Bipolar 2 From Inside and Out

Archive for the ‘Mental Health’ Category

Internal and External Scars (Trigger Warning)

I was a clumsy child and am a clumsy adult, so I have lots of scars. They can be categorized into three types.

Accidental scars. These are the ones that resulted from my clumsiness. I have a huge scar on the inside of my left leg from tripping over a metal milk box. (For the youngsters among you, this was the box where empty milk bottles were placed and full milk bottles took their place.) Back in the day, you didn’t go to the emergency room for injuries like that, so the scar remains jagged and irregular, coursing across my inner thigh like a river.

There’s also a scar on my right foot from the time I dropped a Coke bottle on it. (Yes, this was during the era when Coke bottles were made of glass. I’m old, okay?) And one that bisects my eyebrow, lengthwise, from when I bumped heads with another child and my glasses were pushed into my face.

Non-accidental scars. The one that I am contending with right now is a medical scar. It came from a punch biopsy of my forehead to determine what a lump was. (It was a sarcoid.) I freaked out when the doctor asked the nurse to hand him the “puncture scalpel.” Seeing my distress, he changed it to “sampling tool.” That scar is fading, though, and I hope it will soon become invisible.

Another non-accidental scar came when I was in fifth grade. Some kids and I were at a bus stop and they thought it would be fun to throw rocks at me – actually crumbled pieces of the street macadam. At first they threw them at my feet, and I “played along” and jumped over the missiles. One kid, though, threw harder and higher than the others. The rock hit me in the forehead, and I started crying and bleeding all over my mittens. I heard one of the kids say, “We didn’t mean to hurt her” as they scattered and ran, a sentiment that I somehow doubted.

My mother was sent for and I was taken to the doctor’s office, where to add more pain to the incident, I received three stitches, which were in some ways more traumatic than the injury that led to them. This scar was right along my hairline, and isn’t really visible these days. But, believe me, it still hurts.

More distressing (and the warning for the trigger warning on this post) are non-accidental scars that I inflicted on myself. These are the scars that resulted when I took a knife to my wrist. Nowadays they call this NSSI (non-suicidal self-injury), and indeed that’s what it was. I wasn’t suicidal. You could call it a suicidal gesture, I suppose. But it was not a serious attempt, was never meant to be seen, and was not “a cry for help.” In fact, for many years I tried to hide the three inch-long white lines on my wrist by wearing a wristband or long sleeves to cover them. Now I view them as reminders of how bad things can really get and what incompetent coping mechanisms I had back then.

Internal scars. Some of these are most likely related to my self-inflicted scars. They came from a variety of situations, not least of which was being literally stoned while I was an impressionable young girl. There were many incidents of threats and bullying, which begin to pile up after a while. There were the internal scars that come with depression – feeling useless and worthless and unlovable.

There were also relationships, those that ended badly and those that were bad from the beginning. They reinforced the idea that I was useless and worthless and unlovable, and scarred my psyche.

Those scars don’t show on the outside, and I have worked hard not to let them become visible through my words and actions, as I used to do. I have not been completely successful, of course. Like the visible scars, I expect they will always be with me in some form. Like the visible scars also, I expect they will become fainter and harder to find unless I go looking for them, which I try very hard not to do.

They remain, but they fade, and I am satisfied with that.

My Triggers

By shane / adobe stock.com

Bipolar disorder is a funny thing. It can come on with no warning. One moment you’re fine, and the next you’re in the infinite doldrums or jagging on a spike of enthusiasm. Most of the time, it’s like that. The moods come on unexpectedly and stay as long as they want.

Sometimes, however, there are things in your life that seem to trigger a bout of depression or mania.  This isn’t quite the same as what’s commonly called a trigger. In the usual sense, a trigger is something in your past, like a traumatic memory, that comes bursting through when you read, see, or otherwise encounter a reminder of that memory. Suddenly, you are thrown back into the situation that triggered you, reliving the trauma, feeling as if you were still there, re-experiencing it. Triggers are most commonly associated with PTSD (or Post Traumatic Stress Disorder). Many people associate PTSD and its flashbacks with veterans and war, but other traumas, such as rape, assault, and natural disasters can also cause PTSD.

Trigger warnings are controversial. Some people need a warning that the content – especially books, blog posts, or films – may trigger a suppressed or otherwise traumatic memory and leave the person caught up in the sensations during a public moment, such as in a classroom. Obviously, people with traumatic memories would prefer to avoid this, so a trigger warning is placed at the beginning of a story, novel, or even a song that deals with rape, domestic abuse, or other traumas, especially ones depicted in a particularly graphic manner.

