“I wept not, so to stone within I grew”

Io non piangea, si` dentro impetrai.
-Inferno, Canto 33

It is 3:40 AM, the witching hour, and my being awake cannot be a good sign.

Of course, I have been awake at this hour every day for quite some time now. Maybe wanting to get up and write is a good sign.

Things here are, well, empty. I suppose it is a depression of sorts, though fortunately like the ones I suffered as a child and teenager, before the “manic” part was added to the title. It is much more bearable, at least on the surface, than the episodes I have suffered in the last few years, because I am just quiet and still and numb. No racing mind or body torturing me with horrible thoughts that come faster than any human was meant to think. If I didn’t have the practicalities of running a life to worry about and could just crawl into bed until it goes away, it wouldn’t be bad at all.

It is strange how it has come full circle, taken me right back to where I started. It does remind me of that time when I was 12 and my mind broke for the first time, for seemingly no reason. It is familiar, if not comfortably so, ha ha. It makes me a little nostalgic for that time, when I thought that the worst that could happen, crazy-wise, was the need to crawl into bed for months. Before I knew what could really happen, all the ways a mind can burn and break that I know now.

It does get better throughout the day, and by evening I am almost normal. Unfortunately, 9 PM is not the best time to apply for jobs or deal with the mundane details of life. Every night I go to bed thinking of what I will do first thing in the morning, the interview I will schedule, the tax papers I have been avoiding (two forms, that’s it, two forms!) for months.

And then morning rolls around at 3:30, and I am numb and frozen and terrified again and nothing gets done.

I have not worked in four months. All solid job offers are shift work, night work, in busy, miserable emergencies for minimal pay. Seeing as that is what made me so crazy over the last few years, I have not accepted any of them. I don’t want the responsibility of not missing a heart attack for $5 of pay. It makes me physically ill to think about going back to medicine.

I wrote before that it wouldn’t be so bad if I weren’t trying to keep up with life, but I am not sure that that is entirely accurate. I woke at this atramental hour, and beyond the dampened terror of my bank balance, the horror at the thought of returning to the repugnant job that is the only one I am qualified for, a little voice dared to run through my head and say the one thing that I have not allowed myself to think: “Your hope is all gone,” the voice intonated. “Your mind will not work again. This is what you are now.”

I miss very much the streams of words that used to race through my mind, needing to be caught on paper before they got away. I miss writing, which used to be an automatic and unconscious activity. Whatever force I used to channel, whatever it was in the universe that fed me the words, has left. I have been alone, without even the words that I could always count on to come, unbidden. I try to force myself now to write, but I sit and try to think of words. I have to choose them, and they are never quite as right as the ones that come from without. I never used to “have to” make myself write. The words used to just come, words and phrases and alliterations and allusions would streak through my head, unannounced and at odd times, often surprising me and making me laugh or smile at their unexpectedness. All I ever had to do was appreciate them, and transcribe them, and be thankful for the electricity that ran through me when they were flowing, the sense of pure purpose, that this is what I had been put on this planet to do.

But whatever consciousness it was in the universe must have moved on, found another emissary or oracle.

Not only the words are gone. The more primal, wordless passions, the pathos and exultations of life, are muted into nonexistence. For months now, I have been walking around on the verge of weeping, with tears in my eyes that obstinately refuse to fall. I think that if I could weep, something might shift, maybe for the better, maybe not, but at least there would be motion.

I don’t understand where those tears are coming from, why they are so firmly fixed behind my eyes. Maybe when my muse left, someone else’s tragedy mistakenly got into the void left in my eyes, and I, having picked up the narrative in the middle, cannot identify the nature of the misfortune, and thus, cannot weep for it. I have no reason to be sad now (unless I think of the countless broken bodies and broken lives that surrounded me and sometimes touched me over the last years). So I am not sad. Just numb.

The lack of hope – another entity that has left me: something in my head keeps whispering, maybe this is it…this is the best you will ever be. Sometimes I wish that the “maybe” would disappear. If I were to be sure, I could figure out how to arrange some kind of half-existence around what is left. But as long as there is still a memory of how I used to be (abstractly, anyway – I cannot channel how I felt when I was alive and ready to do anything and conquer the world, but I can picture my younger self smiling and full of energy, doing things, doing everything), there is that little last bit that keeps me waiting, as the song says,  busco un mejor momento. In some ways, this keeps me from playing the hand I have been dealt. I am always waiting for the next deal.

For my own record, since I do record this shit, I just saw a new shrink. It was horrific and humiliating, as usual, but no worse than most new shrink appointments. The decision was to raise the bupropion, give that two weeks, and if it isn’t enough, add valproate. I have a hard time seeing much logic in this; it seems to me that the last thing I need now is a drug that will slow me down or make me stupider. But I suppose I have nothing to lose (except my hair and my hormonal balance and my lack of diabetes and any potentially normal fetus I may someday conceive), so I’ll try. Mostly because I don’t want to be that patient on the very first meeting with a new shrink.

