him details at the time, just that I was not feeling well. Despite having a house full of kids and being a busy doctor too, he called me at least every other day to see if I was ok, and let me vent without asking for details. Since at the time I was pretty much confined to the sofa, those phone calls were incredibly meaningful to me.

He always invited me to a weekend dinner with his family and I always declined, but once when I started to feel a little better, I went. Of course, I was nearly non-reactive, and when I did speak it was a huge faux-pas with his mother-in-law. But no one ever made me feel strange about anything. Even though it wasn’t a particularly memorable evening, it marked a lot of coming back to life for me. I felt horrible, was minimally groomed, but I was out of the house and back among the living.

This incredibly kind gesture, those daily calls, which must have been miserable, for no reason, was something that stays with me until today.

And I know that if I ever really flip out and end up in a hospital, I wouldn’t languish there at the mercy of some fucked up psychiatrists. A few close friends with connections in the med world would come to my aid and beat them down from over-drugging me. I’d die of embarrassment and probably try to keep them from even knowing, but I wouldn’t be alone at the mercy of the system.

8. I read a lot, though since these episodes have been so out of control, it has been a lot harder to focus. But this month I finished two books. Not my normal rate, but better than before. It used to be a big part of my day, especially when I was a kid. It is probably some escapist coping mechanism that isn’t so healthy, but I enjoy it. In my bedroom, on my side of the bed, I have a big pile of books and note papers. My partner calls it “my world.” Whatever I’m reading, which is usually one or two new books, and a lot of old favorites for when the mood strikes, are there. There are lots of books on the edges of the sofas too, and all over the house.

9. Food: not much of a cook, when I do cook, it is healthy fare, or something that goes together quickly. A grain and a legume. I don’t cook with much that “you can’t tell where it came from.”  Often, as I said, it is takeout from a local place. There is only one that is close by. Too much fried shit, but it is quick and good. On call, I eat at one of the many coffee shops in the adjacent shopping center – salad or pasta, usually. Usually I go with whoever I happen to be working with that day, but not always.

I hate all this Atkins shit. I love carbs – pasta and potatoes and bananas and grains. I’d rather give up fat than my carbs.

I can’t cook that well, but I’m a really good baker. I make all kinds of wonderful cookies and cakes. Nothing flashy or pretty, but the kind of thing you just can’t stop eating, out of simple ingredients. I haven’t in a while because of being busy and also not wanting to eat a whole batch, but it’s my secret skill.

10. I have a ton of makeup. Nothing expensive, but I used to be a sort of punk ass kid and I still have a lot of stuff left over from high school. I don’t get to wear it anymore much, but when I’m off work, I do. I wear my long hippie dresses, my slightly gothic looking black velvet stuff, my Wuthering Heights collar jacket. I guess some of it could pass at the hospital, especially if I wore just one piece, mixed with mostly business looks. But I hate having the clothes I like “contaminated” by work. The problem is that I don’t go out a lot to other places where I can wear them.

One of the books I’m reading is a pop culture version of a book on Schema Therapy – basically cognitive therapy that people with deep problems have them from deep assumptions rooted in childhood about themselves and the world. The pop culture book tells you all these signs of which false beliefs you might have. One of them was “Dressing more conservatively than you would like.” I think that was supposed to point at an “outsider” belief: that you feel like you don’t fit it, are somehow different. This can be a “defective” belief; you feel that you are somehow basically flawed, and damn well better hide it.

And damn if I don’t feel that way in medicine a lot. Most docs come from a very different background than I do, with very different social rules. Very upper middle class and conformist. I always feel like I’m trying to ape a look that they have…and I hate myself for sticking out because I don’t ever quite like them, and I also hate myself for trying so hard.

I remember in med school, there was this one girl from a very affluent city. She was a bitch, shallow, mean, basically obnoxious. Spoiled brat, rich parents who divorced and just threw money at her. She sort of pretended to be my friend, but always with an air of, I don’t know, like she would be my social guide. I didn’t really like her, but she terrified me because she was so mean. She always criticized my makeup, my clothes, whatever. One day I was wearing fishnet stockings (probably with Doc Martens but I don’t remember; certainly not with fuck-me-pumps or anything) and she came up and rolled her eyes so hard, and said to me with a snort, “God, don’t ever wear those again.”

This girl was a caricature; she was ridiculous, and no one else ever took her seriously. But she was from “the right side of the tracks” and this rich town and seemed to know the rules that I didn’t. And every time I let her do that to me. In high school, I would have gotten into a fistfight with someone like that. And I would have taken her down.

And I never wore fishnets to med school again.

Somehow I think that story is symbolic of what med school and the doctor world has sucked out of me.

And once again, I digress into psychological topics.

But I guess I can tie that in to this post, because it is something that, apart from my crazy, is prominent in my inner world lately. I am slowly coming to the realization of just how much I have let medical school and being a doctor kill my soul. How different I am from when I started. And I think back to all the times I should have said, “No. This far, and no further.” Years ago, in maybe the second year of medical school, with the animal experiments. And a million other examples. Right now, I am working very hard to recover my soul, my woman’s wild soul, from inside the soulless monstrosity that is modern medicine.

A funny thing happened lately…I have been so depressed off and on that I finally let my meticulous makeup go and have been going to work without it, with just a little bit. And looking generally disheveled, hair uncombed, because I just can’t deal with it. (I have finally grown a half-meter of hair, which I love, but it’s just so hard to wash it all after 30 hours on my feet, and I know I’ll probably cut it, but still, I worked so hard to grow it out.)

And I’m not sure, maybe I’m just imagining it, but it seems like I’m getting less disbelief when I walk in and say I’m a doctor. Most of the girl doctors look like that.

I’m not sure what bothers me more, that I am letting myself go like that, or that no one can imagine a doctor who doesn’t look like C. Everett Koop (and even he had some goofy facial hair going on).

I also hate how many comments I’ve gotten about how I look so much more “professional” without the makeup. (One from that attending who tore me down.) Even the shrink said I was “prettier bare,” that I didn’t need to “hide behind all that.” (Was that a borderline inappropriate comment? I’m never sure.)

If I want to wear it, none of their fucking business. Women have played with masks and veils since the beginning of time. Why can’t I?

At home, though, I immediately change into sweats, warm, cozy things that I’ve had forever.

But – I love playing with makeup and looking slightly like I stepped out of the wrong time century. Even if now I just do it in the bathroom alone before I get into the shower.

11. Other things in my life every day: sometimes I promise myself a good cup of coffee on the way into the hospital and that is the thought that keeps me going as I get out of bed, get dressed in the cold bathroom, sitting on the bath mat as I brush teeth because I’m too tired and down to get up. I feel like a little kid, bribed with candy. But sometimes, that’s a big part of my day.

