While I wasn’t crazy

The meds (Goddess be blessed) seem to have been working out and things suddenly, almost overnight, turned OK. (For those who are wondering – it’s Lamictal-Paxil, both in very low doses.) It has stifled the writing a little, as well as taking away much of interest to write about here.

I had a lot of last month off – not necessarily for fun stuff, CME type stuff and credentialing mostly, but still…not work. This was wonderful.

I’ve been able to appreciate the world again, to want to see it and love it.

Last night and into today, after being back about a week, and again on shift work, though not as brutal as before, I had nightmares all night. I know some of the readers are into that psychological stuff, so I’m going to do a highlights recap here and see what anyone thinks is fun to toss out as interpretation.

To be fair, I’m not sure at all what I believe about dreams – whether they are from the unconscious or some kind of psychological source, whether a neurological cleaning and memory mechanism (probably I mostly believe that), or something metaphysical (“One-sixtieth of every dream is true?”).

I will note the following events over the last week. When I was at the clinic, a doctor was attacked by a patient and the patient’s relative. It wasn’t particularly scary when it happened, more like a high school type fight, and I called the cops to come break it up. I was upset by it but not terribly, more at the fallout regarding how the doctor was treated by management and licensing authorities.

Second, there was a recent break-in at the neighbor’s apartment. Simple theft, about a month ago, but I felt sort of invaded. It’s not like car theft, I mean, it’s someone’s home.

Third: I have been practicing lots of meditation/metta style (though that one feels oddly selfish to me) and various other techniques. I’m in the “noble failure” stage, but am still working at it. I’ve finally come to see the value in a settled, happy person as being kinder to the world (whereas in the past, I thought, very much in line with my culture, that a degree of righteous anger and discontent was necessary to keep one working to better things). Last night I came to bed somewhat anxious, and tried the deep breathing techniques, and tonglen, which has seemed scary in the past. I’m wondering that, if you believe in it, it’s psychological resistance to trying to calm anxiety.

Fourth: I don’t write about this a lot, but I live in a part of the world embroiled in a violent conflict. Last week, the government on “my side” (if one can say that, though in this case, that kind of thinking – the my side / their side just means everyone loses) did something violent and inexcusable. And it feels like there’s nothing that anyone can do to stop this, and my partner and I have once again been wondering: United States, Australia, New Zealand? Over the last ten years, every time I am in North America, I feel like it is very shallow, everyone having these long conversations about which tile to pick out. I was there recently, though, and my partner and I promised each other that if we go there, we wouldn’t become that. And when we came back here, and this event happened, we said, Fuck…maybe the conversations about floor tiles aren’t so bad. Especially compared to the ones about casualty numbers.

Fifth, the most prosaic: it has turned hot here, and sleeping during the day (and night) means a lot of sweating and physical discomfort and icky sleep.

Dream One Woke me up at 5 AM, panicky, to the point of having to turn on the light and check the house:

It is night at the clinic, toward closing time, maybe 1 AM. We’re trying to close up – the clinic in the dream is pretty much like it is in real life, nothing distorted in the layout, same auxiliary staff, and they keep letting people in (theoretically, we see everyone who walks in by official closing time). I’m sorta pissed off because they keep letting “one last patient” in. (Note: this actually happened last night.) At the end, everything is closing up, lights are off, doors are locked, and we’re trying to see the end of the patients.

Then someone comes to the door. He’s scary. He is tall, maybe 7 feet, and thin and has shoulder-length hair and doesn’t look quite human. His eyes are dark and blank, he looks sort of like pictures of Jesus, but scary. He’s dressed in white. He has no facial expression, but he is here to be treated.

And he is terrifying, and we tell them, “Don’t let him in,” but then something about having to treat all comers and ethics pops up and they let him in. It becomes immediately apparent that he is a murderer. Also, he removes two prostheses from his lower legs, revealing bilateral Syme amputations, and he walks on the stumps, and his shins are disproportionately long anyway so he’s still tall.

He has a medical letter describing that he is part of a white supremacist motorcycle gang (not really something found in this part of the world), and lost the feet in an accident. He is also described as having had sociopathic tendencies during the hospitalization.

We are terrified, I go to call the police. On the phone I calmly tell them where we are, and fumble trying to think of the street number (Note: this is exactly what happened when I called the police for the real-life incident, we’re in a shopping center and everyone just says that and no one knows the actual number, but they asked.)

Everyone tries to hide from him around the clinic, while still trying to treat him. I wake up suddenly with the image of the man in my mind, and wonder if this will be one of those terrible dreams that are almost forgotten by morning. My beloved cat is sleeping on one side of me, my partner on the other.

In the end I turn on the light and get up and check the house.

