Book review: Mindfulness For Bipolar Disorder

MindfulnessForBipolar

Mindfulness for Bipolar Disorder: How Mindfulness and Neuroscience Can Help You Manage Your Bipolar Symptoms by Dr. William R. Marchand lays out specific areas for mindfulness practices that be useful in managing bipolar disorder symptoms (and most if the book is also applicable to other mood disorders).  I believe mindfulness can be a really helpful thing to incorporate into one’s life, so I had originally intended to write this as a summary of the book’s suggestions rather than as a review of the book.  However, along with the good stuff I found a fair bit in the book that bugged me as well, so I didn’t think I should leave that out.

A note on language:  The author talks about things like “your everyday bipolar life”, “your bipolar self”, and “being bipolar”.  If people who have bipolar disorder want to talk about “being bipolar” because that’s how they conceptualize their self and their illness, that’s totally fine, but when people who don’t have a mental illness start talking about “being” bipolar/depressive/schizophrenic/anxious/personality disordered, it grates on me.  It bugs me because it sounds like they’re telling us that we are our illnesses, even though it’s not up to them to define us, our identities, and where our illnesses fit in.

Ok, time to delve into the practices the book suggests.

Daily meditation practice:

This meditation is focused on breathing, and bringing the focus back to the breath any time the mind wanders.  This noticing and refocusing is an important part of the practice.  The breath serves as an anchor for all of the other meditations described in the book.

Targeting bipolar depression:

This chapter looks at recognizing and moving out of autopilot thinking patterns, which often serve the purpose of trying to avoid emotional discomfort.  Instead, the aim is to accept the reality of the moment, unobscured by our own beliefs.  By mindfully accepting depressive symptoms rather than fighting them, they are more likely to fade away on their own.

The mindful minute meditation is suggested as a regular practice three times a day plus more often as needed.  It involves taking an inventory of the body, autopilot scripts that are playing, and mood, and then finding acknowledgement, acceptance, and presence.

Calming bipolar anxiety

The book talks about confronting one’s fears of impermanence.  “Being present with impermanence is the toll-free expressway to freedom from suffering.  This path leads to the solution to the bipolar puzzle and the solution to the puzzle of all our lives.”  In my own experience, when I’m depressed, I’m not experiencing fear about impermanence.  Quite the opposite, actually; ideas of permanence get me bogged down in hopelessness.  Maybe there’s a freight train blocking my toll-free expressway.

Avoidance is described as a cause of suffering, and the suggested meditation practice involves sitting with an anxiety-provoking idea.  This sounds similar to imaginal exposure work.  The steps in the meditation are:

  1. Focus on breath as an anchor for around 5 minutes.
  2. Bring into awareness a moderately anxiety-provoking situation.
  3. Observe what happens, including thoughts and bodily sensations.  Notice when shifts to autopilot occur and then refocus.
  4. Watch anxiety begin to fade.  However, don’t hold onto a preference for it to go away.

Observing your thinking pattern

This chapter focuses on autopilot, an idea that’s similar to negative automatic thoughts in cognitive behavioural therapy.  Autopilot learns from our past experiences, and one of its jobs is to protect us from getting hurt.  While this can be useful at times, it can prevent us from taking risks and lead to us getting stuck.  It’s useful to recognize how much we’re driven by autopilot, and see autopilots as just thoughts that are neither good nor bad.  Rather than suppressing them, we should try to be fully present.

The steps of the recommended meditation are:

  1. Focus on the breath.
  2. Expand awareness to physical sensations and then sensory input.
  3. Watch your thoughts like clouds in the sky.
  4. Relax in mindful awareness.

Working with mania and desire

While desire is a major source of motivation, it can also underlie discontent and dissatisfaction.  Autopilot scripts are often aimed at wanting to be different, and satisfaction doesn’t last long after desires are fulfilled.  Mindfulness allows desire to be seen as empty of substance; satisfying it doesn’t lead to true happiness.

The recommended meditation involves the same first 2 steps as in the previous chapter.  Then you bring a desire-provoking situation to mind, imagine an open space in your awareness where it can be present, and notice what arises in you.

Managing irritability and anger

In this chapter, thoughts and emotions related to desire and aversion are identified as causing the most problems in bipolar disorder.  It’s important to learn to be present with these emotions rather than try to suppress them, and recognize that thoughts and emotions don’t define who we are as people.

Mindfulness is presented as a way to find freedom from fearing your symptoms; it is this fear that tends to trigger autopilot.  The author goes so far as to suggest welcoming your symptoms, since they’re present anyway, and this will make it more likely that they will move along.  I’m uncomfortable with this choice of words, as I see a considerable difference between accepting what is and actively welcoming it to come and join the party.

Rethinking your bipolar self

Mindfulness gives distance from thoughts about self, which can fluctuate and often become more frequent with depression and mania; instead, these thoughts are allowed to just run in the background.  Mindfulness can allow you to be less attached to your own viewpoint, moving from an egocentric to a wider perspective.

The author explains that, “The answer to suffering is to move into mindful awareness, where you can be fully present with reality without needing to fix or change it.”  I think this is overly simplistic, and based on some of the other books I’ve read recently (A Fearless Heart and The Book of Joy), compassion is a major piece that’s missing here.

Furthermore, mindfulness “means experiencing at a deep level that, in each moment, the universe and everything in it – including you – is perfect as it is.”  From where I stand this is a load of crap.  It’s quite a large leap from acceptance to perfection.  If you consider the Buddhist idea that compassion is a wish for others and the self to be free from suffering, to see everything as perfect in the moment appears to deny the suffering of others and thus is an uncompassionate stance.

