The Emergency Room Visit Guide for Crazy People

I’ve been doing a lot of time in the ER lately. Today I saw a girl after an intentional overdose (she was ok).

I hope I treated her in a way that didn’t make her feel uncomfortable. I don’t know the shrink who was on duty, don’t know if he was any good. I would have offered to do the psych eval but that’s not done in this hospital.

It’s strange, I didn’t make a long or deep connection with her, but at least that kind of stuff doesn’t freak me out, which probably makes me a better doctor for her than anyone else who could have seen her. I didn’t do the awkward deliberately not asking about what happened, and also didn’t do the “overly sympathetic from someone who has no idea what they are talking about” thing, and I also didn’t do the “gawk at the accident” thing either that some docs do – immediately asking extremely probing and personal questions loudly (“Why’d you do it? Were you raped?”). She could have been seen by that attending who flipped out at me yesterday. At least I spared her that.

I asked if anything particular had happened recently. She said no, she just was tired of it all. I checked her body. I hoped she could tell I wasn’t one of those doctors, the incredulous ones, the holier-than-thou-how-could-anyone-do-such-a-thing ones.

I wanted to let her know that somehow, I understood. I hoped she saw something that made her see it – maybe one of my piercings, or the blue-black nail polish.

When I see how hard it is for some patients to once again face someone who looks down on them (and this isn’t only psych patients – it also is common with gay patients, the elderly), I wish I could give them a secret signal to show them I get it. We need a Crazy Handshake.

Then I thought about how much I hate my clothes, how I look now and what she must see, my goth makeup all gone (well, mostly, I still do the pale thing), my hair now colored a very natural sunny blonde. I’ve been working so hard for the last years to fit into the medical world, that upper middle class, extremely conservative but not really stylish look.

And I’m old. My days of cool are long gone. Someone who looks like me couldn’t possibly understand angst. Right? I proved it yesterday.

* * *

On a few medical blogs lately, there have been posts and discussions about certain behaviors in the emergency room – one of them being a patient refusing to open his/her eyes, presumably because whatever symptoms they are having are so horrible.

Now I know that we crazies are often treated very badly in the ER, sometimes justified, but usually not. See the comments on this post, especially that of Sophie, to get the idea.

So here it is: A Crazy Person’s Guide to the Emergency Room, with rationales from the other side. I am certainly not endorsing the opinions held by the medical profession or their behavior, I’m just attempting to explain a reality. I’m going to try to show examples of where the miscommunication occurs.

Hopefully this will help you navigate that reality more successfully. And plenty of not-crazy people could use some of this advice, too.

Caveats: One: this is NOT medical advice, and will not be construed as such. It is for informational purposes only. Do these things at your own risk. Two: you can do everything right and still end up fucked over (again, see Sophie’s story). It’s not your fault.

First of all, your goal is to look and act as normal as possible. Again, I’m not one for insisting that everyone has to act the same and that crazy is necessarily worse than not crazy. But in the emergency room, it is a truism that if you have the ability to yell or complain loudly, you have at the very least healthy lungs, a patent airway, and some cardiovascular reserve. If you get triaged to wait, it is probably fair.

Example: The guy that threatens the nurse to get him seen faster is not going to get anywhere. What he thinks: You have to be noticed or you’ll get ignored. Reality: Emergency rooms all have systems of logging in patients and you will be seen when you will be seen. You cannot change ER bureaucracy by force of will. It would be easier to change the laws of physics.

Be unfailingly polite. This is true for everyone, but counts double for crazies because you have two strikes against you. Yes, you may very well be panicked, feel ignored, or any number of feelings that are difficult to deal with while you are feeling well, not to mention sick. If you’ve been there forever and you do think you might have been forgotten, it’s ok to remind them that you are there. But do it nicely.

One common and very bad approach is threatening that something horrible is going to happen if you aren’t seen immediately. “You’re all just standing there while I’m dying in the waiting room!” is a very bad strategy. This gets you labeled as crazy, and in the medical world, you can be crazy, or sick, but not both.

Example: Patient who has been waiting a long time asks very pointedly when he will be seen, or if “everyone is just going to sit on their asses all day.” What he thinks: I feel ignored, and I am angry about having to wait, and want them to know that I am angry. Reality: This approach brings nothing to the table except making everyone more upset.