12. I worry about money a lot. Not paying the rent and bills and all that; and I never run up the credit card. I’ve always managed to live within my means, which at times were ridiculously meager…except for one thing: my massive student loan debt. I have no idea how I will ever pay this off. Or even make payments that make a dent in it. Once the deferments and all that are up, the payment alone will not leave me enough for rent. Hoping for a miracle. I guess I’m just like everybody else in this. I obsessively read the “get out of debt” stories, and “America’s Cheapest Family” and all that. But the thing is, there’s not much more I can cut. I don’t buy clothes, I don’t go out to bars or to eat much (the takeaway is cheaper than buying enough basic stuff to cook for me), really the only thing I do buy is books, and even most of them are used. I would try to cut back, but part of the problem with libraries is that what I read is always too obscure, or in the wrong language. No one ever thinks, when they move to another country, how much they will want to read in their native language – and how expensive it might be to find imported books.

My credit card statement is funny – it breaks the charges down by categories. All I ever have are groceries, gas, insurance payments, pharmacies, and books. Every time I open it in front of someone, they just laugh.

I guess I could go carless. I don’t really need one. Local mom and pop grocers deliver, and, while it does cost money, it’s less than a car. But after my contract is up, I don’t know where I’ll be working, and then I might need one, so I don’t want to get rid of one just yet.

13. I always keep a bus pass in my wallet, and sometimes I take the bus to the hospital. The walk to the stop is nice, and it is quicker than having to park there. The hospital is toward the end of the line, so the bus by then is usually full and I stand up. It is nice not to drive and worry about when my car is going to die.

14. I take something to write with everywhere. Often I get writing ideas that fly through my head, and if I don’t get them down immediately, they’ll go away, be forgotten. My life is full of the backs of receipts, of ticket stubs, of gum wrappers, on which are written things like the perfect end to my novel. My close friends laugh at me because they can see when I zone out into an idea, and sometimes laugh or am otherwise altered by the words that run through my head, how my attention is both in the conversation and far gone. People like that girl above think I’m weird. But the people who love me think it is just another part of me, a quirk.

* * *

I think I wanted this post to be even more about minutiae, things not concerned with my mind or medicine. I’ll try to let some more ideas come to me as I go about my day over the next few days. Maybe if I ride a bus.

* * *

Next time: remind me tomorrow to write about how I cried at the shrink’s a few days ago. I didn’t think I had tears left, I thought I was too cold. I think he kind of had contempt for what I cried over…but that’s ok, it reminded me of something important, pointed the way to me to the things I need to be able to cry about again, the things that I can’t, ever since becoming a doctor.

Self-harm from the doctor’s point of view

Edit added at the bottom.

First of all, this is going to be detailed, and if it might upset you, please do not read.

I’m going to leave the details of the story pretty generic to be sure to protect patient identity, though it was a pretty typical self-harm story, I guess, the kind that is seen in emergency rooms ’round the world every shift.

As I said in the last post, the subject of scars has been going around the internet, how people feel about them, having them for the rest of their lives, after they have stopped. So that was very much on my mind when she walked in – that I wanted to leave her the minimal scars possible, so that when she gets older and better, she won’t be disfigured.

I have no idea what her actual psych problem was. She was quiet and pleasant, hardly spoke, probably some depressive affect in there. She was brought in by her mother, technically being a minor. She looked much younger than her age. She had, by the record, been in a few weeks before for the same thing.

My only hint as to what I would find was the fact that her arm was heavily bandaged from the hand all the way up to almost the shoulder. I think (though I’m not basing this on anything) that more common is maybe 5-10 cuts on a forearm.

I took her into the stitching room and set her on the table, ready to unpeel the million layers some nurse somewhere had wrapped on. I asked her her name. She made one request before I started, was very childlike in speech and mien: “I don’t want my mom to see it.” The mother was there, knew full well what had happened. I thought it was actually a sign of maturity, wanting to deal with her problem herself, to not upset her mother. I was fine with that, I mean, if she’s old enough to request, and to be in this kind of trouble, then she’s old enough to deserve some privacy. But then some ER manage walked through and heard and flipped out that she is a minor, the mother has to be in there. I got kind of pissed off at that. My patient, my call. I now wonder if I was mad for the sake of her autonomy, or for having my authority undermined.

So I sat the mother down in the room and closed the curtain around the table, leaving the mother “in the room” but not visible. I started to unwrap. The nurse who had dressed it somewhere had slathered TONS of iodine all over everything.

It was a tremendous mess of dried blood, fresh blood, and the fucking iodine. (Which is not shown to prevent infection any more than washing with saline.) It was impossible to work. We had to wash it all off. She didn’t want to come over to the sink, so I let her lie with her hand and arm hanging off the bed and started to wash with bags of saline. Plenty of the wounds were full of clots and dried blood, some were actively bleeding, and the iodine was everywhere.

And as I unwrapped and cleaned, I realized the extent of what I was seeing.

From what I had read on blogs and their accounts of the emergency room, I assumed that self harm was usually around 1-10 cuts in various shapes or lines, usually on the arms.

This girl had perhaps fifty or sixty slashes to the subdermis, about 5-7 cm long, in parallel, parallel to the wrist and elbow creases, on both the wrist and back side of her arm. She went past the elbow, halfway to the shoulder, and some of the cuts higher up had actually had skin removed. They weren’t just slices, but rather ellipses – but not the lines of ellipses, ellipses with the skin inside removed. I couldn’t imagine actually sitting there and doing that. Plastic surgery creeped the hell out of me, the lifting of skin from its bed. She must have done that alone somewhere.

Washing up took at least half an hour, digging out the mess in each wound. I told her to tell me if it hurt, or if there was a spot where she’d rather clean herself. She did but ultimately was too tired or depressed to do much of it. By the end, my feet were soaked in fluids and blood. I hoped she didn’t have any blood-borne disease.

Then just finding enough Dermabond was a nightmare. That shit is expensive, so I had to raid the whole place to find some – each cabinet had one or two vials only. This also took a long time.

Just for public record, since I guess many people might not know this, stitching or closing a superficial wound is not to stop bleeding or prevent infection (closing actually increases the chances of infection). The idea is to bring the edges of the wound as close as possible for the smallest possible scar. It is a cosmetic technique only.

Putting it back together was another story. There wasn’t enough skin between the cuts to really stitch anything, there was no room to land a stitch that wouldn’t tear. She was sliced to ribbons. The The hand ortho guy decided to try to glue them. Some of the defects were clearly not fillable and would have to be left open, invariably leading to horrible scars. I kept thinking about when she was older. In just one cutting episode, she’d probably achieved arms that some people achieve in a decade.