Being bipolar and happy

In this chapter, Dr. Marchand writes that ,“Mindfulness can teach you to view your illness as a gift.”  While it seems that what he’s trying to say is that there are things we gain from our illness experience, in my mind calling it a gift makes light of the very real pain and suffering people with mental illness and their loved ones experience.  Acceptance of the illness can be a powerful thing, and can allow us to see that there are things we gain from our illness, but that is very different from framing it as a gift.

Happiness is presented as something that “is always available to you right here and now…  From the viewpoint of mindful awareness you can be happy and joyful in this very moment…  That is the gift of mindfulness.”  I’ve ranted before about the idea that happiness is a choice.  I’m not saying that mindfulness can’t make it easier to find happiness, but I strongly disagree with the assertion that happiness is always available to everyone at any given moment if you only think in the right way.  According to Dr. Marchand, this is as simple as doing a meditation that begins with the breath, then expands the awareness, and “now allow happiness and joy to arise”.  The ad slogan “thanks, Captain Obvious” jumps to mind.  How remarkably unhelpful.

So in the end, for me the irksome in this book tended to drown out the good, but I still believe in the benefits of mindfulness, and I’m going to continue to work on incorporating it into my life.

 

You can find my other book reviews in my blog index.

 

 

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In times of life or death

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As some of you are likely already aware. one of our fellow members of the mental health blogging community attempted suicide earlier today, and posted a suicide note on her blog.  I choose not to link to her blog here because for those of you who aren’t already familiar with her amazing work, I don’t want to introduce you to her at her most desperate moment.

I saw it about an hour after it was posted, and my heart started pounding as I wondered what the hell I was going to do.  I flailed around feeling powerless for a bit before realizing that her Twitter page stated where she lived.  I called the police there, and they said they’d already made contact with her.  I then saw that I’d gotten a message from one of her Twitter followers, who had made the initial contact with police that resulted to them getting to her in time (thankfully; who knows, this may not have been the case if mine had been the first contact).  The police were able to get to her and get her much needed help because there was sufficient identifying information in her online accounts for them to figure out who and where she was.

That got me thinking.  Many of us value our anonymity, and very deliberately choose not to put identifying details about ourselves online  And at the same time, many of us do experience thoughts of suicide at times due to our illnesses.  If we, in moments of desperation and hopelessness, were to publish our intentions or actions with respect to suicide, would fellow bloggers who wanted to help us be able to figure out how?

WordPress doesn’t have a lot to say about the matter.  In their page on “Self-harm and online safety“, they suggest calling the authorities if you know the person, and posting suicide resource information for them if you don’t.  You can “report content“, but it doesn’t sound like this is likely to accomplish much, if anything.

Thinking about myself, the city where I live is displayed on my Twitter account.  I don’t use my full name, but I’ve done some guest posts under my full name, and that probably wouldn’t be too hard to find.  They would mean my first, middle, and last names woild be available, , plus I’m already in the local police system as an “emotionally disturbed person” (police jargon for contacts they have with someone with mental health problems), so they’d probably track me down fairly quickly.  I’m not sure how comfortable I feel with that, to be honest.

Being on the other end, as a fellow blogger wanting to help, the feeling of powerlessness is terrifying.  The desperate desire to help crashes headfirst into having no idea where to even start.  In this particular instance, enough pieces were there, but what if that wasn’t the case?

I’m not sure what the answer is, or if there even is an answer.  We can hope this is an issue that won’t come up very often, but I think the reality is that it’s inevitable that sometimes it will arise.  It’s probably better that we start to think about it when we’re not trapped in the darkest depths, and consider how many crumbs of information we’/re prepared to dole out, and much power we are willing to offer to our fellow bloggers to help us if things get really bad.

 

Image credit: Ian Espinosa on Unsplash

Book review: Birth of a new Brain – Healing from Postpartum Bipolar Disorder

Birth of a New Brain book cover

Birth of a New Brain – Healing from Postpartum Bipolar Disorder chronicles author Dyane Harwood’s journey with postpartum onset bipolar disorder.  The story’s rich, vivid descriptions draw the reader along on the intense roller coaster ride of the author’s illness experience.  Many elements of her story will be hauntingly familiar to those whose lives have been touched in some way by bipolar disorder, including mood symptoms whose true nature only became apparent with hindsight and well-meaning attempts to get off medication that result in disaster.

Mental illness was a part of Dyane’s life from the beginning, as her father had bipolar disorder.  When she first began to struggle with her own mental health, she was diagnosed with depression.  Glimmers of hypomania made occasional brief appearances, but as is so often the case with hypomania the symptoms were only recognizable as such upon later reflection.

Depression is the most recognized postpartum mental health problem, while postpartum hypomania may not raise red flags.  As Dyane began to recognize that her thoughts were problematic, she became concerned, as many mentally ill new mothers might, that disclosing the true nature of her thoughts would result in her being designated an unfit mother.

It was after the birth of her second daughter that mania openly reared its head, resulting in a diagnosis of bipolar disorder with the specifier of “postpartum onset”.  Dyane described the surreal experience of hypergraphia, an uncommon symptoms involving excessive writing, including the juggling act of franticly writing while at the same time tandem breastfeeding her infant and toddler.

Dyane was hospitalized multiple times for her illness, and she recounted the sorts of challenges that are all too commonly faced by those with mental illness.  On one occasion she was handcuffed by police and taken to hospital in the back of a police car.  She was reported to Child Protective Services by one hospital psychiatrist, and when she reacted angrily she was placed in a seclusion room.  Being on locked wards that prevented from going outside and kept her cut off from internet and cell phone use had a detrimental effect on her recovery, and her hospitalizations worsened her anxiety and raised concerns about post-traumatic stress.  Mental health services could certainly benefit from incorporating this type of feedback.