Another common misconception is that a few hours make a difference, that something bad will happen to you during the wait time. This is understandable when you are in pain and also in a state of great uncertainty about what is going on, both with your body and with the ER system. There are very few medical conditions that need immediate attention. (One exception – you can’t breathe due to asthma, choking.) Fever doesn’t. Abdominal pain rarely does. Dizziness almost never does.

If you are in the waiting room and something suddenly changes in your state, it’s also ok to inform the triage, calmly, that it has happened. If it really is something bad, they’ll know and move you up. Again, you must do this in the approach that they are on your side and want to help, not that they are trying to push you back. Do not demand. Tell them, “Hi, when I came in, I had these pains in my chest, but now I feel like I’m having trouble breathing. I’m just updating you/just worried – just so you know that something is getting worse.” Do not demand to be seen, and don’t do this unless something really changes, not just “a little more nausea than before.” Do not say, “It will be all your fault if you leave me out here.”  Threatening to die will get you pushed to the back of the line.

The reason I say this is that I know what it is to have a much lower threshold than most people for fear, anxiety, and even pain. I know that we get freaked out faster than someone with perfect mental health. But you have to hold it together – it’s good practice for you, and it will ultimately get you better treatment.

It is hard. On the other hand, it isn’t that they are ignoring you while playing computer solitaire. Sadly, it means that someone is sicker than you are. Try to be thankful that you aren’t that person.
A few groups have strikes against them before they even start. One group is women – you are automatically more hysterical and sensitive to pain and “fretting.” Also true if you belong to an ethnic minority which is more expressive than the dominant culture. Act as WASPy as you possibly can. Look to those repressed cowboys in Brokeback Mountain for inspiration. That’s your goal. You want to show them that you are as anal and uptight as the doctors in suits walking around with the poles up their asses.

Example: A woman is with her 18 year old daughter. The daughter has stomach pain. The woman begins screaming to be seen immediately (while many people who arrived before her are still waiting). She will be seen, but not any faster. What she thinks: “I am standing up for my daughter, who is in pain. I’m doing what any mother would.” Reality: All she is doing is making the medical staff want to get away from her as quickly as possible. But worse, her daughter is now at risk for a quickie evaluation because everyone wants to get away from that mother (after all, no one likes to be yelled at), or at risk for excessive medical testing, because a mother like that is seen as likely to sue.

Do not exaggerate your symptoms and do not convey them in a dramatic manner. This is the kind of thing that the recent posts around the internet discuss. Explain what happened. It is ok to be upset if what happened is out of the ordinary. It is ok to say that you are scared in general, or scared about x, y, or z. But it is not ok to flail around, speak in a whisper, or delay answering simple questions for thirty seconds while you wince. You are an adult, “help us to help you,” etc. People are under the misconception that saying their pain is worse than it is will get them taken more seriously. What will happen in reality is this: you will either be dismissed as crazy because your pain is out of proportion to anything you actually have, or you will end up getting high doses of radiation as unnecessary diagnostic testing is performed because your pain makes the doctor worry that you have a more serious condition than you actually do.

What you think: “I am really bothered and frightened/in pain/upset by my symptoms and I want to be sure they know that.” It is often very hard for crazies to express ourselves when upset in a calm or direct way. Reality: please tell me if you are frightened or hurt or your mom had the same symptoms and died of cancer and you are terrified. I will do whatever I can to help, but by exaggerating, the natural reaction of a doctor is to undervalue everything you say.

Give your own medical history. Do not let someone else speak for you. Walking in and lying down and gesturing for a spouse or family member to explain what happened is only acceptable if your disease directly affects your ability to speak, such as a stuck fishbone in your throat or an asthma attack. Rationale: The mentally ill are seen as incompetent and infantalized by the medical profession and society at large regularly. Do not do this to yourself. Show that you are a responsible adult.

Tell me what’s really worrying you. We can’t help you if we don’t know. Example: If you come in for stomach pain and you want to be evaluated, I will talk to you about your pain, examine you, and possibly do some tests. But if you are afraid you have ovarian cancer and want me to specifically say that you don’t, I won’t, because I won’t know that this is what you need to hear. Medicine is a focused discipline. There is no such thing as a “test for everything.” Evidence is gathered slowly and most tests only rule in or out what we already suspect.

In this same vein, don’t insist on certain tests. People in the ER often think that they need CTs or some other test, and RIGHT NOW. They often also get into some kind of us-versus-them mindset, in their panic or frustration, it seems like doctors or hospitals are trying to withhold tests for money reasons or laziness. We become the authority figure that says NO, at the exact moment you’ve unfortunately been thrown into a state of dependence on us for help.