I also wondered: it seems like most forearm cutters make slices in that direction, in a “slitting the wrists” way. Unfortunately, to me (not sure on this, but it seems like) that seems like the way that goes exactly against Langer’s lines, probably the worst way to scar, because every time you flex or extend your arm, that skin is getting pulled. It probably is better to do with the line.

We started gluing, but discovered the same problem. You couldn’t glue one closed without pulling the one next to it. There just wasn’t enough to anchor anything to. And to glue, everything has to be dry. Blood from upper wounds kept dripping down into the field. It was just not possible.

The plastic surgeon was called; maybe there was a special trick here that we didn’t know. No, she said. Leave it alone, bandage it up. There’s nothing to do here.

So we wrapped the girl up and sent her on her way. I made sure to tell her goodbye, using her name. Throughout the whole thing, I kept thinking of people’s stories that I have read, about the various versions of both good and asshole ER docs who have stitched them up, and I didn’t want to be this girl’s terrible story. She didn’t seem too chatty, so I didn’t push, just asked her often if something hurt, didn’t make a big deal of it. Tried to treat her like a person. Offered to try to set things up so her shirt wouldn’t get wet or ruined.

I wanted to tell her this, but I didn’t think her mother would be too happy, so I didn’t. I don’t feel bad about putting this out there, because it is a basic harm reduction principle, which I believe in.

Instead, I’ll tell all of you now: I know that it is a hard thing to stop. I know that nothing I can say will stop you, and that sometimes, that is the safest kind of relief available. I get that while you are doing it, you are kind of in a trance, and probably not thinking too clearly. But you will have to live with the scars one day when you are better. Try to space them so that they can be aesthetically closed. Try not to cut in areas where the skin, during natural movement, is pulled – this will widen your scar, instead, go with the grain of the skin, in a place where it isn’t pulled tightly. Try to stay as superficial as possible, the less deep you go, the better it will look.

We might consider some of our scars, both physical and emotional, badges of pride. But these are different, because they are so public. Someday, you will feel better, and you won’t want to be reminded of such a bad time every single day.

* * *

Edit: a point I wanted to make originally, and somehow forgot. I wanted to explain how I felt toward her, what she evoked in me.

I didn’t feel pity or sorry for her. I didn’t feel annoyed at her like a lot of medical personnel do at self-inflicted problems (and this means all kinds of lifestyle problems, not just psych). I didn’t overly “feel her pain.” I felt, at the time, that it may as well have happened by falling through a glass door or something.

This might come off as cold, but I was glad. I think this is actually a sign of medical maturity, I didn’t have any superfluous judgments (good or bad) about who she is/was, what she did, etc. She needed medical attention, period. Also, my own life and pain didn’t carry over in any way to how I felt toward her, positive or negative. She was just another case. And that was good.

As to a more thorough psych evaluation at the time, I’m sure I could have pulled more out of her if I had tried, but what would be the point? Obviously, plenty of people with lots more experience than I have are involved with her and not succeeding. Everything about her said she didn’t want to talk. She wasn’t silent in a “just-ask-already” way. There were no signals that she wanted to talk, she didn’t make eye contact, nor actively avoid it in an obvious question-seeking way. She was just silent, alone in her thoughts. Right to privacy is important. This gets lost in psychiatry a lot – especially after suicide attempts. Every doctor that comes through thinks that he or she has the right to ask, “Why did you do it?” They don’t. She doesn’t have to be “grilled” by me just because I happen to be treating her arm.

If I could have gotten the mother out, I might have tried to talk more openly. But I knew nothing about either of them, nor of the relationship between them, other than that the mother seemed kind of abrasive and gave me the impression of looking for someone to blame or sue, so I didn’t want a complaint later about how I told her daughter it was ok to cut. There wasn’t enough context, though, for me to be sure. Maybe it just sucked to be in the ER at that hour and she was tired. Neither spoke much. I only asked about what she used, to think of things like infection and tetanus.

Talking more during the hour I spent on the wounds wouldn’t have been helpful. It would have been for my curiosity or to satisfy my need to “help.” As much as we want to “help her,” she doesn’t have to justify or explain her injury any more than someone with pneumonia does. And I’m glad I didn’t feel an overwhelming need to ask or try to “empathize” or anything else, for any reason. I treated her with respect, like any other patient, and I am proud of myself for that.

Don’t let me slip away

I want to write a post about a self-harm patient I saw last night. (Seriously – I guess the message for what I should be doing with my life is clear, medical treatment for crazies. I went maybe 9 months without seeing any psych patients and then this stretch of them just when I’m ready to quit medicine…) Especially since the topic of scars and regret has been going around on a few blogs lately (for example, here and here). I think as far as damage goes, it was a fairly severe case, though, as I said, I haven’t seen many.

My point is – if anyone wants to hear about that, remind me, sit on my ass to do it, because so much material gets lost by my laziness and losing interest or having moved on to the next thing and forgotten the incident that I wanted to write about in the first place. I write only a fraction of what I want to, and if I don’t write, I forget.

But I need to get some sleep before the all-nighter sets me off; I think this bupropion seems to be pushing me toward the manic side (that’s a good thing for me) – it’s ok as long as I am super careful about light and sleep and caffeine and exercise, but last night I worked until 2 AM or so, and then we split to sleep, and I couldn’t – because I was full of racing thoughts that jumped from one topic to another. Not worries or anything like that – the real true racing thoughts. And then the panic of realizing what that meant. I was in the stupid on-call room bouncing off the walls. Usually you PRAY for your phone not to ring at night. I think my most sincere prayers, considering I’m pretty much an atheist, have been those ones.

But last night, they called me at 3 AM and I was glad for something to do, another patient to see instead of lying there crawling out of my skin. I think I joked with them a lot more than I have been doing lately. In the morning, right before going home, I actually made a cup of coffee, because even though I was all over the place, I wanted to keep feeling good.

And now I came home, and instead of going straight to shower and bed, I made breakfast, and wanted to come see if I got comments, and now I’m writing this! And I could easily keep going all day. That’s exactly how my last manic episode started – a long night and then I should have gone to bed, but at 5 AM the sunlight was so tempting,  and I spent the day shopping on foot in the city, meaning I was most of the day in that sun. And boom.

Which means it is time for some heavy benzos. I got the shrink to agree to leave the Wellbutrin and no mood stabilizer if I’d take zolpidem or something similar when I start to not sleep. So I guess I better.