I have no mental association of a man of that description whatsoever. Or white supremacist gangs.

Dream Two

I am lying in bed, and for some reason I am sobbing and very ill. Sweating. I hear noise outside toward the apartment door (it opens onto a courtyard), and go to see what happened. I discover that the window and door have been attempted to be broken into; the window is open, and the metal and paint around the door lock is chipped away, and the thing that covers the gap at the bottom of the door has been prised off, leaving a gap.

The gap under the door is big enough for my cat to go in and out, and he is there creeping under and playing around, along with a strange cat who I don’t want in the house. Also, I know that now I have a hole where mice and snakes can enter and I think, Shit, what can be done about this?

I decide to call the landlord and tell him this needs to be fixed. I think I am in underwear and a T-shirt and I see my neighbor (a sort of friend, my age, her husband went to med school with me) heading off for the day, and I realize that my face is all red and it is obvious that I have been crying, so I try to explain that I’m ill, not crying. Somehow it all feels like a ruse – both the illness and the crying.

At some point in this dream, I am sweating and shivering and feverish curled up on a miscellaneous shrink’s couch, being observed. I think that also somewhere in the dream, I receive an invitation to my medical school graduation ceremony, an invitation which is vaguely threatening. I am trying to make the connection between those two events.

When I wake up, I am truly sweating because it is hotter than hell in the room, being mid-day in a bedroom that gets morning sun.

Dream 3

The last dream.

I am in my mother’s room – but the house of my middle school years, where we all were desperately unhappy, not the house of childhood that I loved, or the one in late high school where my mother lives today, which is her house more than anything. Whenever I have a nightmare that takes place at a childhood home, it is in this house, and whenever I dream about this house, it is a nightmare.

In real life: We moved there in my father’s desperate attempt to climb a social class, and all went to hell there when we didn’t fit in and life did not become the dream that this McMansion was supposed to buy him. I lost my neighborhood and school friends and he became more and more miserable.

In the dream:

I am in my mother’s bedroom and she’s sitting in bed, we’re chatting. My sweet cat is there, and he has found a little kitten that looks a lot like him. (Note: in real life, my mother recently visited a friend who is bottle-raising a litter of kittens and she told me that there was one who looked like a baby version of mine.) I am trying to convince her to keep him, as he is very cute and I feel sorry for him. The two cats seem inseparable, playing around various places in the house.

The two cats keep playing around. I see that the little kitten is somewhat dirty and has fleas. I take him into the adjacent bathroom – also true to the original floor plan of the house, down to the two vanity sinks, and wait for the water to heat up to bathe him, thinking that I need to go out and buy something as a flea treatment too.

I fill the sink with water and wash the little guy, chatting with Mom all the while about how long it takes the water to warm up, how much nicer he’ll look cleaned up. But the kitten starts choking a little, and I make sure to keep his head out of the water but he keeps choking.

Somehow, he seems to be getting smaller and in more and more distress. Finally, as the water drains, I realize he has become even smaller than a newborn kitten and has died, and changed shape. The core of him seems to shed the fur and creep off down the drain. I am terrified and don’t know what happened, what I did. I saw that something inside of him, something stick-like, slithered down the drain, so I wait, not sure he could be really dead. The skin and fur are still in the sink.

Then, a fully grown green dragonfly emerges from the sink, spreads and shakes out its wings, looks like a praying mantis. It flies around and I realize that whatever the thing was, it wasn’t a cat, or it was, and became a dragonfly. It flies around the bathroom. The turn of events is horrifying – how could this have happened? How could it have not been a kitten?

Downstairs, there is someone at the door, and my beloved cat goes to see who. I don’t open the door, because I know it is someone frightening. I think it is this trashy neighbor who lived a few doors down.

And then I woke up – the phone rang.

I have very few associations with this dream, except that this house appears from time to time in my nightmares. I’m not particularly afraid of dragonflies and have no associations with them other than admiring their long lifespan in high school biology. That bedroom and bathroom were on the third floor, don’t remember any kind of bug problem there.

My cat did once bring a praying mantis home (in my current apartment, he wasn’t even born at the time we lived in that house). Why did he have a double?

* * *
The only unifying theme I can see here is doors, closed doors, intruders behind the door. As a kid, door knocks when I was home alone used to terrify me, I’d run and hide, I think as a result of being a sensitive kid shown those “Stranger Danger” type filmstrips at school. I have never been the victim of a home burglary or assault. No one scary ever came to the door in real life.

So – anyone see any other threads? For whoever likes this kind of stuff – you’re invited to go at it. Is something coming for me?

Oddly, my partner also reported a night of nightmares, making me lean more toward either the metaphysical or heat explanation.

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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.

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.

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.

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