Believe me, doctors are scared enough of missing something or getting sued that they err on the side of caution. But we also want to protect you from things you may not know are dangerous, such as radiation in imaging (I cringe every time I have to order a CT), or invasive and dangerous or unpleasant. If you insist, you’ll probably get it, but there’s a thing called “pre-test probability,” and if it is low, there is more chance of the test harming you (by being falsely positive, leading to more tests, exposing you to contrast material, etc) than of helping you. It is very hard for your doctor to be in a situation where he is working in your best interests to the best of his abilities, and be accused of “withholding.”

Example: I recently saw a young patient with new onset psych issues, who had a few recent physical problems, also after extensive evaluation, most likely related to stress. She had appointments for several studies and specialists. Her parents were insistent that we fix her right now, didn’t want to leave the ER.

What they were thinking: “We want our baby girl back how she was. Our heart is breaking.” Reality: a problem that has been building up for a month rarely can be fixed in a few hours in the ER. Her father nearly insisted on invasive traumatic procedures, at 3 AM in the ER. He was furious with me that I refused. But I felt obligated not to perform invasive unnecessary genital procedures of questionable benefit to make someone’s father feel like they got “full treatment.” Honestly, the easiest thing for me to have done would have been to drag the poor girl behind a curtain and stick her up in stirrups (and if she was lucky, no one would barge in in the middle). If you insist on something, you may end up getting what you ask for. This might not be good for you at all.

This brings us to another point: have reasonable expectations. An emergency room treats emergencies. The previous example is good for that. This same father also said, “Yes, we have an appointment for an ultrasound next week. But it just can’t wait anymore. And if you all, with the big hospital, can’t fix it, how is some tiny ultrasound clinic going to help?” This is a common misconception, that the ER can solve problems that are best treated in the community.  The emergency room and the hospital are not “better” than your family doctor; they are different services. Your primary care doctor will direct you to the right one for your problem. Hospitals are horrible places for sick people, and any good doctor sees hospitalization as a last resort.

Now, my specific advice for people with mental health issues:

Consider not disclosing. This is a very tricky issue, and I cannot officially recommend it. However, I regularly practice this myself.

Know, however, that if you get caught, it will backfire. See my comment in the comment section about what happened to me at the gynecologist after I tried this. If you have an extensive medical record at that hospital and the minute they open the computer they will see it, well, you’re screwed. If you have recently started or changed a medication and there is any chance that your symptoms are related, do not follow this tip. On the other hand, if you are coming in with dehydration from stomach flu and you’re just going to get fluids, do they really need to know? Probably not.

Cases in which case you NEVER should hide your psych history and meds: always tell the truth to an anesthesiologist, if liver or kidney disease is even a remote possibility (almost all drugs are metabolized through one or the other), if you have glaucoma, in a life threatening situation, if you are going to undergo surgery or a diagnostic procedure, or heart rhythm problems, or if you suspect an overdose/too high levels of something.

Diagnoses you should almost never disclose: the reason being that they have no bearing on anything and will get you treated like a crazy person: fibromyalgia, irritable bowel syndrome, borderline or any other personality disorder. These diagnoses are fairly meaningless as far as interfering with any medical treatment and are not terribly reliable. I’m not condoning and I know that people suffer tremendously from all of them. I’m just telling you how it is.

However, if you have undergone an extensive workup, for, say, stomach pain, and it found nothing, and your diagnosis is IBS, be able to tell what tests you have had done and what they found, or didn’t find, without saying IBS. Save the IBS management for a trusted doctor who knows and respects you.

If you are being treated like a crazy person, or get caught hiding the crazy, it is ok to address the issue. I’m telling you now, because you need to plan for this ahead of time because it will be too upsetting when it actually happens to think of the right thing to do at the moment. I’ll go back to my example at the gynecologist. I was too busy fighting back tears of humiliation and rage, but the best thing for me to have done would have been to say, “Yes, I’m sorry, I didn’t tell you because I’ve had bad experiences with healthcare practitioners before. I guess that isn’t fair to you to prejudge your reaction.”

Notice something important here: I am without doubt the one who was wronged in this situation. I am the one who deserves an apology. But I apologize to her. Fair? Hell, no. But it is practical. Think of it as a preemptive strike. Take pride in the fact that you are being the better person.