Birth of a New Brain captures the frustration and desperation of treatment-resistant mental illness.  Dyane was trialled on numerous medications that triggered horrible side effects rather than a therapeutic benefit.  One particularly harrowing experience was with the antidepressant amitriptyline; taking a single dose led to intense suicidal thoughts requiring hospitalization.  Electroconvulsive therapy (ECT) was helpful, but she struggled with the considerable logistical and financial barriers that often go along with outpatient ECT.  For therapies like ECT to be at their most effective, it is important that mental health services work to minimize these sorts of barriers.

Over the years Dyane went off medications multiple times.  Despite giving it careful thought, consulting books by credible sources, and incorporating alternative strategies, her illness relapsed.  Finally she found success with an MAOI antidepressant, an option that has strong evidence of efficacy but is seldom considered due to the need for dietary restrictions. Once she was finally stabilized on an effective medication combination, she accepted that for her the reality was that medication would be an essential part of her wellness.  The book also describes a host of holistic strategies that Dyane incorporates as key elements of her treatment plan.

Birth of a New Brain offers hope to those struggling with mood disorders, and raises awareness about the little-known postpartum onset specifier for bipolar disorder.  By the end of the book the reader is left feeling as though Dyane is a dear friend who has bravely shared all and held nothing back.  While mental illness plays a starring role in the story, as Dyane concludes her final chapter, “I’m so much more than bipolar.  And so are you.”  Her book reminds us that no matter how hard the illness journey may be, recovery is possible.

Birth of a New Brain – Healing from Postpartum Bipolar Disorder

Foreword by the perinatal psychiatrist and acclaimed author Dr. Carol Henshaw. Available on Amazon in paperback & Kindle versions!

You can also find Dyane Harwood on her blog, Birth of a New Brain, and on Twitter @DyaneHarwood.

 

You can find my other book reviews in my blog index,

Psych meds 101: Mood stabilizers

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This is the 3rd in a series of primers on how psychiatric meds work.  The previous posts were on antidepressants and antipsychotics, and upcoming are anti-anxiety meds and sleep meds.  These are based on my professional knowledge as a mental health nurse and former pharmacist as well as my own experiencing taking these medications (although with a diagnosis of major depressive disorder I’ve never taken any of the anticonvulsant mood stabilizers).

Mood stabilizers work in a number of different ways to control signalling between nerve cells.  They are used to treat and prevent both mania and depression, although some drugs are more effective for one than the other.  They fall into 3 broad categories: lithium, anticonvulsants, and atypical antipsychotics.

Lithium

Lithium has been around for many years.  It works via a number of different mechanisms, including regulating genetic expression of various neuron-related factors, and boosting activity of the calming neurotransmitter GABA.  GABA counterbalances the excitatory neurotransmitter glutamate.  Lithium is effective for both mania and depression, and has been shown to decrease the risk of suicide.

Lithium is a type of salt, so blood levels are affected by kidney function and hydration status.  In the past, some people developed kidney damage from long-term lithium use, but that is rare now as we have a better understanding of what levels are safe.  People taking lithium need periodic bloodwork to check their lithium and creatinine levels (an indicator of kidney function).  Target levels are 0.6-1.2 mmol/L, with higher levels being needed in acute mania.  It takes 5 days after a dose change for blood levels to restabilize.

Lithium can potentially cause a lot of side effects: nausea/vomiting/diarrhea, tremor, weight gain,  hair loss, acne, frequent thirst, frequent urination, hypothyroidism, and effects on the heart.  And if that wasn’t enough, lithium toxicity (levels over 1.5) can cause confusion or even seizures and coma.  Yikes.  Except lithium works very well, and some people may have no side effects at all.

Lithium has definitely been effective for me.  I’m using it for depression, so I aim for levels between 0.65-0.8 depending on how I’m doing.  I have side effects, but for me the benefit outweighs the negatives.  I have a tremor, which is worse when I’m fatigued or if I’ve had to increase my dose.  Taking propranolol (a beta-blocker) helps with this.  I’ve gained weight on meds, but I’m on 2 other meds that cause weight gain so it’s hard to tell what’s causing what.

Anticonvulsants

These medications were initially developed as anti-seizure medications, but have since come to be used as mood stabilizers.  They affect signalling between nerve cells by acting at voltage-sensitive ion channels that allow sodium/calcium to flow in and out of neurons, and they also boost GABA neurotransmission.

Valproic acid/divalproex

These are essentially the same molecule, but divalproex can be formulated into an enteric-coated tablet that decreases stomach upset.  Valproic acid is effective for mania, but it is less clear how effective it is for bipolar depression.  Dosing is targeted to reach a blood level of 350-700 µmol/L.

Side effects include nausea, sedation, weight gain,  hair loss, tremor, negative effects on the liver, cessation of menstrual periods, and polycystic ovarian syndrome.  It is also teratogenic (causes harm to a developing fetus).  I talk more about this in my post on mental illness and childbearing.

Carbamazepine

Carbamazepine is most clearly effective for mania.  It affects the liver’s cytochrome P450 system, leading to interactions with a number of different medications.  It can also decrease the reliability of oral contraceptives.

Side effects include gastrointestinal upset, sedation, dizziness, impaired coordination, and negative effects on the liver, white blood cells, and platelets.

Lamotrigine

Lamotrigine is not effective for bipolar mania, and works best for the prevention of bipolar depression.  It interacts with both valproic acid and carbamazepine, requiring adjustments in dose.  It must be initiated slowly to decrease the risk of Stevens-Johnson syndrome, a type of severe rash.

Other side effects include dizziness, headache, double vision, drowsiness, impaired coordination, nausea, and weight gain.

Others

There are other anticonvulsants that have been tried in bipolar disorder but don’t necessarily have strong evidence to support their use.  These include levatiracetam and topiramate.  Gabapentin does not appear to be effective.