And things have undoubtedly improved ever since getting out of the miasma that was the previous shrink. I miss him, maybe, as a person, and on some level I think I like him more than this new one, but I cannot ignore the overwhelming experiential evidence that it was bad for me, and there were too many lapses in professionalism to ignore (see “refusing to release records”).

Sometimes, though, in these tenebrous hours, his words still haunt me: accusations he made, (mis)interpretations of things I did or said that nonetheless were hurtful. The insinuations from someone I trusted that something is so wrong with me that it is a miracle I function, and that I will never be “normal” without serious interventions, which apparently have not yet been invented.

For these reasons, even though it is all I think about almost every day, I am trying to avoid anything psychological or mental health related. When I am away from the whole paradigm, I’m just a flawed person, no more or less than anybody else. When I let them near me, I become an amalgam of pathologies and brokenness. Sometimes I wish I never had gone to any doctor. Then, I would have just been eccentric, or emotional, or melancholic, or even just plain crazy.

I have to remind myself that I don’t even believe in their system of belief, that people lived for thousands of years without shrinks, that 99% of the world’s population has never even heard of their concepts. I try to remember who I was before I ended up so entangled with this bullshit system. I was a person. I wasn’t perfect but I was alive and I did things and knew people and sometimes felt something.

Somehow, all of that has disappeared, and all I can think about are all of the words that have been used by the priests of this odd religion to judge my essential being. I do not believe in their religion, yet somehow, their damnation of my many sins, that they delineate in the clinical terminology of their liturgy (affective instability, noncompliance, Melancholia, Mania, narcissism, Cyparissusism, Axis I, II, III, x, y, z, the asymptote of mood-personality-behavior), haunts me.

I don’t know why I cannot break the hold this farcical cult and its practitioners have on me. I suppose it is my version of the person who doesn’t really believe in God anymore, yet somewhere deep down, is too frightened by the spectacle and rhetoric of the fundamentalist hellfire to actually get up and leave the pew.

And so…back to the title quotation. I feel that underneath the conspicous anodynia, there is a well of misery hiding. Hell, it keeps trying to creep out through my eyes. I can’t help suspecting that the underlying pain is for all that I have seen over the last few years and all the people I have lost. I would drain the well, cry profusely and feel deeply, if I only knew how to reach the stygian waters.

But it is too late. So many years of having wept not, I both created and became the adamantine stone.

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.

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.

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.

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.

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.

On mental illness and stigma in medicine

Today I saw a patient for a pre-operative evaluation. This is a consultation for a patient that needs surgery, but who has other medical problems that make the surgeon nervous, and the surgeon basically wants someone like me to sign that I evaluated the person so that I can be blamed if something goes wrong. At least that’s my semi-cynical version of it. My fully-cynical version of it is that surgeons make relatively little money seeing a patient in clinic (though a lot more than a family doc or internist does), and they don’t want to waste time evaluating a patient when they could be operating and billing for the real benjamins.

Of course, I’m messing with the details of the story, but it went something like this: this woman was elderly, but under 80, and had the usual medical problems that go with that age, but not more – mild diabetes, mild high blood pressure, a few other things like that, but no history of smoking, no lung disease and no significant heart disease.
I think that over time I’ve collected a few doctor readers, so I’ll add this list of meds, more or less: some vitamins, a beta blocker, metformin, maybe there was an ACE inhibitor in there, can’t remember, a statin, a laxative, a bisphosphonate and some ranitidine, and a few other drugs, which I will get to in a minute.

She also had a recently discovered cancer, which was the occasion for the operation. The operation is a large one, but not “heroic” or the kind of thing they call people to come sit in the balcony to observe. It’s not a Whipple or anything close, but it’s not a lumpectomy either. It probably will not lead to a cure, but will almost certainly lengthen her life considerably, and will definitely prevent at least some of the uglier complications in the future. It is the standard of care.

Now, the rub: one of her diagnoses was “Depression.” No further explanation. In addition to the above, she also receives lithium at a healthy dose as well as paroxetine. This was the first time I saw her and she is an immigrant who does not speak any language I speak, so we had to speak through her son translating. But she was perfectly pleasant, totally coherent (able to give full medical and surgical history since childhood) as far as I could tell without speaking her language. To my shame, I didn’t ask what her profession had been. (I just didn’t think to while trying to sort out a complicated medical history.) I had never seen her before, and she came with almost no written medical information other than the recent imaging and investigations that were directly related to this cancer. I have no idea how her depression presented, why lithium was added, how long she had been stable or ill, or anything about that particular illness other than what I saw. To be fair, I also had no information about the history and control of her diabetes or blood pressure, though all three issues were controlled during my examination – blood pressure was good, sugars fine as well as HBA1C.

And then this: among all of her documents, I come across a paper that is a statement by a consultant psychiatrist that she is competent and able to both consent to and undergo the operation.

The surgeon and anesthesiologist had both refused to treat her without this evaluation. The surgeon’s referral put the demand for a full psychiatric evaluation (at the family’s expense) above cardiac, geriatric, oncologic, or functional evaluation, and refused to proceed or even make a tentative statement on her suitability for operation without this.

