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In an unpublished email, Milo wrote this comment to me: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



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

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

Why I Don’t Fire the Shrink, and follow-up

I’m sorry to drop the last post down because I think it is one of my more important ones and would like it to get as much traffic as possible. Maybe I’ll make it a page or something, but I wanted to write a little more today.

Tony White over at Graffiti left me a beautiful post with a deep answer to a question about what constitutes a “characterological” or “personality” problem. I guess I asked since I have been accused of the same, though I don’t agree.

I have been trying to draft further questions to him but his website isn’t working. He did, however, inadvertently answer sort of what I guess this shrink is trying to get to do with me – make a connection that will be stable and somehow “heal” whatever is fucked up. Whether I believe in this or not – sounds like one step away from alien healing to me, well, that’s another story.

But I thought I’d give some follow-up to the shrink-related part of this post. I thought that if I’m so curious that I’m writing about it in depth, fairly eloquently, I may as well ask him. I did not go and say, “Hey, buddy, aren’t you kind of useless?” Instead, I phrased the question, “Do you think that maybe at this point, the right thing to do would be to stop trying to make me better and shift into working with the condition I’m in and getting me to a point where I can live with this?” After all, I am functional, I’m not in a state where I’m homeless or actively suicidal or beating my partner. It could be worse.

His answer was an emphatic no, that it is definitely doable to get me to better health.

Leaving me to wonder who in the room really has the denial problem.

* * *

I did call in sick, I think maybe for the first time in my life, the day after that post. I really was sick from whatever drug was doing that to me, had been writhing around and vomiting since 3 AM, but I felt incredibly guilty, and am waiting for the universe to punish me. I did make an appointment with the shrink that day, arrived pale and sweating, and he flipped out and tried to send me to the emergency room (shrinks don’t deal well with physical illness). But still, I’m waiting to be punished.

The worst part is, it doesn’t really matter if I’m there or not. The exact same work still gets done. That’s the bind of this job – it is an incredible amount of work with an incredible amount of responsibility, pay below minimum wage, and yet you are utterly expendable. I did call in, but no one even noticed I was gone the day after.

On the up side, I have started investigating other possibilities for employment when I finish. I think this is a positive sign; instead of helplessness and despair at the world of medicine, I’m being proactive and looking for solutions. Not depressive thinking at all.

* * *

I realize I’m down on the shrink a lot and a lot of the things he says are horribly insensitive and sexist, that everyone I know encourages me heartily to fire him. So for anyone who cares, here are the reasons why I haven’t.

1. He is basically a decent person and is trying to help. I realize that this argument could be made for, oh, say, Sarah Palin, but after seeing psychiatrists from the other side in med school, I know that there are some truly Machiavellian types out there. I could do so much worse. He means well, though our views on what is wrong with me, let alone how to fix it, are worlds apart. It is sad that this is an important point, but it really is. At least I can be fairly certain he’s not out there making jokes about me with colleagues.

2. He has seen my episodes on both ends of the spectrum. I can’t say that he really “knows” me, not at all. But I just do not want to have to start the whole history thing over somewhere else. I don’t want to have to go through admitting to manic behavior. And he has seen it, at least glimpses of it, what I don’t manage to hide, so he has a firsthand clinical impression. That counts for something.

3. He is available. He understands the vagaries of a junior doctor’s schedule and is incredibly flexible about seeing me when I can, including sometimes 7 or 8 at night. He can see me on short notice and understands when I disappear for weeks at a time. I know this also sounds like a dumb reason, but I had to quit the counselor I liked best since starting med school (one of those tough, New York feminists) because we simply could never find a time to have an appointment. Others have demanded a set hour every week, which is impossible for me. I also see this as an extension of reason number 1 – he really does care and is trying to help, even at his own inconvenience.

4. He understands the brutality of medical training. This is the first time I’ve had any kind of therapy with an actual psychiatrist, and one thing that is nice is that I don’t have to explain the concepts of on-call, of how it feels after 30 hours, etc.

5. He picked my good meds. This gave me 4 years of normal, good life. I guess in retrospect he fell onto it more out of luck than talent, but still, I am immensely grateful to him for those four years, in which I lived like a normal person and managed to build a decent life for myself, even if it is all going to shit now, and might actually be crueler to have had and lost than never had at all.

6. About anything not related to my mental health, we get along well. Though here it may sound like a lot of angry silences and friction, whenever we are just chatting about something, we mostly get along. We share an unusual hobby and can chat in a friendly way. Just as long as we don’t drift into points where his basically bourgeois or sexist views come out, but mostly they are only a problem when discussing my life and its twists and turns, which he can’t really understand, being from such a middle class boring place. This is a big issue – he misses a lot of what is culturally normal for me and sees it as psychopathology. We come from the same ethnicity, but grew up in different parts of the world – he in a very conformist (though not necessarily right-wing) place and me as a hippie liberal. He’s the kind of man who pays lip service to liberalism but sees marriage and 2.5 kids and a mortgage as normal and anything else as deviant.