To other people, reacting to a trigger is an admission of fragility, at best, or at worst, an excuse for avoiding content that most people can easily handle. This is part of the mindset that leads to calling the severely traumatized “snowflakes” for their perceived inability to deal with stimuli that “normal” people take for granted. They do not understand the power of traumatic memories or the power they have over people who have been through trauma. They consider such people weak. They consider themselves strong, even if – or especially if – they have been through traumas themselves.

In general, my life has been less traumatic than some, more traumatic than others. There are memories that invade my dreams, situations that cause me panic, and stimuli that rev me up. I am not in control of these stimuli, or what they do to me.

Most of the stimuli trigger depression in me, as my bipolar disorder is heavily weighted towards depression. (In fact, I was diagnosed with unipolar depression before a psychiatrist finally recognized my condition as bipolar 2 with anxiety.) When I encounter one of these “personal” triggers, I am panicked, unable to communicate, and immobilized, or nearly so, and must rely on the help of others, especially my husband, to get me through. There’s no telling how long that depression will last.

Primary among my triggers is what I call “the rotten ex-boyfriend who almost ruined my life.” It was a toxic, gaslighting relationship that left my soul sucked dry and my emotions shattered. Fortunately, I do not often encounter anything that reminds me of those days. A friend I met during that time, in fact, has helped me heal both then and for many years thereafter.

Still, I have dreams – ones where I am traveling to the man’s house, ones where I am in the house but he is not present, and ones in which he is. I wake feeling vaguely seasick and nervous. The feeling persists like a hangover through most of the next day. It interferes with my ability to do work and to interact with people. My reactions used to be much worse, with specific words even able to throw me into panic and depression.

Another thing that triggers me is disastrous financial matters, or at least ones that I perceive that way. IRS dealings are by far the worst. A letter with that return address throws me into a panic. Once I even collapsed on the street after an IRS engagement and was unable to get up without assistance. Overdue bills and dealing with personal finances are triggers, exacerbated by the fact that I pay most of the bills, despite the fact that I make less than half the money. This is one of my contributions to the household since there are many things I am unable to do. Such situations leave me with my head in my hands, shaking and catastrophizing, unable to do what must be done until I calm down. (My husband is by now adept at helping me do this.)

And I have one of the more “traditional” trauma triggers – a natural disaster. A year and a half ago, our house was destroyed by a tornado. At the time it hit, I was upstairs in the bedroom. I remember the roof coming off. I remember putting a pillow over my head and hoping for the best. For many months I suppressed the trauma. But now it has come out. When the wind blows very hard or the rain blows sideways, I panic. Despite the fact that upstairs is the very place I shouldn’t go, that’s where I end up – in bed with a pillow over my head. (I also avoid movies like Twister. I’m not even sure I should try The Wizard of Oz.)

As for hypomanic triggers, I have few. Most of my hypomanic flights are unexpected, lifting me up with no warning. Although they can be exhilarating, they are also dangerous. One of the hazards is unwise spending, which of course can lead to the aforementioned financial depression triggers.

One trigger that takes me as near as I ever get to hypomanic sexuality, though, is a sensory, rather than a situational, trigger. For some reason, the smell of Irish Spring soap brings up the heat in me. I distinctly remember the first occasion on which I noticed this. A coworker walked past me and I smelled the distinctive scent. It started my juices flowing. Later, we became lovers. My reaction to Irish Spring is less extreme these days, but it still triggers a memory of the feeling. I seldom encounter the scent anymore, as my husband prefers Zest.

At any rate, it is my experience that triggers can arise from sensory memories, from dreams, from upsetting situations. I have few triggers related to textual representations, though I am not immune to those in films (I left the movie “What Dreams May Come” before it was over and waited in the lobby until it was over).

What I can say is that people’s triggers do not make them “snowflakes.” Triggers elicit visceral reactions that are no less real for not being visible to outsiders. While I don’t advise purging any possible triggering material from, say, academic curricula, I do think a trigger warning on syllabi or blog posts is only polite, and possibly psychologically necessary.

 

Mental Illness and Homelessness

By Halfpoint / Adobestock

There are a lot of assumptions made about mental illness. One is that all of the homeless population are – or at least predominantly are – mentally ill. That’s far from the truth.

Homeless people get that way for a variety of reasons. Some lose their jobs or are evicted from their housing. Some have no friends who can put them up when that happens to them, so they have time to pull themselves together and find a new job or living situation. Some live on the streets because of alcohol or drug addiction.

And yes, some people are homeless because they are mentally ill. Disorders such as depression and bipolar disorder, schizophrenia, anxiety disorders, and substance abuse disorders are frequently seen in the homeless population. According to the Harvard Medical School, “about a quarter to a third of the homeless have a serious mental illness — usually schizophrenia, bipolar disorder, or severe depression — and the proportion is growing.” 