The surgeon, for that matter, does not speak her language either. But I assume he saw a similar patient to the one I did, as he had seen her less than 3 weeks before.

Just the fact that she came in taking certain medications, with a psychiatric diagnosis, one that, for that matter, has no bearing on her ability to decide how to live her life or to comprehend information, could have caused life-prolonging, standard-of-care treatment for cancer to have been withheld, to have been considered “inappropriate” or “unnecessary” or “unsuitable.”

In her case, fortunately, the psychiatrist did not write a full three page summary of her personal flaws (as I have seen sometimes in these types of evaluations), but rather summed it up with a line something like, “Patient understands implications of illness and treatment options and is competent to make any and all judgments blah blah blah.” But how many of these cases never make it that far? How many times, when surgery is an option, do surgeons see a diagnosis like that, or a drug like lithium and decide that the patient simply isn’t a candidate for surgery, or decide not to present all of the options?

I also wonder, if it had been an older man with “depression,” whether he would have been put through this humiliating evaluation, or whether only hysterical women need to be qualified as competent. Or if it had only been the paroxetine and not the lithium? What was it that pushed her into questionable incompetence? Does the referring doctor understand the implications of demanding an evaluation like that – that they are essentially calling into question a person’s sovereignty over their own body? I am hard-pressed to think of any kind of mental disability, including those conditions that include intellectual disability, in which a person cannot be presented with options in a manner fitting their understanding.

I don’t know whether to be angry, or to want to cry, or what. But I think mostly I’m afraid that someday I will be that little old lady with an ugly diagnosis on my chart, whose life is seen as only questionably worth saving.

My Answer to the Commenters

I started to put this in the comments and then just decided to post it as a regular post, because it was turning into one in length.

Thanks for writing, everyone. Thank you especially 5150 for reminding me that it will fade. I kept telling myself that during the worst of it…that it wouldn’t be forever like this.

I have zero benefits or anything. The one private disability insurance I bought probably wouldn’t cover this as a pre-existing condition and it only replaces about $700 a month of income anyway (a percent of what I am paid by the hospital and not the government – and the government pays most of my salary). Jjunior docs have no benefits at all – we are almost hourly wage employees – do not even have personnel benefits at the hospital that the cleaning staff has.

The option would be another job. I constantly remind myself that approximately 99.999999% of the jobs in the world are something other than “physician.” But it seems like such a shame, when I am so close to finishing training not to just suck it up and pull through.

On the other hand, when I find myself on the roof again and again, I keep telling myself, just walk away. You have a choice. You do not need to do this.

And the worst part of it is that it isn’t the practicing medicine that is killing me. It’s the bickering with the nurses who walk all over me, the paperwork, the phone hassles to get tests done. It’s not the essence of the job itself. Sometimes I even think that being decent to people and helping ease their way through something is what is keeping me going.

Another thing is that I quit taking the Wellbutrin and the lithium a few days ago and feel immensely better. One of them was doing something bad to me. I’m not sure which one…but I could feel it physically – shaking, throwing up, feeling drugged and surreal. You’d think that that was a creeping up lithium level, right? But it also came with a terrible agitation and that unreal feeling was never something I got from lithium. It felt like that first time I took the Wellbutrin and flipped out. Lithium, even at its worst, always chilled me out. I semi-wanted to call the shrink and ask what he thought but never managed to have a free moment to do that while it was a decent hour. And don’t even think about getting to a lab to have lithium levels done during business hours. I’ll probably slowly restart the lithium today.

The other thing I am slowly coming to accept are some limitations. While the idea of leave scares me, I realize that I just can’t keep up with my peers with the no sleep thing. They consider a day after call a day off. I can’t even move, and if I don’t sleep through until the next work day morning, I’m crazy. This saddens me. I used to be unstoppable, so ambitious, wanting to take care of everything, be the best at everything.

And I’m also coming to accept the idea that since my good cocktail is gone, I just may never feel totally well again. It’s been a year now, or almost a year…and nothing is any better than when I first started. That’s what sort of fucks up the idea of taking leave to fix the meds – the meds may never get fixed. I may never be what I was.

I think I could be okay with that if I could do a few things that are really important to me. First is to write – which I can’t really do in this state. Others are a creative habit that I can no longer do because my hands shake too badly, and flying, which I can’t do because I’m always on the edge of vomiting anyway. My three passions in life have been stripped away, which is hard. Maybe I just need to throw myself into medicine, which is something I can still do well, and find a real life in it, which is something I never have been able to do. Satisfaction, sometimes. Purpose, yes. Pleasure at using a skill for the good of others, yeah, I guess.

But passion…never.

Yes, I am a tremendous whiner, compared to so many people whose lives have been much more devastated than mine, I’m bitching about having a job as a physician. But still, a dream lost hurts, no matter how grand or small, and I dreamed of something so very different than this squalid sleepwalking broken-down life I am left with.