But, as I said, if we stay away from that, it’s ok. Light banter is always pleasant.

7. He doesn’t fall for my manipulation. This is also a big one. For whatever historical reasons, I’m a master manipulator of men – by anything from mental gymnastics and rhetoric to sex appeal, I always get my way. I do get furious when I don’t with him, but I think somewhere deep down, it’s good for me.

8. He recognizes that I’m wasting my life and talent. In fact, has made that very comment to me. This is one of the hot spots of what is bothering me. Unfortunately, most counselors I’ve seen see that feeling, the feeling that I am wasting my talents, as pathological, and try to address it, because on paper I look like I’ve done a lot for my age. He once, unprompted, told me I was wasting my life…and I thought it was one of the most insightful things anyone had said – that he sees through my impressive resume to see the dilettantism behind it.

* * *

But the main reason is #1 – I know I could do so much worse. If it’s all bullshit, I may as well stay with someone who means well.

And no, none of this excuses his obvious countertransference-gone-wild issues, the sexism of calling me borderline because I am an angry female, the utter unwillingness to discuss what he sees as the problem and how he plans to therapeutically fix it, the dismissal and blaming of the patient…but still, at least he’s nice. And that means a lot. Do I really want to go find someone with all that same shit, who also is mean or cold?

* * *

Edit: Tony White read this and pointed out a reason number 9, one of which I was not consicouly aware, but of course, he’s right. It made me laugh to realize that I hadn’t realized this, when it was so obvious to someone else.

Lithium Carbonate Shells

It was a harsh night in the ER. A rate of something like three chest pains per hour between 3 and 6 AM.

The doc who went on after me last time was there. Of course, that patient had not had a stroke, so that was just my crazy.

One thing I am jealous of is how most of my co-workers consider the day after call a “day off.” I can’t do anything but sleep, lest I go fucking nuts.

Lithium is a strange drug. It doesn’t exactly drug you, but you don’t feel quite right either. It seems to perform a turning-off function. Rather than a million racing thoughts, I am now in neutral if not directly stimulated, with no initiative. I do what I have to do, but nothing else. Not quite depressed, but certainly not not-depressed either. Psychiatric limbo. I suppose that is why most people end up having to augment with an antidepressant. If that could restore some feeling, I would be rather pleased. But antidepressants mostly have toned me down too. Which, I guess, is the desired treatment effect for me.

Still, I don’t think I can stay on this drug long-term. Even though objectively I’m good – look, Ma, I’m even writing a little – there’s too much of a pervasive low level dysphoria, lack of enthusiasm. I never want to do anything, I only have to.

I have developed a tremendous amount of sympathy for the poor, negative symptoms-riddled schizophrenics. I wonder how much of that is the disease and how much is medication.

Somewhere, even though I’m calmer, unshakable even, I know I won’t stay on this drug forever. I can’t bear the idea that if I stay with it, I will never again feel the cosmic unity. Life without this feels unbearably sad. I can’t really talk to anyone about this, because we have decided that in this day and age, this is a sign of a broken brain. Hell, I know it and preach it myself. I drug up someone who comes in claiming to be the Messiah at least once every few months.

And yet, while I’m not a religious person otherwise in any way, not a believer in much of anything, and while I do know that it does come to me through neural wiring, I don’t want these few experiences of creativity, of heightened awareness, of the few moments in this lonely world in which I have had real true faith that there is something other than this mire and abyss – I don’t want these experiences turned into something pathological.

Blake's Jacob's Ladder

Blake's Jacob's Ladder

So I won’t tell a shrink about this.  I know that I am crazy. But rarely, that crazy gives me a gift.  The gift never stays long. Once out of that state, I don’t continue to believe; I can’t recapture that feeling, it does not change my life in any appreciable way. I don’t turn into Jodie Foster at the end of Contact trying to evangelize based on my experience. I stay the same old cynic I always was.

But maybe that’s why I need to know so badly that someday it will come back.

Even if it is just an extension of brain wiring, full of sound and fury and signifying nothing, it is a facet of human experience for which I am grateful to have been able to partake in. They say maturity is the point where you recognize your wound as your gift. Much of the time, I do. The lithium has made me realize even more how much I do – even the shitty feelings without it have depth – a depth that, despite its ability to deliver horrible wrath and writhing pain, is mine, my wound, and sometimes my gift.

In somnium veritas

I thought this blog was getting too self-centered, but it seems like people are likely to visit any blog that is regularly updated. So here’s a dream update. Why can’t I listen to my gut, my dreams? Especially when they tell me something I already know.