Psychiatric Times states, “There is clearly a link between psychiatric disorders and homelessness; disentangling the nature of this relationship is complicated….Mental illness had preceded homelessness in about two-thirds of the cases. Homelessness in turn has been associated with poorer mental health outcomes and may trigger or exacerbate certain types of disorders.” 

PTSD is also a factor among homeless veterans and others with traumatic pasts. Many military veterans suffer from it as a result of their experiences in combat situations. A traumatic event such as witnessing or being victim of an attack, sexual assault, and so forth experienced during homelessness can itself cause PTSD. And homelessness itself can be the traumatic event that leads to PTSD.

The system is rigged against homeless people. With no address, phone, no reliable transportation, no place to bathe, it is hard to get and keep a job. Many times homeless people are taken advantage of when they can get day labor such as mopping a store, cleaning toilets, or sweeping a parking lot. The job “broker” for casual labor can easily demand a kickback from the homeless person in exchange for finding the person a job.

Some homeless people have been kicked out of their houses because of their alcoholism, drug addiction, or disturbances caused by mental illness – or because of “tough love” philosophies.

And let’s not forget people who have been released from jail or a mental health facility. It can be almost impossible to find a job and an affordable rental. Thanks to a broken system of both prisons and psychiatric facilities, the recently released have no place to go but the streets. When Reagan closed down and defunded “asylums,” he took away the most common way for the mentally ill to get help. Where did these people end up? Either in prison or a homeless camp.

In fact, being in jail is a luxury for some homeless people. They may commit petty crimes in order to be arrested and put where they know they will receive “three hots and a cot” for at least a couple of months. But there is little to no psychiatric care for homeless people in jails or prisons. Despite this, the prison system is clogged with mentally ill people who have no way to get better and nowhere to go when they are released.

With a few exceptions, people do not choose to be homeless. Many people look down at the homeless, sure that they know what would be best for them or clinging to the outdated notion that a homeless person can “pull themselves up by their bootstraps” and conquer both mental illness and homelessness. People who experience schizophrenia or psychosis are particularly hard to place, even in shelters.

What about those shelters? To begin with, they are overcrowded. Not everyone who needs one is able to get a place. Many are horrible, crowded places, where theft, assault, and rape occur. Many make the residents leave at 7:00 a.m., whether they have a place to go or not. Many others make residents adhere to codes of conduct little better than jail, or insist that a resident profess the preferred religion of those who run the shelter. And don’t forget bedbugs, lice, and infections linked to too many people being in an enclosed space. COVID restrictions make it even harder to find a place in a shelter. There are more shelters for women – and especially women with children – than can accommodate the women who make up 29% of the homeless

And what about the violence associated with both the homeless and the mentally ill?

Lynn Nanos, in her book Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, makes an excellent case that schizophrenic and psychotic patients, especially those with anosognosia, are the most likely of all psychiatric patients to commit violence and be victims of violence. 

But murderous violence is not the only kind. An NCBI study reported that “mental illnesses only moderately increased the relative risk of any violence, that is, assaultive behaviors ranging from slapping or shoving someone to using a weapon in a fight.” In addition, they said, “the absolute risk was very low; the vast majority of people with diagnosable serious psychiatric disorders, unless they also had a substance use disorder, did not engage in violent behavior.”

In terms of the myths about the mentally ill homeless, much of that is related to the stigma surrounding the seriously mentally ill. When we look at the facts we find that, while mental illness may be one cause of homelessness, it’s wrong to say that all the homeless are mentally ill – just as wrong as it is to say that all of the seriously mentally ill are homeless.

It’s often said that most of the U.S. population is one paycheck, spouse, illness, job loss away from homelessness. Let’s add mental illness to that list of potential causes. As the sign in the accompanying picture says: Once I was like you. We need better programs to serve the homeless, the mentally ill, and the homeless mentally ill.

 

 

 

 

 

 

 

Are Lobotomies Gone for Good?

By alexlmx/adobestock

If I were a few decades older, I might have undergone a lobotomy. Treatment-resistant bipolar disorder (or manic depression, as it was called then) and schizophrenia are some of the disorders lobotomies were recommended for. It was thought that such mental illnesses were caused by faulty connections in the brain and that the cure was to sever those connections. Lobotomy pioneer Antonio Egas Moniz received a Nobel prize for inventing the operation.

The main problem was it didn’t always work as planned. There were other problems as well, such as the flattening of affect and severe brain damage (what a surprise). The most noted person to have a lobotomy (also called leucotomy) was Rosemary Kennedy, the developmentally delayed sister of John and Robert.