Atypical antipsychotics

The mechanism by which atypical antipsychotics have a mood stabilizing effect is not entirely clear, but may be related to their action at the 5HT2a serotonin receptor and resultant effects on glutamate, dopamine, norepinephrine, and serotonin signalling.  They are useful for both bipolar mania and depression.  Examples include lurasidone, aripiprazole, quetiapine, and olanzapine (which can be combined with the SSRI antidepressant fluoxetine for bipolar depression).

For more detail on atypical antipsychotics, please have a look at my post Psych Meds 101: Antipsychotics.

Role of antidepressants

There are two key problems with antidepressants in bipolar disorder: they don’t work particularly well, and there is a risk of triggering mania.  The International Society for Bipolar Disorder task force on antidepressant use found that evidence for antidepressant use is limited and weak, and as a result they could not broadly endorse the use of antidepressants in bipolar disorder.  An exception is fluoxetine, which is effective when used in tandem with olanzapine.

For more on antidepressants, you can read my post Psych Meds 101: Antidepressants

In conclusion…

I hope that this has all made sense and shone some new light on mood stabilizers.  If you have any questions please feel free to shoot them my way!

 

Photo credit: nosheep on Pixabay

Organizing my way through the darkness

day planner book

I will freely admit that I’m a bit of an organization nut.  It’s a trait that has served me very well in terms of maintaining functioning while bogged down in an episode of depression.  I’ve been doing this depression thing long enough that I know what my deficits tend to be when I’m unwell, and I draw on that knack for organization to create a sort of safety net for myself.

Mental illness can wreak havoc on memory.  When I’m ill, my brain feels like a strange hybrid of Swiss cheese and mashed potatoes.  Since I am aware of this, I can try to plan ahead for it.  I do this by setting up an organizational system that can compensate for some of my deficits.  When it comes to important things, my backup plan needs its own backup plan, since I know that I might not always remember to put things in my calendar, for instance.  This has come to the rescue a few times, including saving me from being a no-show for visits I’d booked with my patients for my home care nursing job.

I rely heavily on my Google calendar.  Everything goes in there as soon as it’s arranged (unless I’m really scattered and forget this crucial part of my system).  I use color-coding to separate work and personal, and have recurring reminders set up for things like bill payments.  I’m also a great lover of lists, and use Google Keep along with Apple Notes.  I’ve got checklists breaking more complex tasks into individual components for those days when I’m feeling too overwhelmed to know how to do anything.  The goal is to rely as little as possible on my brain to remember things.  Working on getting/staying well is hard enough, and any brainpower I can free up is a good thing.

2017 calendar displayed on a smartphone

When depression muddles my thinking, making simple decisions can seem overwhelming and impossible.  If I haven’t decided ahead of time what kind of yogurt I’m going to buy, I might stand in front of the yogurt section at the grocery store for 10 minutes with a blank stare on my face and absolutely no idea how to make a decision about what to buy.  It’s not a matter of anxiety over what the right decision is, but more like that part of the brain that knows how to make decisions has decided to close up shop and take a siesta.  There has been many a time that I have simply left a store empty-handed, because the default decision is do/buy nothing.  I’ve learned that when I’m feeling like this, I need to decide exactly what I’m going to get ahead of time, when I’m not faced with an array of options.  It feels a bit silly to be so rigid, but it’s a lot less silly than staring stupidly at a sea of yogurt containers.

Mental illness can warp how we see the present in relation to both past and future.  It can be very hard to see a pattern in our symptoms and what might be triggering them.  Technology can be a powerful tool to gain insight into what is happening both inside and outside the mind and body.  I use apps to track almost everything I do: sleep, mood, diet, activity, menstrual cycle, medication changes, alcohol, stressful events, work, etc, etc.  Again, it feels kind of silly to be this rigid, but it helps me understand how I’m doing, and makes it s lot easier to answer questions that my health care providers might ask.  When my depression leaves me feeling totally powerless, tracking things on my apps can help me feel a little bit more in control.

cup of coffee, cell phone, and book sitting on a tableHaving a routine is very important to me, especially when I’m not well.  It gives me a sense of peace, and makes it easier to turn down the volume on my thoughts.  Most important is my morning routine.  I drink tea, tea, and more tea, read the discussion forums on a mental health app I use, meditate, and do crossword puzzles.  Even my pet guinea pigs support me in sticking to the ritual – they know that their veggies come at the same time as mama’s first and second cups of tea, and if I happen to forget, they will give me loud squeaky reminders.

We all have our little tricks to help us cope with the day to day experience of mental illness.  These are some things that have worked for me, but it’s always great to learn new strategies from other people who are dealing with the same sorts of issues.  Together we can be stronger, and our bags of tricks can help us make it through.

 

Photo credits:

stevepb on Pixabay

geralt on Pixabay

Juja Han on Unsplash

When taking a shower is like climbing a mountain

silhouette of a mountain climber

 

We’re supposed to dream big, aim high, reach for the sky, and all that crap.  But what about those days when your mental illness is kicking your butt and you barely have the energy, motivation, interest, or presence of mind to haul your a** out of bed, much less hold yourself up for the duration of a shower?

Let me be clear, setting goals is a good thing.  Pushing yourself to do more than you think you’re capable can allow you to do things you thought you could only dream of.  However, the goals you set should be realistic, and what’s realistic is going to change based on how your illness is currently affecting you.  If you’re setting yourself up for failure, how is that doing you any favours?

When my depression is severe, just getting out of bed can be a gargantuan effort.  If I were to try to go outside for a walk because that’s what you “should” do when you’re depressed, I probably wouldn’t make it beyond the front door.  That would make me feel even more negative about myself, and reinforce the thoughts that I’m useless, pathetic, etc., etc.  I find that I don’t tend to devote a lot of energy to comparing myself to others (perhaps because I hate people when I’m depressed), but I do compare myself to my level of functioning when I’m well.  Realistically, though, that’s not a fair comparison.