The practical advice: You have, every right in the world to be furious enough to start breaking office furniture over this treatment. But this will not get you anywhere.

If you get a bad vibe immediately with a new doc, it is fair to say, “I’m sorry to have to ask, but I sometimes am worried that doctors won’t take me seriously because of my diagnosis. Are you ok with it?” at the start of a visit.

In an ideal world, we’d have the secret sign, and you’d be able to walk into the ER and give a little signal that means, “I need a crazy doctor, please,” and every ER would have me as a doctor, but only a select crazy few will be that lucky. (Haha, is the new med making me grandiose?)

(And I’m not sure how well this would work, because the doctors with mental illness are often the toughest and most anti-mental illness, it’s compensation or projection or one of those defenses I forgot.)

If the doctor has already dismissed you as crazy, you might try something like, “This is very awkward for me, but I’m getting the feeling that my diagnosis of manic depression/affective psychosis/anxiety/whatever might cloud the issues at hand, it’s happened to me in the past.”

Again, remember the above rules, always be exceedingly courteous and never be accusational or confrontational. You probably have a right to jump over the table and choke him, but do not do it. Remember, you want to be more staid and controlled than he is. Do not burst into tears of humiliation and frustration. Do not open with, “Do you have a problem with me?” or “You’re treating me like a child!” or “The way you are treating me is derogatory.” You may be absolutely right, but remember, he probably isn’t doing it on purpose and likely isn’t even aware he’s doing it. He’s not a bad person, he’s just been through a long, brutal socialization process into a subculture with very specific beliefs about mental illness. Keep your tone as pleasant as possible, even if you are about to lose it, because that’s what people who are reliable and don’t have mental illness do, at least in the eyes of the medical profession.

Your goal is to present yourself as a responsible adult, aware of yourself, and understanding and accepting of your diagnosis. Keep it incidental. “Yes, I have manic depression, but I’m here because of stomach pain today.” If you are matter-of-fact about it, and don’t make a big deal, and show acceptance, you already are halfway to getting them to be too. Doctors don’t always understand mental illness, and even if you are perfectly calm and sane, you can always fall on a jerk. Try to remain calm, express yourself in words rather than other emotional or physical forms. I’m not saying it’s wrong that you or I have trouble with emotional control at times or are easily upset or sensitive to pain. I’m just saying that the medical subculture has little tolerance for that, and it helps you to speak their cultural language.

* * *

The “me” update, for anyone who is interested (and thanks to everyone who wrote): I took the bupropion with valium (to cut back on the shakes and shivers and all that, and the inevitable panic attacks it will induce) and actually had a much better day. It is amazing how fast that shit kicks in; I’ll remember it whenever I need to get someone out of a depression fast. (Is it really that different than slow-release cocaine? I sort of don’t think so…) I don’t feel good but at least I can move again. It stopped the suicide plans instantly, because I suddenly don’t feel so hopeless and overwhelmed…again, because I can move. I saw patients at a decent rate. The amphetamine-like action, I guess.

Of course, I also almost vomited and vasovagaled for no reason (I turned my head a little fast and that set it off) in the middle of the day. That’s why I quit it last time. But I don’t really care right now.

I think seeing that girl first thing in the morning might have been just what I needed to remember there is a reason I’m here. And maybe to remind me that what I’m going through isn’t that rare.

I also had a long talk with Jake about what had been happening. He also suggested firing the shrink, finding one in the big city an hour away. I admitted almost killing myself, how frightening it is to suddenly be totally impaired, to lose touch with reality so quickly and to set myself to planning a suicide so fast.

He reminded me that it’s just how I am built, I go down precipitously fast and low, but come out of it too, respond to meds fairly quickly. I said it scared me that the shrink just wanted to throw benzos at me, with no anxiety indication…that in his eyes I’m at the “just shut up” stage of medication. He agreed with my concern, and also with my reasons for not wanting to take the other meds out there. I guess I really needed a friend. I hope I can repay him somehow; I know having to sit and hear the details of someone else’s psych problems is about the worst thing in the world.

Right now, another close friend of ours is ill and we are quite worried, our circle has taken a lot of hits lately between me and that.