There were two kinds of lobotomies, though only the method differed. The prefrontal lobotomy involved drilling holes in the patient’s skull in order to get to the frontal lobes, where the trouble was thought to lie. The other, and to me more alarming, version was called the transorbital lobotomy. The “orbit” in transorbital refers to the eye socket. An instrument was introduced into the brain by going through the eye socket (without disturbing the eye) and used to sever the connections between the frontal lobe and the rest of the brain. Around 50,000 lobotomies were performed in the U.S., most between 1949 and 1952

Doctor Walter Freeman was the champion of the transorbital lobotomy, often called “icepick surgery” for the slender instrument that was inserted and then swooped about, in hopes of severing the faulty brain wiring. Dr. Freeman was so adept at this that he could perform many of these surgeries in a day, and indeed performed around 3,500 during his career, including 2,500 icepick lobotomies. He once performed 228 of the procedures in a two-week period and taught the technique to countless other doctors. Some of his patients underwent more than one lobotomy.

Eventually, the lobotomy came into disrepute for A) being the horrible invasion that it was, B) reducing many patients to an emotionless or brain-damaged state, and C) being depicted in Ken Kesey’s 1962 novel One Flew Over the Cuckoo’s Nest as a punitive, brutal, and unnecessary procedure. The lobotomy all but disappeared from the psychiatric and surgical landscape.

But wait! Lobotomies may be out of fashion, but psychosurgery (or “functional neurosurgery”) is still performed for treatment-resistant mental illnesses. In these operations, however, rather than randomly severing neural connections, the surgeon removes the areas of the brain thought to be the cause of the psychiatric problem. Modern versions of psychosurgery include “amygdalotomy, limbic leucotomy, and anterior capsulotomy,” none of which I know enough about to comment on. Suffice it to say that the days of drilling burr holes in patients’ skulls or taking an icepick to their brains are, as far as I can determine, gone. 

Psychosurgeries are now performed rarely, deep brain stimulation being the preferred form of treatment, especially for non-psychiatric conditions like Parkinson’s or treatment-resistant seizures. And they’re always performed under anesthesia. The patient’s consent is required.

Electroshock therapy is much less invasive and is still used today, although in a lower-key and safer manner than the original procedure – under sedation and with lower amounts of electricity. It still has side effects, such as the loss of short-term memory for the period surrounding the treatment.

Electroshock therapy was considered in my case because of my long-term, treatment-resistant case of bipolar 2, which involved years-long depressive episodes. At first I was terrified, but after doing some research and talking to knowledgeable people, I was just about ready to agree to it. At that point my psychiatrist suggested we try one more drug first – which worked, alleviating (though not curing) my condition like turning on a switch.

(Side note: When I began researching lobotomies, I found that the book My Lobotomy, by Howard Dully, was particularly interesting. The story didn’t follow the usual pattern. Instead, it seems, Dully’s hospitalization and operation (in 1960, when the boy was 12) were largely instigated by his stepmother, who wanted him out of the way, though schizophrenia was diagnosed by Dr. Freeman (see above) before the transorbital procedure.)

 

 

Caregiving: What We Owe Our Animals

By fantom_rd / adobestock.com

I’ve written before about emotional support animals and what a difference they can make in the life of a person with a mental illness such as bipolar disorder. And that’s still true. Emotional support animals and trained service animals can make a vast difference in helping a neurodivergent person cope with life and their disorder. (A thorough guide to emotional support and service animals can be found here: https://adata.org/guide/service-animals-and-emotional-support-animals.)

It’s unfortunate that misunderstanding and misuse of emotional support and service animals have made it more difficult for persons who really need them to have the comfort and utility of such a companion when they really need it. The fact that pet “vests” labeled Emotional Support Animal are available willy-nilly online is a disgrace. (I saw one site that sold all kinds of vests with assorted patches, ID cards, and collar tags. It had “It is fraudulent to represent your dog as a service animal if it is not” in really small type on only one page.) Real service animals require thorough training and provide specific kinds of support to their humans.

There are many animals that provide comfort, companionship, and emotional support without being official, trained service animals. Cats, for example, are notoriously bad at being able to perform actions such as diverting a person with OCD out of a behavior loop or reminding a person to take medications. Hamsters, rats, and fish, while providing hours of comfort and emotional diversion, are not really qualified as service animals. Monkeys can be officially accepted as service animals, as can pigs and miniature horses. But the ADA (Americans with Disabilities Act) makes no provision for emotional support sloths, lizards, or rabbits. People who take these animals onto airplanes or into restaurants – or people who take untrained dogs there – screw it up for those who truly have need of nonhuman support.

But that’s not what I’m here to talk about today. I want to discuss people with mental illness and what they owe to the animals they live with. Caregiving.

It’s great that animals can act as supportive caregivers to human beings in need, but the animals have needs, too, and it is up to the human being to accommodate them.