The way I try to look at it is that goals should be proportionate to the amount of energy you have and the amount of energy it would take to complete a task.  If depression is sucking the life out of you and your energy level is so low that if it were a gas tank you’d be running on fumes, is it reasonable to plan on going for a 4-hour drive on that empty tank?  Hmm, not so much.

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So I say, if taking a shower when you’re severely depressed takes about the same amount of energy that it would take you to climb Mount Kilimanjaro when you’re well, then taking a shower is a huge goal and an accomplishment worth celebrating.  The fact that showering when you’re well is easy is totally irrelevant.  It’s not an apples to apples comparison or even an apples to watermelons comparison; it’s more of an apples to mountains comparison.

As I nurse I try to tell both myself and my patients to aim low and dream small when feeling really unwell.  Achieving a “small” goal will serve you better than failing at a bigger goal.  And don’t forget to congratulate yourself for that mountain-summit-equivalent shower that you didn’t think you could do.  You absolutely earned it.

 

Photo credits:

Sam Mgrdichian on Unsplash

Catherine McMahon on Unsplash

This one flew over the cuckoo’s next: ECT in real life

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Ask anyone of a certain age what comes to mind first when they hear the term electroconvulsive therapy (aka ECT, aka electroshock therapy, aka shock therapy), and chances are they will mention the film One Flew Over the Cuckoo’s Nest starring Jack Nicholson.  Given the lack of more realistic portrayals of this treatment, ECT may be viewed as a dangerous, obsolete treatment.

Except it not.  ECT is a very effective treatment option for depression, and can also play a role in mania and psychosis.  One of the biggest benefits is that it works fast, much faster than antidepressants could be expected to start working.  That’s why I first received ECT; it was my first hospitalization, I was highly suicidal, and the treatment team just wasn’t prepared to wait the weeks it would take to see if I would respond to the antidepressant that had been started.  I was too ill to be able to remember any of those first few weeks, and I was being treated on an involuntary basis, but being a mental health nurse I probably knew at least on some level that this was a good idea.

The ECT process itself is fairly simple, and very different from Jack Nicholson’s ECT scene in One Flew Over the Cuckoo’s Nest.  In the movie a bite block was roughly shoved in his mouth, a shock was applied with no anaesthetic, and he began wildly thrashing about.  None of this is representative of current ECT practice.

As a patient, they put you out cold with a general anaesthetic (such as propofol) and a muscle relaxant (succinylcholine).  These are given by IV and knock you out within seconds.  I had the odd experience of getting a yummy smoky sort of smell after they injected the meds, even though the only thing coming through the mask on my face was oxygen.  One of the reasons I like ECT is because I love that smell.  This is not something I’ve heard anyone else report, but I experienced it every single time.  Once you’re anaesthetized, they fit the rubber bit guard into your mouth to protect your teeth and tongue.  The shock is delivered via two electrodes placed on the head.  The muscle relaxant means there is not a visible seizure; instead, the intensity of the seizure is measured via EEG (electroencephalogram).  You wake up feeling fairly clear-headed (at least in relation to how you were feeling beforehand); sometimes I haven’t even realized the ECT had already been done.

cuckoo_clock

There are various parameters that can be adjusted in the delivery of ECT, one of which is the electrode placement.  Unilateral ECT, which involves both electrodes being placed on the same side of the head, is less likely to cause side effects.  Bilateral ECT, which involves one electrode on each side of the head (on either the temples or forehead), is more effective but also more likely to cause side effects.  Unilateral didn’t work very well for me, so after my first few treatments I’ve always had bilateral ECT.  I’ve also required relatively long courses of ECT; instead of the typical 8, I’ve needed 15+ during a couple of my hospitalizations.

I am one of those mental health professionals who tells clients that ECT typically doesn’t have significant effects on memory.  That’s absolutely true, but my experience was not typical.  I have experienced a lot of memory loss from ECT, although it hasn’t impacted my ability to form new memories after completing treatment.  Mostly it was short-term memory that was effected, but some of the memory loss has gone farther back.  There have been substantial chunks of time that have gone missing from the months leading up to my first hospitalization.  Some of these eventually did return, but many didn’t.  It was truly  bizarre to have people tell me things that I did or even show me photographs taken of me, and I would have sworn that these events never occurred.  I feel absolutely certain I’ve never been snow-tubing, yet there’s a photo of me doing exactly that at a local ski hill.  My family tends to notice the memory loss the most, as I say the same things and ask the same questions over and over.  On a lighter note, after each discharge from hospital after a course of ECT, it was kind of fun to return home to an assortment of what seemed like brand new clothes/shoes/household items that I had no memory of purchasing.

Despite the disruptive effects of the ECT-induced amnesia, it remains very much on the table as a treatment option for me.  I would probably ask for outpatient ECT right now if it weren’t for the requirement that someone be available to take you home after treatments and keep an eye on you (a safety precaution because of the use of general anaesthetic).  This is just not feasible in my circumstances right now, and it bothers me that this restriction limits my access to effective treatment.

So, that’s my journey over the cuckoo’s nest.  A lot less movie-worthy than Jack Nicholson’s, but a lot more real.

 

Image credits:

Kellepics on Pixabay

OpenClipart-Vectors on Pixabay

Do I look fat in this Seroquel? – Mental illness, meds, and weight

scale

Society is obsessed with how we look, and in particular what size we are.  Even people who are generally quite polite feel entitled to comment on our weight and body shape, without having any idea what the backstory might be.  In the case of mental illness, there is often a great deal of backstory.