It’s the end of an appointment with the shitty shrink. I get up, head for the door as usual. As I get there, he stands next to me at his work table and I look over as I’m on the threshold, and see that he is doing something so unprofessional, so inappropriate, some total violation of medical ethics, something illegal. I’m not sure what it is – maybe something I see written on something on the desk, but I know that it means that unequivocally there is no way I’m coming back. And I’m glad. The decision has been made for me, that I have proof of what I suspected all along – that I should not be there.

So much pathology in this that I don’t even know where to start. One, if I know this, what the fuck keeps me from acting on it? Why does a situation have to get to full-on abuse before I say enough? This echoes so many situations in my life, such as my partner. How bad does our relationship have to be before I say “enough” if even now I know it isn’t right? Or being a doctor?

I also wanted to thank everyone who has commented. I am always happy to hear that someone else can relate, might have found a bit of comfort or sympathy or feeling like they aren’t the only one in the world to live through this shit. I guess the way to get more readers is to write regularly. I will try to be better. I had a mild hypomanic blip (let’s hope for that to continue) as I dropped the lithium dose after the accidents started again. Most of the writing inspiration during that will not be for writing here, I don’t think. But thank you nonetheless for reading and commenting. Believe me, I have been helped by this blog far more than I have given help. And I’ve learned a tremendous amount about psych medications…I suppose the internet is a good counter to the drug company propaganda. Maybe I should open a site: “Where to Go When Your Wonder Drug Isn’t.”

Mixed states?

I can’t sit still and can’t find anything to do, having finished a million projects today and now I am filled with an insatiable appetite for anything physical. Sex, food, violence, motion. I forgot how strange a trip it is from starting medication to the phase where you are balanced again. Crossing all sorts of strange valleys, strange depressions and strange manias. The med has done enough to drag me out of depression but not enough to make anything feel right.

This leaves me pacing like a wild animal. All instinct, no intellect. Normally, in this state of activation, I’d write, but my cognition is still too slow to do anything like that successfully, my mind is still depressed. So instead, I pace, clench and unclench muscles, feel cagey like an animal. Eat apples again and again – something about their crunch is satisfying, raw, the just-right substrate for my fangs. I feel like prowling the streets, looking for sex or a fight. I feel like growling and hissing.

And, unpleasant as it is, at least when it is unsatisfied, I am not altogether sure I want this feeling to end. It feels like me at the core, stripped away to my most raw, untrapped by drugs, society, identity. While there is no place for this person now in my life, my location, I wouldn’t want her to disappear forever. I just wish I knew what to do with her, what she needed, what she is trying to say.

My Dealer and I

A nice surprise. No lamotrigine, no carbemazepine, actually he came up with the idea of trying Effexor alone. I was sort of surprised, as it was his first suggestion and I was okay with it. So I’ve already taken the first pill. It has made me feel a little spacey and pukey, but that’s alright. Hopefully, it will be the solution, and will work fast enough to get me functional by the time I need.

And I’m off to the races trying to get everything done that I need to this week. I got a call from my third job that they need me to come do something. This job isn’t worth the hassle, not enough money to be worth my time anymore. But I always feel so fucking guilty and obligated. When that phone call came in, I almost lost it, almost broke down crying right then and there. One more thing that is going to take a half day or whole day that I have to run and do. I am so, so achingly tired.

I have a new med that doesn’t make me panic at the thought of swallowing it, though I do suspect it will kill my emotions and sex drive. Probably my writing as well. But for now, I can live with any of that, just as long as it gets rid of this horrible insomnia, and inability to sit still. Later, I can worry about being me, having a life that is worth something.

I still came out of there feeling pretty bad. I was late because there was a huge traffic mess on the way, and the thing is, I really am at the end of what I can take here, but I think nobody ever really notices that. “You’re still working, right?” they ask. “Then it can’t be that bad.” I guess maybe they are right. Maybe I really am ok. But I always get the sneaking suspicion that I might be that one kind of person who looks fine and does everything perfectly and then one day jumps off a bridge and everyone says, “What the hell? She just was at work like usual. Nothing seemed wrong.”

Do you have to be unwashed and uncombed to be depressed? I certainly have had those days, but the idea of being homeless because of not paying bills is a huge motivator. I just can’t see how that will help me. I certainly haven’t been working well, not a valuable employee or anything, but I’m not one of those people with a family to fall back on, someone who will help me out of trouble, so I keep showing up.

Anyway, I am exhausted, to put it mildly, and my reserves are winding down. Despite the med solution, this meeting was terribly…well, whatever the opposite of comforting is. Intrusive without really being helpful, misunderstood (again, we both are working in a language that is not our native one, where nuance is often lost), and dismissed. Accused of being too judgmental, the real ache apparently invisible. Exhaustion and more exhaustion. I guess that’s sort of a good description of my life.