Unfortunately, when I had my worst major depressive episode, I was not able to provide proper care for my companion animals. The cats needed regular food and water, a clean litterbox, and appropriate medical care, at a minimum. Fortunately, when I was too ill to provide those, I had a caregiver (my husband) who was. If he had not been available and willing to take over the pet-care duties, they would have been neglected, and suffered for it.

This is not to say that people with mental illnesses should not have pets. Companion animals can be a wonderful solace and comforting presence. My cats’ purring, lap-sitting, and other behaviors have been soothing and peaceful at times when I really needed it. Just their presence could bring me out of myself for a while. Caring for some other being is a powerful adjunct to therapy.

Even persons with severe mental illnesses can benefit from the presence of animals and are able to care for them, sometimes even better than they can care for themselves. Think of the homeless veteran with PTSD who cares for a companion dog, making sure it eats even if he doesn’t, and finding it shelter from the cold. It’s hard to say which is doing more for the other. And people with depression, for example, may find that caring for an animal brings them out of themselves, at least a little, and connects them with a world wider than the inside of their head.

What I am saying is that people who know they may be incapacitated by their mental illnesses probably should make preparations for a time when they are not able to care adequately for their animal companions. I was lucky to have a caregiver who was as emotionally invested in caring for the cats as I was. He took over the caregiving for them as well as for me.

It is, however, only sensible to make plans for your animal companions if you know you may be unable to give them proper care – for example, if you know you are facing hospitalization. Pet-sitting or boarding arrangements can be made in advance and called upon in case of emergency. Even a pet feeding and watering station that provides several days’ worth of sustenance can make owning a pet more practical when your coping skills disintegrate.

I wouldn’t give up my cats for anything. Unless giving them up was the only way to ensure that they received proper care. No animal should suffer just because I do.

Time Flies When You’re Bipolar

Finding stability is difficult when you have bipolar disorder. The days seem to melt into one another, either life in dense fog or life on a tightrope. You can’t remember whether you’ve eaten that day or showered that week or when you need to pay that phone bill.

And forget those lists of self-care things you should do. Contemplating even one (“go for a walk outside”) leaves me feeling defeated. It involves too many steps – getting out of bed, finding clothes, getting dressed, and then the actual walking. Most of the self-care lists contain things that are next to impossible for a truly depressed person to do (wash one dish), or too mundane to engage a manic person’s psyche (nap, complete one craft project).

For myself, I get lost in the week, since I usually measure time by weeks. What was I going to do on Thursday? Isn’t there a call I need to make this week? Do I need more groceries this week? I can also get lost in the month sometimes – Is it time to water my plant? Do a breast self-check? Pay a bill? Most of these I can handle with small nudges. Water the plant on the first day of the month. Pay a bill when I get an email or call about it.

When I worked in an office or a restaurant, there were ways to measure days. Casual Fridays were a dead give-away, for instance. But there were no weekly group meetings or, in the case of the restaurant, even specific chores or a consistent schedule for each week. I used to be able to pinpoint Thursdays because it was chicken-n-dumplings day at the Hasty Tasty.

But since COVID I no longer go out to work or to the Hasty Tasty or get dressed for work (I work in pajamas at my desk). I can sometimes tell time by my husband’s days off – Thursday and Sunday – but even that gets confusing, since I measure by when he goes into work (Wednesday, for example, and Saturday evenings) and he counts by when he gets off (Friday and Monday mornings). “Thursday into Friday” or “Sunday into Monday” is too much for my poor glitchy brain to handle.

I have better luck when I measure by my own work. I have off Thursdays and the weekend. Sometimes there is no work on a particular day, and sometimes I take on extra work on Thursdays or over the weekend, so it’s not completely reliable.

I do try to stick to a schedule when it comes to my writing, though. By Tuesday, I try to have an idea for my blogs. Wednesday I firm it up or do research, if needed. Thursday, I write a draft, since I don’t have my regular job to do. Fridays I tweak the draft. Saturdays I proofread and add tags. Sundays I publish. Mondays I check to see how well my blogs have done. Since my novel is finished, I have added doing three queries a day, first thing in the morning. And when I don’t have regular work, I try to either do research for my next novel, or write scenes that I know have to go in it somewhere, though not in order, since I don’t have an outline firmed up.

I suppose self-care encompasses going to bed. I usually get in bed by 9:00 or 10:00 and read to unwind (I know that this is not recommended, but it’s an essential part of my daily cool-down, whatever the day of the week it is). After I start to get sleepy, I take my nighttime pills and read a little more until they kick in. I usually just awake naturally, unless I have a work assignment that’s due early in the morning. Then I set an alarm.

These are the techniques I use to keep grounded in my days and weeks. When something unexpected happens, such as my husband’s days off being switched, I get back into the trap of not really knowing what day it is.