Over the last 10 years, there’s been about an 80 pound span between my lowest weight and my highest, and I’ve ranged from a size 6 to a size 16.  When I’m depressed, I tend to lose my appetite, and at times have lost significant amounts of weight because of this.  When I’m really unwell, I could easily go days without eating, but I know that I should eat, so I try to force food down.  When this is too hard I try to choke down something like Boost instead.  The only time I have ever counted calories was when I was pushing myself to cram in 1000 Calories a day, about half of what I should actually be taking in.  When people complimented me on my weight loss, I would have thrown those bottles of Boost at them if I had the energy.  Why did these people see skinny sick me as somehow better than curvy well me?  It was almost certainly done out of ignorance rather than malice, but that shouldn’t make it okay to essentially say “you look better when you’re sick”.

capsules and tape measureFor the last several years I’ve been on a trifecta of weight gain-inducing meds (quetiapine, mirtazapine, and lithium) that tipped the scales to over 200 pounds.  I had mixed feelings as the weight piled on.  I wasn’t thrilled about the changes in my body, especially since it felt so out of  my control.  Still, that med combo kept me well for a few years, and that was really my priority.  After a solid period of stability on this med combo, I decided to try going off the Seroquel, hoping that would bring my weight down a bit.  What actually ended up happening was that I had a relapse of my depression.  At that point I decided it was time to just fully accept my new body, because if I wanted to be well I needed these meds.

Earlier this year I began seeing a naturopath.  I had gotten depressed again despite my med cocktail, and I was willing to try anything that might help.  Based on my history and bloodwork, one of her recommendations was an anti-inflammatory diet.  It’s not a weight loss diet; instead, it’s all about putting healthy foods into your body and keeping unhealthy things out.  I have ended up losing some weight as a result, and I’m feeling more comfortable in my body, but I’ve faced the issue again of people commenting on my weight loss.  Yes, the weight loss is a healthy thing this time around, but people don’t know anything about that when they make comments.  My body should not be theirs to pass judgment on.

I don’t recall ever actually saying anything in response to the people have commented on the changes in my body.  There’s just too much backstory to be able to fit into a one-line zinger.  Our bodies may reflect to some extent what’s going on inside of us, but often not in a way that is consistent with societal expectations around body size and shape.  From anorexia nervosa to depression to binge eating disorder, our bodies can be warped by our illnesses.  I just hope that someday more people will understand that.

 

Photo credits:

TeroVesalainen on Pixabay

mojzagrebinfo on Pixabay

Navigating mental illness and childbearing

pregnant woman in shadow

For much of my life I haven’t wanted children.  In many ways this has been selfish; I wanted to live my life for me, and I wanted to be able to travel and do things that would be hard to do with a little one in tow.  My perspective began to shift after my first episode of depression, particularly after it became clear that it was going to be a recurring illness.  Safety became a flashing neon sign that there’s no way to ignore.

You occasionally hear horror stories of mothers who killed themselves and their infants due to postpartum depression, and I seriously worry that I could be that next horror story.  If postpartum depression can wreak havoc in the lives of women who don’t have a pre-existing mental illness, what is likely to happen to a woman with a history of depression with psychotic features and multiple suicide attempts?  I’m inclined to look at depression during pregnancy and/or postpartum as almost a foregone conclusion if I were to get pregnant, and while I might be exaggerating the risk to some extent, there is very real cause for concern based on my history.  It doesn’t help that this is not something that easy to talk about.  There is so much stigma around this issue, despite the courageous women who speak up and share their stories (like the amazing ones here on WordPress).

Medications are also a safety issue in pregnancy and, to a lesser degree, in breastfeeding.  Most of the meds I’m on are relatively benign, but lithium is known to increase the incidence of Ebstein’s anomaly, a type of heart defect.  In my case, the risks of going off lithium would almost certainly outweigh what is still a small absolute risk of this birth defect, but the idea of putting something in my body that is known to pose a risk to a fetus is disturbing, to say the least.  I can’t even imagine what women stabilized on highly teratogenic (i.e. likely to cause birth defects) psychiatric medications like valproic acid must struggle with when planning for a family.

parents' hands cupping baby feet

Electroconvulsive therapy has been shown to be safe and effective during pregnancy, although it is not often used.  ECT has been helpful for me in the past, and it’s likely something I would turn to again if I got pregnant.  I have to wonder, though, what level of stigma would go along with that.  I would imagine that most people’s initial gut reaction would be that this must be dangerous for the fetus, and to be honest, I would probably have a hard time silencing that thought in my own mind.  Postpartum, I would be concerned about my ability to care for a child if I was getting ECT, since I tend to have significant memory problems as a side effect.

Then there’s the issue of passing on genetic susceptibility to mental illness.  I don’t want to put a child through what I’ve had to struggle with.  The interplay between genetics and mental illness is complex and not well understood, and there are genetic counselling services available to get a more realistic evaluation of the risk, but I’m not sure if that would set my mind at ease.  My own family psychiatric history consists of one great-uncle with schizophrenia.  Period.  Yet I ended up with major depressive disorder.  Why did I get sick?  Who knows,  Maybe there is no rhyme or reason to life kicking your ass.

For the time being this remains an abstract question for me, but with my biological clock ticking and my most fertile years behind me, it’s likely a question that will continue to nibble away at my mind.  Maybe I won’t have kids, maybe I’ll adopt, maybe I will have biological children, but regardless of which path I take my illness will never be far from my mind.

 

pink baby booties

 

Photo credits:

Joey Thompson on Unsplash

marusicova on Pixabay

TerriC on Pixabay

Mashed potato brains and other adventures in depression

mashed-potatoes

This has been a busy week for me.  I mean that very much in a relative sense rather than an absolute sense, as I doubt anyone else looking at my calendar would use the term “busy” to describe it.