Oddly enough, that horrific yelling and failure, well, I’m trying to turn that into a lesson too. That I can fuck up too, and it isn’t the end of the world. That I’m not less loved or less valuable as a person if I’m not perfect. That I can forgive myself. I really couldn’t help fucking up this time. I was that bad. I didn’t fuck up that badly. I did not deserve that. I mean, I did, my performance should have been much better, but I didn’t really deserve that.

You would think that with my perfectionistic traits, this would have been a disaster, a control freak’s nightmare. I let the pressure slip for one minute and look what happened, a few days of bad performance and they crack down on me like that and my whole reputation is ruined, everyone’s pissed off at me, thinks I’m lazy. This should be exactly what I’m afraid of. Normally, I would punish myself one thousand times worse than what I got yesterday.

But I’m deciding to not let it be like that. I did fuck up, but I could not have performed better at that time in that state. I was doing the best I could while very unwell. I did not endanger or hurt anyone. Plenty of doctors perform a lot worse than that every day. I am not a horrible doctor or a horrible person.

And also: I can get sick or break like anyone. (Next major step: admitting it to someone when it happens.)  I can disappoint people, people can think I’m lazy. I won’t die from that.

I can’t help wondering, though, if it’s a good thing, or the first step in a long road downhill. And I’m still amazed at myself, keep waiting for the guilt and self-loathing to begin.

Today something happened to me that never happened before.

I got reprimanded at work.

I apologize for the quality of this post ahead…I’m too tired and my brain is too fried to write well. Here’s what happened.

The last few weeks went surprisingly smoothly, the anger was under control, I was performing ok, and things seemed to be moving along reasonably considering being off all meds. My mental well-being surprised even me.

I think if not for two things, I would have been ok.

One was menstruation, which always fucks me up, and the other was another marathon of on-call nights and sleep deprivation.

It started last Wednesday around 1 AM, I started to lose patience, a hand laceration came in to the ER. I didn’t feel comfortable closing it, so I wanted the plastic surgeon or ortho on call to do it. They refused…and I started to blow. I was exhausted and overwhelmed. I did not want to cause permanent nerve damage to anyone’s hand. After being so proud at how I’d held together so well, I lost it again, had a hissy fit of misery about how I hate my job. Mature, I know. I wish I could take it back. But I just snapped.

(I also ended up suturing the hand. I’m sure that after my vocal refusal and claimed lack of know-how, the patient was thrilled to receive me as his doctor.)

I was so tired, and on top of everything, the attending was jerking me around, making me see every patient (while she is paid ten times what I am paid to be there, and it is part of her job to see patients, she isn’t there as a preceptor or consultant, she’s the main doctor on call) – actually running over me about every decision I made, then going and re-seeing every patient I saw. I couldn’t figure out why she was riding me so hard. I wondered if I had recently made a mistake she had to cop to or something.

For example – a 22 year old healthy guy comes back from a long, exhausting trip with mild diarrhea as chief complaint, and, as it turns out, upper respiratory symptoms. (Why he was in the emergency room in the middle of the night, god only knows…) So I write a quick discharge: Diarrhea – Presumed Infectious/URTI. She goes in there, makes this huge deal about how it is URTI with diarrhea, tears up my whole discharge letter because I wrote it as a “diarrhea” letter, including suggesting giardia check & stool culture if it continues (he had camped and drank from streams). I got a huge lecture on how the diarrhea is part of his respiratory infection, how I went way too far…yet on a similar patient, I got also yelled at earlier for not writing a referral to a GI to rule out IBD if symptoms continue. She was just being nasty, and I didn’t know why. On one hand I got knocked for being too thorough, on the other for not being thorough enough.

This weekend I started to sink into the same old depression. I did some meditating and other things, which helped (didn’t run, though) but it hit hard this morning with a busy ER. She kept doing the same shit. Asked me to present at the level of a med student, checked everything I did. Also, though there were three of us, she sent me all the patients, including orthopedics and urology ones, who are supposed to be covered during the day by ortho and uro. She made me see them just for the sake of making me do it. Then she would return their file to the ortho/uro stacks, meaning that they would be seen by ortho and uro, that my work would be useless.

I admit, I was doing a shitty job. I didn’t miss anything big, but my brain is so slow, I just can’t think quickly like you have to in the ER, didn’t delve into anything that wouldn’t have a direct effect on treatment plan. Presented sloppily – while in my head I had a clear picture, I was scattershot about presenting. I felt so overwhelmed.