But as for self-care, I don’t schedule a massage or take up yoga or call a friend (I keep in touch on social media). It’s all I can do to get through a week at a time and be grateful for that.

 

All Mixed Up

Leigh-Prather/Adobestock.com

As I mentioned a few posts ago, my psychiatrist and I are working on a medication change that will, I hope, pull me out of bipolar depression. The medication that we changed was a mood-leveler, which sounds like a productive way to start.

We’re increasing the dose, which means it shouldn’t take the time it would for the old drug to “wash out” of my bloodstream (and/or brain) while we’re waiting for the new one to kick in. I’ve been that route before, and it’s miserable.

While I haven’t noticed my moods becoming exactly stable since the change, I have noticed certain effects. I am able to get through the minimum of what I need to do each day, though nothing more. And I have noticed that I am getting irritable. This does not happen so much when I’m depressed. When I’m depressed, I don’t care enough about anything to be irritable.

In fact, irritability is one of the ways that hypomania manifests for me, before I get to the euphoria/super-productive/reckless spending stage. I get snappy with my husband about all his annoying habits, like never giving me a straight answer to a simple question. (What are you watching? A movie. What did you get at the store? Food.) I think he thinks he’s being funny, but I find it frustrating. Not that I don’t have annoying habits too, especially when I’ve either depressed or irritable.

So, I guess in one way, the irritability is a good sign. It doesn’t mean I have level moods yet, but it seems to mean that I’m not totally stuck in the depression. (I explained to my husband what was happening with me, and he seems to understand more. Though it remains to be seen if he’ll answer simple questions informatively.)

I think what I’m experiencing is a phenomenon know as mixed states. If to be depressed is to care about nothing and mania is to care about everything, a mixed state is some hellish combination of the two. Imagine being immobilized and jumpy all at the same time. That’s what it’s like, paradox that it is.

I haven’t had mixed states too often in my life, though I have had emotions that swerve drastically from happy to depressed in an instant (which is an extreme version, I think, of what’s known as ultra-rapid cycling). This is something different, though.

Now, I use up all my spoons early in the day and nap, or I stay up but go to bed at around 8:00. Ordinarily, if I went to bed that early, I’d read for a couple of hours, but these days half an hour or 45 minutes is it, tops.

Still, I think (or hope) that this mixed state of affairs is a step along the way to level moods that are higher than the numbness and not-caring of depression. It’s not comfortable to go through, but then neither is depression or mania, even hypomania.

It’s been about six weeks since the change in my medication. Within another four to six weeks, it will likely become apparent whether the change, once set in motion, will have an outcome I can live with. Until then, I need to spend my spoons as wisely as I can and try to remember not to snap at my husband, even when he’s being annoying.

Mental Health, Meditation, and Mindfulness

Back in the day, all my friends were doing transcendental meditation. They claimed various effects from it, including lower blood pressure (which I believed) and levitation (which I didn’t). At the martial arts dojo, the sensei did lead a guided meditation which left me feeling energized and ready to train, so I think you would call that a success. Nowadays, I can’t get into a lotus position or even sit on the floor tailor-fashion, which is to say I might make it down, but I can’t get back up. Never mind the fancy kicks and rolls we used to do.

Meditation has come a long way since then, though it is rapidly being overtaken by mindfulness. My psychotherapist recently suggested that I try a mindfulness exercise which could be found on my computer. It took the form of a guided meditation, with the leader noted that the mind would wander, but suggested several ways for me to return my attention to my breath and my surroundings. One distinct advantage was that I could perform it sitting safely in my desk chair. I found it interesting, but not something that I would likely try again. My mind is just too restless, especially when I’m manic. (Perhaps if I tried it regularly, it might have a positive effect on that.) 

You may ask, as I have, what the difference between meditation and mindfulness is. 

In Transcendental Meditation, one of the most popular forms, the practitioner concentrates on a word or syllable that occupies the mind and tries to “transcend the process of thought.”  On the other hand, positivePsychology describes mindfulness as “active awareness of the mind as it wanders and repeatedly refocusing the awareness on the present moment.” The aim of mindfulness,  Rogers Behavioral Health says, is not quieting the mind, but aiming to focus “the attention to the present moment, without judgment.”

According to positivePsychology, mindfulness and meditation are “interrelated,” but “not the same.” The article does note that there is a practice called “Mindful Meditation” that combines the two. Mindful, in describing the intersection, says that mindfulness meditation teaches a person “to pay attention to the breath as it goes in and out, and notice when the mind wanders from this task.”

In essence, the goal seems to be disconnecting the mind from thought, though whether the mind is otherwise occupied differs from practice to practice.