I went and pulled a lot more of the “cyclothymia” references at the medical library last night. Some were in the actual paper stacks, they were so old. I love going up there to the fourth floor where there are medical journals from the 1930s and back, in all kinds of languages. The material is interesting; I read some of it while I was bouncing around and not sleeping. If anyone wants, let me know – most of the files are PDFs. All kinds of funny little tips in there, as in, “They are the patients who like both uppers and downers.” Meaning, purely depressed patients like stimulant drugs, anxious patients like relaxants – benzos and so on. Cyclothymes are the few who enjoy both. Actually, you can tell a lot about a person’s psychiatric makeup by their favorite drug.

They are the ones most likely to refuse mood stabilizers because it flattens them (because their personality is greatly shaped by the mood states, that is the way they know themselves and not having that will make them feel weird).

Or, from way back, something like, “the job of the psychiatrist is not to try to change the person’s temperament, which cannot be done as it is almost certainly a biological substrate, but rather to be supportive through the numerous crises in which the cyclothyme will inevitably become entangled.” I seriously thought of copying that and passing it on to my psychiatrist. I think there was something in there about medications also not being great because we quit because of feeling flat; though when I feel good and not flat (which means that I am fairly unstable, with bad times too, just with also good times), I am incredibly med-compliant.

I answered some comments on the last post as well. I notice that the comments are getting longer, more philosophical.

So write me and tell me to write the damn post! (Oh no, is this the “uninhibited people-seeking” phase? Does my writing sound manic?)

Cyclothymia as a personality disorder; hormones and moods

I have had a partial response at least to the bupropion. Because of the anxiety it causes, I haven’t been overly eager to up the dose so I am still on half a normal dose. I can’t get anything done and feel bad a lot of the time, but I am not wallowing in my misery nonstop. I suspect I need a little serotonin, but as I have been told many times, it is not my job to be my doctor. I don’t even want to suggest anything anymore.

* * *

Things That Make Me Sad

I have done a few calculations that make me sad; these are calculations that probably should not be done.

For two weeks of every month, I am nearly symptom free.

Then ovulation hits and I have 2-3 days of misery, which slightly abate, but then I have two weeks of slowly mounting depression, darkening of the world.

That means that half my life or so is erased.

Add to that my twice yearly or so major episodes – usually one in September-October (depressive) and one in late March-April (manic).  Each lasts about 2 months.

Where exactly am I supposed to live in between all of this? How much time of being normal can I enjoy? Most of it gets eaten up trying to compensate for the things I ignored during the episodes, cleaning up messes I’ve made, trying to forgive myself.

Then, just as I think I might be alright, it begins all over again.

Is it any wonder they accuse me of having a personality disorder? I think the shrink is sort of right about that, but none of them fit because it’s one that has been taken off the books. I checked. I’m not borderline, I’m sure. Maybe some narcissistic traits, but I don’t lack empathy completely. Histrionic, well, no, I’m too shy for that.

When I was doing the reading on borderline to see if it could be, I was quickly relieved that it wasn’t. I read everything in the medical library, including pulling the original Krapelin and Kernberg out of the archives. There was a book from the 1950s or so that described borderline as something slightly different than today (more in psychodynamic terms and with more of an emphasis on the “psychosis” parts), and I was greatly relieved all around by my reading that the shrink was wrong.

(Please, if you are carrying a BPD diagnosis, don’t get offended, I mostly was happy that he was wrong, not that it’s the end of the world to have it. Also, after a horrible year getting used to the idea of being manic depressive, I didn’t think I could take having to go through that again to something else.)

The relief I felt was visceral – the descriptions just didn’t “click” with me the way that the bipolar ones did when I first read them.

When I first realized what was happening to me, that I was in the midst of a terrifying full manic episode, and steeled myself and went and read all night about manic depression (for about 36 hours straight, mania anyone?), something I didn’t know much about. After a few articles, every time, I was nearly physically ill, had to remove myself from the library to just breathe before passing out.

I saw myself described in such perfectly accurate, pathological terms. Shock – someone who had never seen or met me could so clearly describe my life – I knew in my gut that it was right, that as much as I wanted to, I couldn’t argue with it.

When I went to investigate borderline, I started in the big Kaplan and Saddock (I own only the small one) and then went backwards in time. I did some paper in med school on a psych topic and at that time, I’d read a lot of Krapelin and Bleuler and all of the older psychiatric writings, and I remembered that they were far better observationists of phenomena than we are today. Much of what they realized is forgotten in neurotransmission and the pharmaceutical industry, colored by what we are just starting to know about biology, and often gets bogged down in details while missing the big picture of a disease. They had far better intuitive understandings of various mental states and illnesses than anyone living today because they were scientists, observers, not trying to fit a dopamine theory or a serotonin theory or any other theory to what they saw.

So I had found some old, old book, probably translated from German, on borderline states. Hunched over that dusty volume, I turned page after page on borderline, interested out of curiousity, but after hours losing interest because it didn’t speak to me, wasn’t grabbing me by the heart and shaking me around like first reading about the bipolar syndromes did.

And then I turned a page, and the thing facing me was a chart, this: “Cyclothymic Personality” and I don’t remember  if they called it “disorder,” I don’t think so. I think then they were calling it “Personality Structure.” And I read it. And I got that sick feeling again.

The new thinking in psychiatry separates personality from mood, and cyclothymia has been popped over to mood (from what I can tell, this happened in DSM-III), and you can no longer have a cyclothymic temperament and full-blown mood episodes; having a major mood episode bumps you into the realm of “bipolar” somewhere and “erases” the cyclothymia diagnosis, at least as far as I can tell.

But that seems fairly arbitrary; because listen to this description (which supposedly is validated, see Akiskal’s writings in the late 1990s, and also, for BPDers who are reading along, his writings on BPD as an extension of a mood disorder with bad coping features are also very good, and a thank you to that psychiatrist I met once in New York who gave me Akiskal’s name to read up on).

The Cyclothymic Personality:

• Lethargy alternating with eutonia
• Shaky self-esteem alternating between low self-confidence and overconfidence
• Decreased verbal output alternating with talkativeness
• Mental confusion alternating with sharpened and creative thinking
• Unexplained tearfulness alternating with excessive punning and jocularity
• Introverted self-absorption alternating with uninhibited people-seeking

Then, the non-validated but often cited ones, in Akiskal’s rules of thumb for identifying BP in a depressed patient:

• frequent shifts in line of work, study, interest, or future plans
• irritable-angry-explosive outbursts that alienate loved ones
• extravagant, colorful, unusual dress
• frequent changes in residence or geographical location

Is it any wonder I look like a personality disorder? I am all over the place, this is what he sees, that sometimes I never shut up and can’t stop joking (and believe me, I grossly overestimate how funny I am), yet other times can barely speak for shyness. Or “I know every single thing in medicine better than anyone else,” versus “I’m terrified and can’t handle anything.” Or, the astounding self-centeredness of something like this blog versus my feelings sometimes of a vast and shattered love and compassion for everyone and everything in the universe.