I almost got to tears, even while dealing with patients I was trying hard not to tear up; I was already teary from the damn depression. I slipped out at noon or so and called the shrink, told him I wasn’t doing very well, asked what to do. He told me to take some benzo, and I said I didn’t need anything that would slow me down even more. I asked if I should start the bupropion again or what, and he sort of got impatient.

“You’re a big girl, you’re a doctor, you do what you want, you don’t need me to start it again. I can’t deal with this on the phone.” I really am not sure where the hostility came from, except I’m getting it on so many fronts that I know that I must be provoking it.

I just wish he could have been nicer. He’s sick of me too.

I also thought: Now I’m the kind of patient that they don’t even try to limit the benzos for anymore. Take as many as you want, just shut the fuck up.

Then I went in and one of the nice nurses who is my age saw I was falling apart and gave me a hug, said it’s a hard place to work, that that attending can be a bitch to work with, everyone knows (I actually get along with her usually, and I like her). Usual girlfriendy type stuff. I was immensely grateful.

Well, the doc saw this and dragged me off into a corner (in front of other people), and started in about how she’s torturing me for a reason, that I’m lazy and just because I’m smart that doesn’t mean I can be lazy and have such a bad attitude and do a shitty job and the whole reason she’s treating me like that is that I brought it all on myself. How everyone has days they don’t feel like working and they don’t get like me.

This went on for about five minutes. In front of multiple docs. Pointing out many of my failings, personal and professional, number one among them being my laziness.

Ironically, she also said, “I just don’t get it – sometimes you have these periods when you’re so ON, do everything beautifully, you’re unstoppable. And then sometimes you just don’t care and everything you do is shit.” My heart stopped, for one heartbeat I thought she was going to accuse me, then and there, in front of everyone, of being manic-depressive. But she didn’t. She just went on shitting on me.

And get this: I didn’t even care, really. I think that’s a pretty good sign of how depressed I am. Usually something like that would send me into a shame spiral. Now, I’m too far gone to get upset. It’s not like I need any more people telling me how wonderful I used to be, how shitty I am now. I’m living it.

As it went, I just mouthed off back, agreed in that sarcastic way I always did as a kid when I got in trouble, the one that makes them just want to pound you more.

I think I thought that it was better to let them think it was laziness and bad attitude than crazy.

* * *

On the way home, I stopped and bought a sweater for my partner. For some reason, this almost made me cry too. I just wanted to do something nice for someone. Show a little love, which is another thing that has been gone from me for a long time. I wanted to give him so much more, and somehow this crappy sweater just seemed so inadequate, a mute trying to recite poetry. A symbol of the broken shards of what I wanted to be able to give. I want him to be happy. I want him to be warm. I want him to be loved. But I can’t give him any of those things. I can’t give anything to anyone anymore.

Maybe I just cried because I sort of wondered if it was going to be the last thing I ever gave him, and was sorry it was so crappy.

* * *

I then drove to my family doctor, who has office hours this evening. I knew that without an appointment I’d wait, and that was all right. Where was I going, anyway? The shrink was obviously not going to be of any help. I can’t really bring this down on any of my friends. They are under as much stress as I am. I don’t talk to my partner about these things, they aren’t the kinds of things that need to be in a relationship. I didn’t have anywhere else to go.

I brought my dark Soviet novel that I haven’t been able to concentrate on, sat down in the waiting room and tried to read with tears in my eyes. Some elderly woman sat down next to me and started chatting. She was tremendously nice, not annoying at all, but I really didn’t want to make small talk. Maybe she saw me and was trying to help, I don’t know. It was kind of nice finally being somewhere where they didn’t know I am a doctor…to have waiting-room chit-chat with someone on the outside. Someone who, thankfully, didn’t bitch about how bad her doctor is, and who wasn’t a sucking pit of need.

One of the staff members I guess had a birthday and they had a little thing with cake and candles and then passed it around the waiting room. I couldn’t even lift my eyes, though it was a nice gesture and feel in the room. The glowing candles and the singing, a little surreal.

The doc saw me sitting there and called me in fast. I don’t know if that was professional courtesy or what. Of course, having come from work, I was dressed semi-decently and still had on makeup, combed hair. I didn’t look depressed. I don’t think I ever do.

I just told him the depression was back, go ahead, pick a drug, doesn’t really matter what. He tossed me a prescription for citalopram. I also took one for bupropion. I can choose later which to take. He asked what I had taken before. I rattled off a more or less complete list. He asked why I took lithium. I told him, “Because I get like that, sometimes, too.”