Either one is considered suitable as an adjunct to psychotherapy, depending on whether a person’s goals are relaxation or “bringing the mind back to the present moment.” Meditation is thought to be useful in treating PTSD, while mindfulness has been used in treating “obsessive-compulsive disorder, depression,” in addition to post-traumatic stress disorder. Training helps people to become more aware of their thoughts, feelings, and body sensations so that instead of being overwhelmed by them, they’re better able to manage them. The Mental Health Foundation goes even further, claiming that the practice can give one  “more insight into emotions, boost attention and concentration, and improve relationships.”

The journal Mindfulness specifically reports on the usefulness of mindfulness in elementary schools and high schools. This study of studies reports that most of the positive aspects of mindfulness training occurred in high school students and that the effectiveness depended largely on whether the exercises were lead by someone from within the school or “an outside facilitator,” though the article abstract was mute on which was more effective.

NIMH, on the other hand, talks about mindfulness techniques in psychological settings. Specifically, it addresses “mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT),” noting that mindfulness training “should be accessible to everyone with a long-term physical health condition and recurrent depression.”

My own experience is that meditation, lead by an expert in the subject matter to concentrate on, rather than a simple syllable, can indeed be helpful in focusing the mind, rather than merely transcending thoughts. Perhaps the version involving transcending thoughts is more beneficial for phenomena such as relieving stress, lowering blood pressure, and calming agitation is a better use for this style of meditation. Mindfulness, on the other hand, I found to be interesting as a way to corral random thoughts, which I often suffer from, and I can see this practice being useful in daily life. 

I fear, however, that the mindfulness trend that appears to be sweeping the world means many different things to different people, and the benefits of it will depend on what benefits one expects to receive. Any more “mindfulness” is a word that has been taken over by the general population and in particular the business community. It can mean simply “mind” as in “Be mindful of your manners” or “be very aware” or “pay close attention to” as in “Be mindful of how much is spent on travel and entertainment.” Perhaps some agreement on what mindfulness is and what the practice consists of will prove to make it more useful in psychiatric and other settings. 

In that regard, both meditation and mindfulness practices are worth exploring further.

 

Distance Psychotherapy: Is It for You?

By Alice / adobestock.com

I will make a confession: I have never used distance therapy, except for when I couldn’t drive to my therapist’s office, my husband wasn’t available to drive me there, or when I had the last-minute I-just-can’t-go-today feelings or I’m having-a-crisis feelings. This was in the days before teleconferencing, texting, and other long-distance forms of therapy, so occasionally my therapist would agree to do a telephone session, which I appreciated greatly. In general, they didn’t last as long as the standard psychotherapy 50-minute hour, but at times they were lifesavers.

Now, when everything seems to be online, and especially during pandemic lockdown, quarantine, or simply fears of going outside, tele-psychotherapy seems to be becoming a thing. Many services are now available via the internet, smartphones, and whatever way you pursue your online life.

I’ve been looking at these services, not because I need one now, but because I want to know what’s available in case I ever should. The APA (American Psychological Association) provides a lot of helpful information on the subject. Their site has provided a list of pluses and minuses regarding telehealth for psychology. They note: “With the current research and with the current technology, mobile apps and text messaging are best used as complementary to in-person psychotherapy…Research does show that some technological tools can help when used in conjunction with in-office therapy,” though “There are cases in which Web-conferencing or therapy via telephone does seem to be a viable option on its own for some people.”

Inc.com provides a helpful list of the pros and cons of online therapy. Some positive aspects are that:

  • People in rural areas or those with transportation difficulties may have easier access.
  • Most online therapy services cost less than face-to-face treatment.
  • Scheduling is more convenient for many people.
  • Individuals with anxiety, especially social anxiety, are more likely to reach out to an online therapist.

among the negatives are:

  • Without being able to interact face-to-face, therapists miss out on body language and other cues that can help them arrive at an appropriate diagnosis.
  • Technological issues can become a barrier. Dropped calls, frozen videos, and trouble accessing chats aren’t conducive to treatment.
  • Some people who advertise themselves as online therapists might not be licensed mental health treatment providers.

Despite the concerns, research consistently shows that online treatment can be very effective for many mental health issues. Here are the results of a few studies:

  • 2014 study published in the Journal of Affective Disorders found that online treatment was just as effective as face-to-face treatment for depression.
  • 2018 study published in the Journal of Psychological Disorders found that online cognitive behavioral therapy is, “effective, acceptable and practical health care.” The study found the online cognitive behavioral therapy was equally as effective as face-to-face treatment for major depression, panic disorder, social anxiety disorder, and generalized anxiety disorder.
  • 2014 study published in Behaviour Research and Therapy found that online cognitive behavioral therapy was effective in treating anxiety disorders. Treatment was cost-effective and the positive improvements were sustained at the one-year follow-up.
  • A recent review of studies published in the journal World Psychiatry compared people who received CBT treatment online with those who received it in person.  The two settings were shown to be equally effective.