What about on an existential level? My alternating nihilistic atheism with my sense of magic and wonder and unity and ultimate gratitude and worship at the universe?

No wonder one would think something is inherently unsettled in my self-concept. I always try to explain that it is the mood that is the problem, not me, but no one hears. I don’t feel like I change at my core, rather that the core is filtered through the mood. The mood grabs me and shakes me and twists me around, building me up, tearing me down, over and over again. It is exhausting. But it doesn’t erase who I am, though over time, I’m sure it has changed it some.

I don’t have identity issues. But I think that might be kind of hard for someone on the outside to see, especially someone who trained in the times of DSM.

If I remember correctly, that same book said that most of the way to distinguish between borderline and cyclothymic is that borderline has additional sine-quo-non attributes:

• the abandonment issues and fear of such, the behaviors that go with that
• disturbances of self-image: the sense of not knowing who they are/emptiness/fear of disappearing
• splitting and the black/white worldview

The rest of the criteria can be or not be in either disorder. There are some that tend to be more common in one or the other (big ones: seasonality and sleep changes, more in cyclothymia; rejection sensitivity and unrelenting suicidality in borderline). Mood lability, interpersonal conflict, impulsivity, seductiveness, bisexuality, rages…any of these can appear in either disorder, maybe in slightly different forms, but they aren’t distinguishing characteristics.

* * *

I don’t know where I’m going with this post. I started this post wanting to update on how things are going before I go work another all-nighter, but also wanted to add some content. I doubt it is that informative for anyone – if you’re a shrink you probably already knew it, and if you are a patient, not sure what it could possibly do for you. Maybe I just wanted to point out that who we are is a tricky subject. Or that in psychiatry things need to go back to science and observation, not have theory dictating. Maybe that a system that catalogues pathology without normal workings is problematic in medicine.

I have been on a light schedule since January 1, and it has been both good and bad. Physically, I’ve been able to catch up on sleep, eat a little more healthily, but in a way, the sleep deprivation, while making me terribly unstabile and volatile, kept me out of the worst of the lows. I wanted to ask other women out there what to do about the mood stuff – I’ve tried every hormonal birth control type thing available, and all of them just made things worse. I’d do an oopherectomy in a second if I knew it would make this stop.

So that is the current state – floating, not really sick, not really well. Faith isn’t quite back, worry is still hanging around. Trying to rally some of that enthusiastic energy that has been gone or in rage form for so long to enjoy patients tonight. Not sure I’ll get there by tonight. Sending love to the universe as best I can, hoping some of it will come around to you, and maybe back to me. Until next time…

* * *

* Note: I used the term “borderline” without any qualifiers for several reasons. I find the whole “diagnosis” terribly subjective (and I think it has been shown to be fairly nonreliable though I don’t have a reference on hand), often a result of dislike for a patient, offensive as a woman, and unfair to the patient, who is pathologized, while the person who raped/beat/molested her is left with no stigma. I see patients with the patterns described, but once I let myself see them as “borderline,” I become free to ignore or brush off what they say, to shirk my duty to them. While the syndrome described exists, it is also perpetuated by treating physicians who treat patients as less than responsible adults.

Other reasons: One, in my opinion, “personality disorder” is a perjorative phrase. Two, it looks like the disorder is going to push over to the affective disorders. Three, I didn’t use “emotional dysregulation disorder” or any of these newer terms because they are not yet widely used enough to be easily recognized. Four, I am also discussing historical uses, which did use that phrase in a very different way than it is used now but nonetheless used it for similar phenomena.

I think the suggestion I like best for a new term will never catch on: Mercurial disorder. It’s catchy, one-word, poetic, and descriptive while not proposing a root cause, which we really and truly don’t know. (Emotional dysregulation disorder sounds nice, but do we know that that is the disorder and not an effect of it? Is that the central defining feature? Far from certain.) I used the word myself in a previous post without knowing it had been proposed as a replacement name.

Another psych patient. Could the signs be any clearer?

Another psych patient just fell on me last night. (Not the two other cases I didn’t write about.) We had split the night up and gone to bed – two hours and twenty minutes for each of the three of us on call. Two patients came in on my watch with abdominal pain. One was seriously psychiatrically ill.

He knew none of his medicines except for valium, which also was the only one he brought with him. (I actually can understand this; in an emergency, I’d definitely pick the clonex over just about any other drug.) His pain wasn’t really probably that serious, but his anxiety levels and panic caused him to pace around screaming, “I’m dying! I’m dead!” Fist pounded into wall. “Give me something for the pain!” He had a bed, but didn’t want to stay in it. He was doing the exact thing I described here. The nurses and staff were sick of him, especially since at 3 AM, most of the ER was sleeping and he was disturbing other patients. It would have been easy for me to get annoyed too, but I couldn’t, having written what I wrote just days earlier.

Everything about the story and exam suggested nothing serious. When talking to him calmly, he calmed down considerably. Touching his abdomen, even deeply, caused no obvious discomfort as long as I kept talking to him about something else while doing it. He had taken so much valium at home that I was hesitant to give him a narcotic, even though I did believe that he was in a lot of distress. I explained that to him. I thought that the thing that most would help him would probably be to give him a little more valium, maybe even IV, but I didn’t. I didn’t know how much he took regularly; he said he had taken 40 mg at home. He didn’t seem calm at all, so I figured that was just about maintenance for him.

In the hospital’s infinite wisdom, the psychiatric hospitalization discharge summaries in the computer are blocked. I couldn’t see what he was taking other than that (thinking along the lines of drug ileus), or what much of his problem was. An old medical summary had PTSD in there, but also mentioned a psych evaluation that had included episodes of psychosis under stress, borderline IQ. Whatever. All I wanted to know was what meds he was on.

The thing is, since I was already up, and not really feeling safe about giving him serious pain relief, and the nursing staff was going apeshit, I decided that it was time to try a “non-pharmacological pain control” mechanism, the kind of shit you learn about in the touchy-feely medical lectures, but never actually have time to do, and don’t believe will work anyway. I went over to the bed, stood at the head, put him back into bed, and I actually dropped the head of the bed down to put him below eye level for me. I always tend to walk in and the first thing I do is put the head of the bed UP so people don’t feel so helpless, and because it’s weird to me to talk to someone not on eye level, but this time I wanted the opposite effect.

I decided I was going to try something I’d never done before. I was going to do like the ER docs do. He was still yelling to “do something, I’m dying.” I summoned up my most authoritative “doctor” face and posture (and believe me, that gave me a little internal laugh), and instructed him to lie very still.