He asked what about the shrink, and I told him that I think he’s just frustrated, sort of given up. “You know how it is,” I said. “The patients who don’t get better, no matter what you do. After a while, you just don’t want to see them anymore.”

He said I should try valproate, but that wasn’t his job to deal with. I told him that mostly what was bothering me is that I’d had a year of bad function and was scared I’d never be normal again. He asked in a general way about “dark thoughts,” the kind of thing I could answer, “No more than usual,” without feeling like a liar. He didn’t ask directly about suicide.

* * *

I guess I’ll start taking one or the other. Maybe the bupropion, because it worked so fast. Probably should cancel the shrink later in the week – I can’t see how it could do anything but make me feel worse.

I’m scared. I’ve had plenty of internal disasters, but I’ve always been able to hold it together externally. I know that in this last year, I’ve ruined my reputation everywhere I’ve worked, that no one wants to work with me because of my attitude, which isn’t really attitude but rather me doing my best through a granite tsunami of depression and mood problems. Mood disorders. I am mood disordered. I am disordered.

* * *

From the outside, I can’t escape a feeling that these little things are all harbingers of doom. I can’t help thinking about all those statistics and sayings, the ones about x% of people visit their regular doctor in the four months or week before suicide; about the typical case study, the perfectionist who fucks up, some seemingly inconsequential narcissistic insult that somehow is the invisible riptide that pulls him under. If I were watching this like a movie, like a novel, I couldn’t avoid the heavy-handed cues, the foreshadowing: Things do not bode well for our heroine.

Psych Meds I Have Taken

Someone recently  blogged a full list, I thought it was kind of interesting, so once again, I’m bumping a substantial post down the ladder for this one. Here is my list; feel free to add your own:

  • Prozac (when it was new and pretty  much the only thing on the market)
  • Zoloft
  • Nortriptyline (my wonder drug, which I had to stop due to freak side effect, and if it were up to me, I’d keep taking it, consequences be damned)
  • Effexor (worst side effects)
  • Lithium
  • Cymbalta (most useless drug I have taken, horrible withdrawal)
  • Bupropion
  • Desipramine

This does not include the various benzos and sedatives tossed my way to shut me up from time to time when I was particularly obnoxious.

The absence of any other mood stabilizer is due to my stubborn refusal and fear of trying them and denial that I probably need one, not doctors’ ineptitude. I may have tossed back a few days worth of some new SSRIs but not in any significant amount.

I guess I’m lucky not to have (yet) been hit with anything harder.

Physical Versus Mental Illness

In an unpublished email, Milo wrote this comment to me:

Personally speaking, i passed a kidney stone last year, and being dead honest here, i’d  much rather the physical illness than having a paranoid episode… i really really do. i tell you one thing Sara, the pain was absolutely horrendous, but no one laughed at me. i felt much more dignified than i ever did when i was locked up in a psych ward… dead honest…

I think that almost anyone who has had a mental illness of any significance would agree with that statement. And the odd thing is that anyone who hasn’t would think just the opposite. Unless you’ve been there, there is a tremendous underestimation of how much mental illness impacts the quality of life. After all, there are very few physical illnesses – even ones involving extremes of physical suffering and death – that are associated with suicide in a way that even the “common cold” of mental illness, a simple depressive episode, is.

It seems to me that a lot of people who are writing journals like this one – experience journals – about their mental illnesses have a higher than average level of physical illness comorbidity, though I’m not sure that has been epidemiologically proven. There are probably cofounding factors – people plagued by crazy moods usually don’t take the best care of themselves (I am guilty here), destructive behaviors, substance abuse, being ignored by doctors.

But I’m also struck by how quickly physical illness is legitimatized by society, bringing with it what public health sociologists call the “sick role,” which is a social convention that is acceptable to society. Something about the whole construct and theory bothered me in medical school when it was touched upon briefly. I don’t like the blanket statements; I think people should be seen as essentially healthy, and by defining a sick role, you are encouraging sick behavior.  No alternative models are presented in medical school. But it does apply on a societal level as a descriptive model, if not the ideal one.