One possible pitfall, warns APA, is that “online therapy or web therapy services are often not covered or reimbursable by most insurance providers. If you plan to be reimbursed, check with your insurance company first. Otherwise, prepare to pay for the full cost yourself.” The services I explored charge about $35 to $80 per week for unlimited messaging and one live session per week. MDLive provides a psychiatrist at $284 for the first visit and $108 afterward. (They have lower rates for seeing a therapist rather than a psychiatrist, and do accept insurance.)

Business Insider, in its article on the subject, dealt specifically with a service infelicitously known as Woebot. Unlike the other services, Woebot is a “chatbot” that substitutes artificial intelligence and natural language processing for a real, live therapist. It uses cognitive behavioral therapy. Their website claims that Woebot “is the delivery mechanism for a suite of clinically-validated therapy programs that address many of today’s mental health challenges, from generalized anxiety and depression to specific conditions like postpartum depression, adult and adolescent depression, and substance abuse.” Like a non-directive therapist, it asks probing questions and responds to questions and answers from the user. For now, it is free to users, though they seem to be exploring a paying model.

Other telehealth counseling services include:

Amwell

Betterhelp

Brightside (depression and anxiety, not bipolar or mania)

Online-Therapy.com

ReGain (couples therapy)

Talkspace

teencounseling (will consult with parents)

If you decide to try online therapy, it’s best to compare services and determine what services they offer, at what price, and what the credentials of their therapists are. If you have already tried it, I would be glad to know the results. Feel free to comment.

 

 

The Journey to Proper Meds

By areeya_ann / adobestock.com

This week when I went to my four-times-a-year med check, I told my psychiatrist that I thought I needed a change in medication. The previous time I saw him I had expressed concerns over assorted Life Stuff that was making me extremely anxious. Given what was going on in my life at the time, the anxiety was understandable.

Since then my anxiety has lessened somewhat, now coming out mostly as irritability and difficulty sleeping. And my depression now makes me feel like I have a low-grade fever – logy, listless, exhausted (which is not helped by the sleep problems) – plus the usual depressive numbness, lack of holiday cheer, and all the rest.

My psychiatrist listened to my symptoms, then discussed my meds with me. There were only two, both mood levelers, that he would recommend increasing. I chose the one that had had the most dramatic effect on me when I started taking it. So he increased the dosage from 200 mg. to 300 mg. We’ll see how that works out. I’m to call him before my next med check if I need to.

I’m used to changes in medications. It took a long, trying – even painful – time for my previous psychiatrist and me to work out the cocktail of drugs that would alleviate my seemingly treatment-resistant bipolar disorder. We tried various antidepressants, anti-anxiety agents, anti-seizure meds, antipsychotics, mood levelers, and I-don’t-remember-what-else. At last, when we were about to give up and try ECT, one of the drugs worked. It took some more tinkering before we got the dosages right, but for years now, I’ve been on basically the same “cocktail” of drugs.

Psychiatric Times, in an article on switching antidepressant medications (most of the literature seems to focus on antidepressants), reports that approximately half of all patients fail to achieve an adequate response from their first antidepressant medication trial. High treatment failure rates make it critical for prescribers to know how to safely and effectively switch antidepressants to ensure patient-treatment targets are met.” Other publications put the figure at nine percent, one-third or two-thirds. Whichever is correct, it’s a substantial number.

One method of switching medication is simply called “the switch.” The patient goes off one drug and onto the other. But there are problems with that, including drug interactions between the old medication and the new one.

The technique most recommended is the one that my previous psychiatrist used with me, which is known as “cross-tapering” – tapering down on the first drug and then ramping up on the second. A “wash-out period” when no drug is given allows time for the first med to clear the body before the second is given. This is promoted as the safest method.

I can testify that it is also the slowest and most miserable. Going off one drug, being basically unmedicated while you wait for the second drug to ramp up, and then possibly going through the whole process again when the second drug doesn’t work either (or has side effects you can’t tolerate) is brutal. I went through the process more than once, and it was hell. Basically, it took me back to full-strength depression during the wash-out period and minimal to no effect as the new drug being tried ramped up.

However, eventually, we found a drug that made a huge difference and that, in conjunction with my other medications, allowed me to function almost normally. Close enough for jazz, as they say. The recent adjustment in dosage does not appear to be having much of an effect yet, but I didn’t expect it to. Pretty soon, relatively, I’ll know. And if it doesn’t help – or if it induces side effects – I still have my psychiatrist’s phone number.

References

https://www.psychiatrictimes.com/view/strategies-and-solutions-switching-antidepressant-medications 

https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

https://www.healthline.com/health/mdd/switching-antidepressants

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