I have always found the cognitive symptoms of depression to be among the most disruptive to my overall functioning.  When I’m really unwell it feels like I can’t think my way out of a paper bag.  I tend to describe the effect on my thinking as “mashed potato brains”; it seems like a fairly apt analogy.  My current depressive episode has stretched over the last year and a half, and the cognitive symptoms have ebbed and flowed over that time.  When my thinking starts to get clearer I’m able to feel a bit of hope and optimism, but then a week like this week comes along.

It wouldn’t bother me as much if there was something stressful that triggered the decompensation (I use this psychiatry term because it’s the only one that comes to mind).  That might seem logical.  But no, I don’t have that excuse.  I have just asked my brain to do a little bit of outside-the-routine thinking, and I get totally overwhelmed.  Hello mashed potato brains.  When I went on Pixabay to look for an image for this post, I couldn’t even remember how to spell potatoes (although I did realize that potatos looked a bit funny).

Just before I started writing this post, I was looking through my WordPress Reader feed, and I saw the post Losing My Mind on Travis and the Brain.  I felt relieved – relieved that I’m not the only one losing my mind, and relieved that even if we’re drowning we can help pull each other out of the water.

drowning_hand

 

Photo credits:

422737 on Pixabay

Photo by Ian Espinosa on Unsplash

“You can be a real bitch” – Is it me or my illness?

man holding up an irritated face sign

I can get pretty irritable sometimes because of my depression.  I seem to lose access to all of my more mature self, and revert to what may have worked best when I was five years old.  This can have a major impact on my behaviour, and sometimes I have let fly with yelling, screaming, and swearing.  This has occurred most often when I’ve been hospitalized, and has been directed at nurses and doctors whom I perceived as making things more difficult for me.  One of my former community psychiatrists once told me “you can be a real bitch when you’re not well”.

Several years after my first hospitalization, I learned that one of the diagnoses on that first discharge summary was borderline personality traits.  Subsequent psychiatrists have disagreed with that diagnosis, as the maladaptive coping mechanisms only make an appearance when I am ill, as opposed to personality disorders involving traits that are consistent over time.  It begs the question, though – to what extent do our coping strategies and behaviour when ill reflect (or not reflect) our core selves?

ostrich with grumpy faceI am not generally an irritable person, so when I become irritable due to my depression, I’m not sure if things are suddenly bothering me that I never would have noticed, or if I’m just more disinhibited about expressing irritation that I would normally just brush off.  In other words, is something new happening, or is there just an amplification of what’s already there?  While in the end it probably doesn’t make a whole lot of practical difference, it’s worth thinking about in terms of self-identity.

Is my mental illness part of me or is it something that happens to me, a monster on my back that I have to carry around?  I have always tended to lean toward the latter view, because I don’t think my illness should define me.  Perhaps it’s also in part because I don’t want the real me, my core self, to be responsible for my bad behaviour.  Then again, no one is responsible for my actions but me, although the options I have to choose from seem to be very much influenced by my illness.

The perspective that I’ve sort of settled on is that we all have our inner caveman brain, including bits like the amygdala, and in times of stress and difficulty, that is what gets activated.  Our prefrontal cortex, the most advanced part of our brain in terms of evolution, is what generates our most adaptive coping mechanisms.  In personality disorders, factors such as trauma can impair the development over time of these sorts of adaptive coping mechanisms.  In conditions such as mood disorders, our ability to access our adaptive coping mechanisms seems to be impaired in the acute illness phase, leaving us to default to what caveman brain can provide us.

So am I a bitch, or is it my illness?  In the end, probably some of both.

 

Photo credits:
PDpics on Pixabay

chezbeate on Pixabay

 

 

My hermitification: Depression and isolation

woman behind a curtain

Okay, so I completely made up a new word in the title of this post, but I’m guessing you can tell what I mean.  Depression is a profoundly isolating illness, as many mental illnesses can be, and as my illness progresses in many ways I find myself evolving into a hermit of sorts.

I have always been an introvert, but I used to really value time spent with close friends.  And then depression hit, and everything changed.  When I am depressed, I hate being around people.  Depending on my particular set of symptoms at the time, being around others can be exhausting, irritating, overstimulating, anxiety-provoking, or mood-lowering.  I used to try to push through this, thinking that I “should” socialize even if it made me feel worse, because that’s one of the things you’re “supposed to” do to get better.  But that now feels like a dead horse that’s been beaten long enough.  Over the last year and a half of this current episode of depression, I have systematically cut almost everyone out of my life.  I don’t have the internal strength or resources to have a mature adult conversation with anyone about this, so I have taken the path of least resistance and just stopped responding to calls/texts/emails.

I don’t like being this person that depression has made me.  My family and friends (now former friends) certainly deserved better.  I feel like they must hate me for my ghosting behaviour.  Yet that hasn’t been enough to stop me from this pattern of behaviour, because it’s not about them as much as it’s been about retreating as a perceived path to self-preservation.

Looking forward into the future, it’s hard to imagine how I would ever rebuild a social life, knowing that I will get depressed again, and I will hide out in my figurative cave again.  Why would I let people in knowing that I would most likely at some point just slam the door shut in their face?  Guilt plays into this too – if I am such a terrible daughter/sister/friend, why should I even deserve to have people in my life?

face partly obscured by handsAs much as I might wish to be able to hide out 24/7, it’s just not feasible.  Yet even when I venture out into the world, it feels like there is a self-imposed barrier that isolates me.  I either am not able or don’t remember how to have a genuine connection with another human being.  So I put on the mask to try to hide the darkness inside of me, and struggle with those superficial social interactions that normally wouldn’t merit a second thought.  It makes for a very lonely existence, one that is entirely of my own making.

Strangely enough, the only setting in which I feel comfortable emerging from my cave is with my patients (I’m a nurse).  Somehow that part of me is still able to function interpersonally, and I’m not sure why that is.  I think it might have to do with spontaneity.  I’ve been a nurse for 13 years, and by now I don’t even have to think about what my response is going to be; I just know, and I do it.  At least it gives me reassurance that i haven’t fully transitioned to hermit mode.  Not yet, anyway.