Yet it doesn’t apply for mental illness – the main two “rights” afforded the ill are not applicable – whether society says it or not, mental illness is seen as, maybe not quite active malingering, but something akin – not quite a “real” illness, not something that justifies the exemptions.  And the second right – that the sick person is not responsible for their illness – it is politically incorrect to disagree with this statement, but hell, if I, medically educated, liberal, and a victim myself, in short,  someone who should know better, insist on blaming myself, well, what can you expect from a society at large?

The “responsibilities” are also problematic. The idea that one should cooperate with a medical model which is infantalizing and patronizing and paternalistic, and often negates the core of one’s very experience with its drugs as well as its conception of pathology (something that does not happen, or at least not as much, in physical illnesses), is equally problematic. I do not agree with my physician – who, according to these same sociological principles, has the ultimate word and is considered the only “technically competent help” I can seek in order to conform with the sick role. Therefore, I in some way abdicate my rights to the sick role.

That’s ok with me on some level. I don’t want the sick role anyway, and, while I know it will probably make a lot of my readers angry, I am often against the institutional reward for the sick role. (Again, another disagreement I have with the basic premise of the theory.)  I think that by making it easier to get benefits for illness – and NOT just mental illness by any means, we infantalize people and encourage sick behaviors, define people as ill, create a permanent and all-encompassing sick role. We create patients who will never get better.

I am all for help, care, love, and rehabilitation – all things that Western countries tend not to give as easily as they give money (which they don’t give that easily either). But the welfare system writes people off, makes them dead long before they are, often encourages them to give up the fight.  It also exempts us as a society from working to improve their health, because they are maintained indefinitely as ill. It is relatively easy to cut someone a monthly check; it is quite difficult to encourage and help them find suitable work – and by work I do not mean employment, but rather “work” in the sense of “to work and to love” – something that gives life meaning. One can be a “healthy adult” with a mental illness. A physical one, too. But not while clinging to the sick role.

Back to Milo: whether we accept the “sick role” concept or not, physical illness is afforded a legitimacy that is regularly denied to mental illness. Here’s my example: I’m not proud of it, but during this last year, while taking one of the meds that made me insanely restless, suicidally depressed, argumentative, and, on top of it all, physically miserable due to akathisia, I landed at one shrink appointment and ended up begging him to do something – anything, just to make it stop. Stop this med. Find another one, one that would work quickly. That I wouldn’t argue, I’d do anything he said, take anything, just to make it stop.

And what happened? I got an annoyed reaction. “You of all people should know that psych drugs take 4-6 weeks to work, that it just doesn’t work like that…and anyway, it seems to be doing you some good.”

This is from a psychiatrist – the kind of doctor supposedly most educated and aware of mental illness, the one who chose to specialize in mental disorders, who presumably thinks they are a source of suffering significant enough to devote his life to treating. If he can’t be sympathetic, how can we expect society at large to be?

I’m not blaming him. I am sure I was annoying and demanding and all that, and there was no easy solution that would have satisfied me. I have certainly lost patience with patients with unreasonable expectations and demands, which mine was. It happens. He also redeemed himself a few minutes later, saying something like, “I know you feel awful,” which was probably what I needed to hear in the first place.

My point: contrast this with the recent very physical side effects of some med or other he gave me, or, what it is looking most likely to be – a peptic ulcer. After all the misery of this last year, the depressions, the irritability, the instability, I hardly cared about the stomach pain and vomiting, which were occuring daily, often during 30 hour call nights. My mood had improved, and the physical shit, while not insignificant and certainly distressing, relative to what I had been through, was almost nothing.

And yet, when I reported these symptoms (which I did at first because I thought they were due to one or another of the psych meds), I was told to rush to a doctor on the same day, if not the emergency room. That got me the sick role, and pretty damn fast.

* * *

Stay tuned for the next post – this one went in a different direction than I intended. I intended to discuss Milo’s point more directly, the way psychiatric illness is seen in the emergency room, by the medical system, and instead ended up here, on a more theoretical note. Later I’ll try to write on comparative suffering – physical pain versus mental pain and whether they are the same or somehow qualitatively different – whether mental illness really is just another type of illness, legitimate suffering, and how doctors really see psych patients.

Link

Things here are mostly the same, maybe slightly better since I’m working back at my main hospital, mood more or less stable, but in a slow decline. Physical health also taxing and on top of it, a massive viral infection (winter in the ER, joy to the world), but whatever. I can deal a lot better with that than the brain stuff.

But for your reading enjoyment, here’s a great post over at BipolarLawyerCook. The third paragraph is exactly what I think about having kids.