I examined his abdomen again very slowly, even though I had done that just 15 minutes before. I told him that nothing had changed, that everything was fine. I kept one hand on his shoulder, firmly, as I spoke. I told him that even when I went to work at the station, he was in a bed very close by, and I was keeping one eye on him to make sure nothing would happen.

To my utter amazement, it worked.

Anxiety and pain are funny, linked phenomena. People regress when they’re scared, need someone to take charge.

Unfortunately, when the morning surgeons came on, they decided that they couldn’t communicate with him well enough to rule out a serious problem without a CT. So he got a heavy dose of radiation. I never would have ordered that, especially given the whole history of the pain.

Damn.

* * *

I guess the lesson of this is for me is that there is a time and place for me to take on the authoritarian role. To speak very certainly, not explain options, just tell the patient that something is fine or not, and what the next step is. “I am now going to send you straight to x-ray,” without explaining why.

Usually when I do a physical exam I talk through it, while I’m doing an abdomen, I say as I move my hands around, “There’s the liver area, look, it’s not tender…and now let’s see about the spleen.” I also note every normal finding as I do it, because a lot of people think the worst. For example, when the doctor listens to your heart, really most of what they check is the valves only. A heart having a heart attack most likely sounds completely normal. It’s my little personal routine, as I move the stethoscope from spot to spot,  to say in between, “Everything sounds good.” This is a fairly meaningless statement, because plenty of hearts with problems sound fine, but still, it seems to me the considerate thing to do. I’ve never had a reaction other than relief or gratitude when I say this.

I also think: after all, it is the patient’s body, not mine. Just because I am trained to know things about it, to extract details about its state of health doesn’t mean that I have the right to know something about it that the patient doesn’t.

Incidentally, I also explain why I ask a weird question when I do, one that might seem irrelevant.

I do this because I remember as a kid, or not even a kid but a college student, the physical exam being so mystifying. What the hell were they doing? What could they tell? Why were they sinking their hands into my stomach? What did they hear in my heart?

But I didn’t do that this time. Instead, I examined very slowly, with a serious face, as doctorly as I could, and then gravely pronounced him “Well.” And…it worked.

* * *

I would like to improve at dealing with angry, challenging patients. Not the ones who come in angry that they are ill, that they had something horrible happen to them, that they had to wait. Those who come in immediately hostile to doctors and to me, often to women in general, and who immediately challenge me on every point, including “Good morning.” They often have very suspicious streaks toward the world in general, or narcissistic ones that mean that no one is a good enough doctor for them, that they aren’t getting the treatment they deserve, no matter what. They also often come from a perspective or worldview that is very violent or power-struggle oriented, in which the way to get something is through a show of threat.

I suck at these patients. One reason is that they are usually men who are physically bigger than me (I’m a teeny thing, even if my presence is larger than life sometimes, ha ha), and it’s always a little scary for me to step alone into an exam room with them. I rarely know these patients beforehand, so I don’t have any gauge of violent potential or what will make them blow.

Furthermore, while I can call security to come stand there, to me that seems like it would just make everything worse. Maybe not, though. Maybe I need to reconsider.

I used to think this was just a situation to deal with, that they were whatever they were for their own reasons, and I just needed to get in and out of there as fast as possible. On some level, I’m probably angry at them for them being able to scare me. I am sure that they see that they intimidate me. Then, they end up pushing me more and more for unnecessary testing, and nothing every satisfies them. A good example would be the father of the girl with no acute problem.

But I’ve noticed that some doctors walk in and manage to defuse the situation, at least partially, very quickly. Lately, I’ve been watching very closely, trying to figure out what they are doing.

I have been dealing with them in the same way that I deal with most patients, explaining everything I am doing and thinking. I think this is where I go wrong. The doctors who manage to deal with them, sometimes even get a “thank you, doctor” from them at the end, don’t do anything like this. They usually walk in very calmly, sit very close to the patient, and are absolutely unruffled by the aggression. Now, to be fair, I’ve seen mostly men who are very gentle by nature do this. And usually they are older than I am, with those few gray hairs that make them look more authoritative, more “like doctors” than I do.

They take a history, explain nothing except what will happen next. Then, at discharge, they say confidently what it is (without admitting to the uncertainty involved in almost any diagnosis), state that the patient will be fine or needs to do x, y or z, and walk out.

I think that what happens is something like this. These patients see everything as a power struggle or hierarchy. This is a primitive kind of thinking, but it is what it is. The doctors who deal with them well, I think, do something like this: they walk in and establish their authority immediately. They use the position of doctor and the socioeconomic gap as leverage; they are not “fellow human beings” in this relationship.

Yet while they do that, they use their calm, gentle demeanor to establish themselves as benevolent authority. When a patient only understands pecking order, he also understands the concept of being in the subordinate position, and can accept that, and is quite happy when the authority is benign and caring. I suspect this is what happens because the “thank you, doctor” they get is often in a very deferential tone. They say things like, “That guy was a great doctor. He knew exactly what he was talking about.”

A position of equality, or maybe of uncertainty as to where they stand, bothers them; they need to know who is in charge. With someone like me, a kid, and a girl, on top of it, all they know how to do is to push and bully. What I see as being respectful and fair and honest is seen to them as an invitation to try to get “on top.” These are the patients who get angry when I offer them treatment options.

My problem with this is as follows: we don’t always know, even most of the time, we don’t know. We can say it is nothing serious with confidence, but God knows we have no explanation for various headaches, stomachaches, joint pain, constipation, etc.

Here is an example. An older man had hernia surgery. The family was very concerned, because a few hours following the surgery, he had one episode of loss of control of urine. After that, he had no problems and the incident did not recur. They were very concerned, which is reasonable enough – after all, there are nerves down there that are definitely in the area operated on. Had he had a stroke? Had he had a seizure?

After that one time, he had no urinary symptoms, no retention, no incontinence. Normal neuro exam. It had been general anesthesia, not anything in the spinal area.

The family kept pressing me for an answer. Now, I don’t think any doctor has any idea why this happened, except that elderly people can lose continence around a medical stress. I was certain that nothing serious had happened. I said, “I don’t know why it happened. It most likely won’t recur, and there is no evidence of any damage.”

They were pretty unhappy with me.

Then a friend of mine came through (at exactly the stage of training I was), and they asked him. He immediately said, with a ridiculous amount of confidence, “It was a reaction to the anesthetic or the muscle relaxant used during the surgery, that caused the muscle to stop working for a little bit.”