 

Photo credits:

Steinar Engeland on Unsplash

Elijah Hiett on Unsplash

Living in fear: The tsunami of depression

crying woman inside a rainy window

While fear may not be a symptom of depression, it is certainly something that has become tightly woven into the fabric of my illness.  When I am well, I am fearful of when the next relapse might be, when the ground might disappear beneath my feet.  When that relapse happens, I am terrified – here we go again with yet another tidal wave to wash my life away.  And as a depressive episode stretches out, I am scared that I won’t get better, that I will drown in this mental pain.

What is probably the most frightening is the lack of control.  I can be doing what would appear to be all the right things, and I will still get sick.  As the years have passed it has become harder and harder to control my illness, so the fear only escalates.  This current episode has lasted for almost a year and a half, and I am utterly terrified that I will never get my well self back again.  I miss her so much, but she is either gone, washed away in the tsunami of my depression, or drowning in a dark basement somewhere.  If only there was a “find my iPhone” for the real me, to give me a life preserver to hold on to.

A few years ago I was making my case before a review board about why I should not remain committed to the psychiatric ward.  As a mental health nurse, I’m a bit of a research geek, so I was talking about the STAR*D research study, which essentially showed that the more treatment failures a patient has the worse the prognosis.  I argued that my suicide attempt stemmed from “evidence-based hopelessness” (although looking back, I’m not sure why I thought that would help my case).  Perhaps a better way to put it, though, would be evidence-based fear – fear based in the evidence of my personal experience and reinforced by the research evidence I was reading.  If I am already fearful that I won’t get better, it becomes very hard to challenge that kind of thinking.

woman drowningI’ve been learning recently about acceptance and commitment therapy (Russ Harris’s ACT Mindfully site is a great resource if you’re interested in reading more), and contemplating how fear fits in with this idea of acceptance rather than resistance.  Is this fear a form of resistance?  And if so, maybe it’s resistance in a good way – a reason to keep fighting for recovery.  Or maybe acceptance lies in making space for this fear, acknowledging it as a neighbour that’s not going to be moving away any time soon.

As I struggle to tread water in the sea of my depression, perhaps I have to both accept and resist.  Resist the urge to stop struggling and just drown already, and accept that another wave might come at any time and push me under.  In the end, whether I feel fear or not, que sera sera.

 

Photo credits:

Milada Vigerova on Unsplash

Christopher Campbell on Unsplash

The lies we tell and the secrets we don’t

person making shush gestureAs a mental health nurse, I always hope that my clients will feel comfortable and safe enough to be open and honest with me.

As a person with depression, though, being open and honest is likely to go straight out the window if it appears to conflict with whatever goal feels most pressing to me at the time.  While this may sound manipulative, it is something I do for the purpose of self-protection and self-preservation.  It is part of the armor that I put on when my illness leaves me feeling weak and defenseless.

The topic I lie the most about is suicidal thinking.  Based on past experiences, I never want to be hospitalized again.  Disclosing thoughts of suicide is probably one of the quickest ways to get committed to hospital, so I keep my mouth shut.  Is that a safe, healthy way to approach the issue?  Of course not.  But in the balance of pros and cons that goes on in my head, there is little that would win out against my desire to avoid hospitalization.  I try to consider this in my professional life and be very mindful of how I’m reacting when clients disclose suicidal thoughts to me.

I also omit symptoms that I either do not want or do not feel ready to talk about.  At one point I had gone off meds for a while after a 3-strikes-you’re-out series of negative experiences with doctors.  After a couple of sleepless months I realized that I really needed to find someone to order some drugs for me.  I didn’t want to talk about my depression for fear of getting a similar reaction to the last few doctors I’d seen, so I only admitted to being unable to sleep.  In doing so I could get my mirtazapine and quetiapine back on board, and after a while I felt safe enough to disclose the rest of what was going on.

girl and face mask juxtaposed on blue eyeIn the end, I can only conclude that we just try to do the best we can with the situation we’re faced with.  And I think the more that health care providers understand that, the easier it might be  for us to start to remove some of that armor.  It’s not realistic to think that we will never feel the need to resort to lies and secrets, but it’s worth reflecting on what underlies them so they don’t end up coming back to bite us in the butt.

 

Image credits:

Kristina Flour on Unsplash

Kellepics on Pixabay

Depression giveth and depression taketh away: Anhedonia and apathy in depression

There have been a lot of horrific events in the news lately.  Hurricanes, the mass shooting in Las Vegas, terror attacks…   As I saw these events on the news, I knew cognitively how terrible they were, but on an emotional level, I just felt nothing.  I am not a cruel, heartless sort of person, but I still felt nothing.

Many people have some idea of the “gifts” that depression gives: low mood, anxiety,  suicidal thoughts.  There is often less familiarity with what depression steals away from those who suffer from it.  Anhedonia refers to the inability to feel pleasure, and apathy refers to a lack of interest.  These deficits that people can experience due to depression may sound relatively minor, but in fact they can be soul-destroying.

person in darkness silhouetted against sunshinePart of what makes us human is the ability to feel things in response to what is happening around us.  If depression takes that away, what does that do to our humanity?  I feel like a monster for not caring about tragic devastation and loss of life, but it’s as though the ability to feel in that way has been turned off in my brain and my heart, and for the life of me I can’t figure out how to turn it back on.

Depression can leave a darkness and emptiness on the inside that can’t be lit up no matter how bright the sun shines.  Perhaps that is harder to understand than that which depression giveth, but the greatest impact on my life has without question come from that which depression taketh away.

 

Photo credit: Spencer Pugh on Unsplash