Now, what he said was certainly plausible, though it isn’t really a listed complication of anesthesia. Was there any evidence that what he said was actually what happened, other than “it could have been?” No. But the family was overjoyed with this “explanation,” and loved him, while assuming I was a shitty doctor.

Most doctors do this a lot for something minor – come up with some “explanation” that sounds vaguely physiological, something that they could believe themselves. But I always feel dishonest if I do this, if I say, “We know exactly” when we don’t. When doctors discharge someone with non-serious, yet undiagnosable complaints that will probably go away on their own, they usually throw a medical word or two at it: You have “gastritis.” You have “a slipped disc.” Do they actually know the stomach is inflamed, or is the history very suggestive of it? Is there any evidence to suggest that the disc is the cause of the pain?

I have trouble doing that. I feel dishonest. I usually say something like, “You don’t have appendicitis. You don’t have gallstones. You don’t have a perforated ulcer. You don’t have anything dangerous at this moment. Given the symptoms you have and the way they occurred, it is most probably infectious and should go away on its own.” I am always afraid to toss out one of those half-assed diagnoses, because I always think that it is possible that as the natural course of the disease plays out, a different and more clear diagnosis will come through, and I’ll be the idiot who said the wrong thing.

But it seems like people really want that. Ambiguity is, apparently, a tough pill to swallow.

* * *

As for me, I seem to be doing better, as evidenced by the fact that I’m writing about medicine and life, rather than my own personal misery. In fact, I’m not sure I want this blog to take that direction; medicine consumes enough of my life, and this was supposed to be an outlet for other things, for me. My misery blog. I wouldn’t want to gather a readership that is the “medblog” group. This is where I want to be allowed not to be a doctor.

And most misery blogs get boring or abandoned once the writers get well. I mean, I’m happy for them and all, but reading these kinds of blogs, well, we mostly do it to find someone who feels bad too. During my well periods, I usually abandon this blog.

But I’m going ahead with it, at least this time, because it is roughly a continuation of the last post and touches on some psych issues, if not mine.

And knowing me, don’t worry, more misery will be on the heels of this good spell. Just stay tuned.

What is the universe trying to tell me with this?

As far as how I’m doing, it’s close to an exact copy of this post, so I won’t go into it. I had a very nice call night, though, now that I’m feeling slightly better. Actually, it was a horrific call night, in that patients kept coming in nonstop for the whole night. The volume was one of the highest I have ever seen. I did not eat, drink, or take a piss for 16 hours. There was no five minute break to catch my breath, to smoke. When I sat down to write letters, I felt my heart pounding from dehydration, but didn’t even have time for a glass of water.

But once I felt better, I enjoyed the patients again. I found my sense of agape for them again, for all their funny ways. Also, the excessive patient load meant that there was no time for dinner so I didn’t have to spend an hour listening to some docs talk about the usual medical politics and their crap. Everyone was so busy that I was spared interaction with the other docs…and the other two were both decent ones, two young women, who are on the low end of the jerk scale for the internal med folks. One even has a nose ring – I wanted to ask her if anyone ever said anything about it.

Even though it was brutal, I liked the work and felt useful again, and only had brief moments of an overwhelmed feeling.

Here is the funny thing from the universe: I saw about 6 psych patients in a row, all sent for medical clearance. Our emergency room is run by specialists at night – there are no “ER docs.” The on-call physician (resident) for each department covers the ER, and triage directs the patients to the appropriate specialty. When I work there, I am either working as an ER surgeon or internist, doing either the stitches or the heart attacks, but not both.

Sometimes patients come in and are triaged to be seen by more than one specialty. This is a horrible system, an excess of a tertiary care, behemoth university hospital – people never get out of there, and often the nurse who does the triage is not very good. Most of the patients  could be handled by a primary care person, but they aren’t.

An example would be a minor head trauma. Someone gets hit by a baseball, and gets a black eye and a big lump on his forehead, let’s even add that he needs three stitches above their eyebrow. Low impact trauma, no loss of consciousness, no vomiting, no reason to think of a fracture. If this person were to go to his regular family doc, he’d get a quick evaluation of the eye and eye movements, brief neuro eval and explanation of dangerous signs to watch for, a stitch-up, and be sent on his way.

If he goes to our major tertiary care center, the triage nurse, who is often also not an RN, will triage him to ophthalmology, neurosurgery (they clear all head trauma), and plastic surgery. The plastic surgeon is in the theater, so that’s a wait of three hours. The neurosurgeon on call refuses to see patients without a CT, so that’s extra radiation and cost. The eye doc is a typical eye doc and refuses to leave the eye department in another building to come to the ER, so the guy has to get sent over there with medical escort. What could have been a fifteen minute in-and-out turns into an 8 hour ordeal. Don’t even get me started on this subject because I will FLIP OUT.

Here’s the weird “message from the universe” part. After I suddenly started feeling better and being able to work again, on that very same call night, I ended up seeing six patients who were triaged to internal medicine + psychiatry. That’s really rare. Usually I go weeks at a time without seeing a psych patient who comes for both psych and physical illness.

Trying to fix their psych problems would drive me crazy, be so protracted and Sisyphean that I’d lose patience. But seeing them for medical problems made me feel like I was in the right place, like I had a calling. I knew that a lot of doctors wouldn’t treat them as people, would lose patience, would count them off as crazy. I was glad to see them, without judging.

I actually felt like I was good at what I was doing, mixing medicine with the humanity that only recently started to come back. I’m, of course, changing a lot of details, though no case was particularly unusual, all were the kinds of things seen in any ER shift.

For the first time in a long time, I didn’t want to run away from clinical medicine. While I’d never choose to have the kind of suffering I have, I felt that maybe my being crazy had given me a gift; I’m not sure how to describe it without slipping into a cliche that I don’t mean. Not the “gift of empathy” or anything bullshit thing like that. Something less specific, something amorphous. Appreciation for crazy, and the people living with it wiggling around in them, maybe.

The first forty-ish guy was talking incredibly fast with circumstantial thinking who kept returning to telling me about his stress at work. I couldn’t even get out of him why he was in the ER except that when he started his monologue there was some phrase like “funny feeling all day.” I let him go on for maybe 5-10 minutes, waiting for the story to come out. It didn’t.

The ER docs hate me for this, that I don’t interrupt patients (it feels rude to me, but my go-with-the-flow approach often makes me look unauthoritative) because they want always a very quick, single complaint, direct history in two minutes. But if you let them go, most patients get to the point within a minute or two anyway, and I don’t feel rude.

This guy didn’t. He just recapped all the events of his day in a very flight-of-ideas manner about how much pressure he was under. Then, in the middle of a run-on sentence about his soon-t0-be-ex wife and how today he had to fill in for someone else at work and said, in the same racing speech, almost incidentally, “Oh, there it is, the pain again…then I was at work and at the last minute they told me I needed to do something for Paul and I got nervous…” He kept going, apparently undisturbed, but also turned gray and started sweating during the same monologue.

“Wait, stop, we’ll talk about work in a minute, but what pain? Where does it hurt?”

“You know, like today when I was going upstairs at the last minute to fill in for Paul, butterfly feeling here in my chest.” He then did the classic heart attack hand thing.

I immediately went and grabbed the nearest EKG machine (didn’t want to wait for the technician to show up), and hooked him up, while all the while he was talking undisturbed, but also looking just like a guy having a major heart attack. Sure enough – huge anterolateral infarct.

It was a strange thing – easily could have been dismissed. If he had been seen in the first ten minutes, between the pains, with no story other than “butterflies,” he could have been discharged and dropped dead in the street. I could have dismissed him as crazy if I had been feeling less well and less patient myself, if I had been depressed like I had been the week before.

But I didn’t miss it.

I’m not saying, oh look, I’m a great doctor, I listen and help, and those ER docs don’t. I could have missed it as easily as any one of them. If I had seen him in the standard 7 minute visit, it is entirely possible that I would have heard “funny feeling in my chest” in a patient who young, was obviously highly agitated and under a lot of external stressors, without seeing the heart attack. Anyone could have dismissed him under the heading of anxiety.

This particular day, I had started to feel better, to want to help people, felt once again able to care. And this particular same day, there were six patients who, I think, were uniquely helped by me. It seemed well beyond coincidence.

* * *

Another patient I saw had catatonic schizophrenia, first outbreak. I don’t know much about that state, I think it is kind of rare. There was the waxy posturing. Eyes closed, she was unresponsive to speech and much of anything, except by breathing and swallowing. I was called to rule out a medical cause, though the story was classic for schizophrenia.

I was curious. I don’t know what exactly that state is, other than recognition of the clinical definition of it. I don’t know what it is like inside, whether it is a result of a psychotic delusion or hallucination that instructs them to stop moving, or a reaction to overwhelming internal stimuli, or a movement disorder related to dopamine disturbances at the core of the disease process. I still can’t find an answer to the internal experience of it – only phenomenology. If anyone knows what it is like inside or can find a description, let me know, please.

I didn’t know what was going on inside, but I decided to assume that she could hear outside stimuli as well as whatever the internal ones were, it seemed like she changed breathing patterns sometimes in relation to things her family was saying to her. And in my past experience, external stimuli get through the overwhelming internal stimuli. You can communicate, at least partially, with someone in a psychotic episode. My gut feeling was that it was an overwhelming internal delusion that forbid her to move. I thought that if it was a terrifying experience, if something was threatening her not to move, that a physical examination would probably be a pretty horrible experience.

So I tried to explain in the most non-threatening voice possible that I was a doctor, I was going to examine her, it wouldn’t hurt, and if I touched something that hurt, to please give me some kind of sign so I could help her. I have no idea if she heard or not. There was no way to make any connection with her, but I hope that at least it was as gentle and nonthreatening as possible.

* * *

A girl was brought in by her parents the morning after taking an overdose of a benzo. It was far from the first time, though she was young, college-aged. She’s the one I mentioned in the last post. The quick way she slipped into anger and the surrounding entourage meant to me that most probably she had borderline traits/disorder, but she was a person, with a million other qualities besides that.

By the time she got to me, the short acting benzo, of which she hadn’t taken that much anyway, was far out of her system and there was, as they say, nothing to see. The first thing she asked me was if she was going to get an NG tube. Ah, the voice of experience. I didn’t want to do the whole psych evaluation, I didn’t want to be so clinical. I just asked her if anything particular had happened last night, and she said no, just a buildup of being sick of it all, a collective sense of hopelessness and exhaustion of never being better.

I just said, “Yeah, it’s like that sometimes.” I meant it. I liked her.

While examining her, I asked what she thought would happen when she did it. She got some tears in her eyes and said, “I didn’t want to wake up.” But she didn’t mean it. They were those forced tears, trying to show me how miserable she was, one of those bids for sympathy, an inability to be able to name her problem and express it. She was trying to show me how much it hurt in the only way she could.

Instead, I joked with her a little and she laughed. I wanted her to get a good consult, so I told her, “Let me go see who the psychiatrist is today, if it’s someone ok. If not, maybe we’ll just talk.”

She laughed, and said, “Yeah, you wouldn’t believe some of the ones I’ve been to.” I laughed too. “I know what you mean.” God knows I know what she meant.

I left her behind the curtain with her parents. I didn’t know the psych on call, if he was any good or who he was even. I called him to let him know he had a consult. Pretty soon there was yelling from behind the curtains, but I didn’t hear the specifics. I didn’t get involved.

One of the things I like about dealing with people with borderline is that they’re so changeable. By the time they actually get to the emergency room, they’ve usually chilled out. They’re mercurial, like quicksilver. It’s not like dealing with someone who is depressed, with that heavy atmosphere, the hopelessness. With the right attitude, you can almost always share a laugh with them, joke them out of their misery and into some human contact for a minute or two at least. If they’re furious at you, it’s ok, because it will blow over sooner or later and you can go back to being cool.

* * *

I’d like to write about one more case, but I’m pretty busy and have to attend to some things today. Tomorrow I’m back on call, but in the surgical ER instead.

The point of all this was that it was such a strange coincidence. On the exact same day that I returned to function, I got all these psych patients who I really liked, who were a good fit for me as a doctor. Maybe that’s my niche. Not psychiatry – I’m not interested in trying to fix the mental health problems, I mean, as far as my opinion on that, people are what they are, and if they’re crazy, well, that’s just what they are and it’s not my place to pass judgment.

But maybe I should just be their doctor, one who can look past the crazy, or understand it, or even like them better for it. Maybe that’s the right place for me to be.

* * *
I started the new year with a visit to the shrink. It was alright. I am more normal now than I have been for a while. And inexplicably, he said he didn’t like the bupropion on me. I have no fucking idea why. I kept asking, and not getting a real answer. “It has side effects, and we want something that is going to be long-term.” I said I can live with the side effects (eye tic, panic attacks), that I feel normal again, that even the good old drug had lots of side effects.

I never know where the fuck he is coming from.

It’s odd, even though I feel better than I have in a while, all the sudden he’s saying I’m not ok. For once, I was actually present, not through the filter of depression or a hypo/irritable state, and I get a really bad reaction from him. I just don’t get it. I left there with a very unsettled feeling about the whole thing. I meant to address this directly (the phone call, and I guess today is an extension of it). I have no idea if the problem is with me, or with him. But I ran out of time before bringing it up.