Research Tidbit #1

I am in the thick of secondary dissertation research. We have a initial ten or so pages due on Friday, which I have just started writing because I am a very organised person. Yes.

I found a new article yesterday that was a research report into a sociological study (very well set up) that was initiated to determine what the actual deficit in ability to give informed consent was for persons hospitalised for mental disorder. I'm not going to go into the results just now because I want to keep this brief but in reading the study I found out something new to me that apparently is common to depressed persons. That is, a distinct deficit in capacity to make decisions successfully. As I was reading their description of what this meant, I did absolutely recognise myself.

According to the study, depressed persons typically were less able to communicate a decision and once a decision had been communicated, they were much more likely to experience distress or regret - often on the presumption that the decision must have been the wrong one. I do this all the time. I had assumed that it was just a part of my character - I still tend largely to think it is - but it is interesting to see that it is a characteristic correlated with depression. I know that it gets worse when I'm depressed but as almost everything seems to get worse when I'm depressed I didn't think of it as having any special relation.

This has, of course, started me wondering whether a diminished capacity to make and communicate decisions is also a reverse predictor. That is, if depression predicts a diminished capacity to make and communicate decisions, does a diminished capacity to make and communicate decisions predict depression? Obviously, that couldn't ever be a single predictor of depression - I can think of other things it might predict - but I wonder whether it might constitute another way to confirm or disconfirm a diagnosis of depression or perhaps be a good indicator of severity.

What do you all think? Does this reflect your experience? Had you heard about it before?

Final Run-in With State Run Mental Health Services in North Carolina

For those of you who live in more civilised countries, let me first explain that in the US, state run mental health services are only for the uninsured and poor. In my home state, they were disastrously privatised in 2003 with more or less exactly the results one would expect.

I have been lucky that by pitching battle with them I have managed to stay under the care of a single psychiatrist for about a year and a half. He turned out to be a good one, which is more than I can say for some of his colleagues and co-workers. You can read, if you like, about one specific case worker I had who was worse than useless and more generally about the difficulties of engaging with these people. All of my readers in the UK may feel free to laugh at me but I am really looking forward to having access to the NHS next year. However bad it might be, and it doesn't sound idyllic, I have often found myself agog with envy at various descriptions even of being in hospital (they're allowed outside? they are allowed to go to the shops? they have crisis intervention teams? they have the option to see a therapist, even with a long waiting list?)

That short list of my own incredulity should give you some idea of what it's like here. Am I now a potential target for BNP anti-immigrant attacks for expressing an interest in the NHS? Or will they hold off because I'm white and English-speaking? Oh dear. I can't imagine, though, that anyone would wonder at it if they had to deal with the state of things in this country - or maybe I don't need to imagine it, just read the papers and see what the Republicans have been up to lately. It does seem to me that as I grow saner, the world has gone a bit farther off its rocker.

Anyhow, all I need do now is swing by there to pick up a copy of my chart (that will be interesting to see) to take with me and I'll be done! No more worrying that they will drop low need patients such as myself, no more worrying that the agency I'm currently enrolled with will go bankrupt (as happened last December - it took me six weeks and repeated phone calls that I would not have been able to make had I not been more or less well to get into a new one), no more worrying that I'll get a job only to have to pay for all this myself since most health insurance policies in the US don't cover mental health at all, or, if they do, have a lifetime limit that I would get through in about six months, a year at the outside.

I'm not going to miss this part of life in the US.

Radioland Visits Broadmoor

I am a regular listener to This American Life on the public radio here in the US. Their last show, titled Pro Se after the legal term for representing oneself in court, really caught my attention. The first long story in it is about a man, here given the pseudonym Tony, who faked mental illness to avoid prison for committing grievous bodily harm. He ended up in one of the highest security units at Broadmoor and has been there for twelve years.

The story goes into detail about the difficulty of shaking a psychiatric diagnosis, especially within the context of a psychiatric hospital. There was a well known study done about the 'stickiness' of psychiatric diagnoses back in the 70's; I can't remember who just now but there is a copy of it somewhere in my research folder and I will find it. The story also includes something new to me - perhaps I've been under a rock and this isn't news to anyone else - which is the Scientologists' campaign against psychiatry. Now that I know about it, I wonder whether that might be behind some of the comments I've seen.

Anyhow, I can't write a proper post about this just now because I am off to my parents' today and I won't have the necessary books with me to write what I want to about it. The reason I have gone ahead and put this up is that This American Life will let you download their shows for free for one week so I thought I'd give anyone interested the chance to do so. If you're reading this after Saturday, you can always listen to any of their shows for free by streaming.




"Brian says Tony's story demonstrates that no two psychiatrists can agree on anything and they basically just make it up as they go along. I think his story demonstrates that it is a huge mistake to screw with psychiatrists and you should be careful not to tell people you're crazy, because you might turn out to be way too convincing about it."

Tony's story is told by Jon Ronson.

Final Fourth of July

I seem to have lost the thread that leads from one post to the next post but I feel pretty sure that if I just keep writing them, I'll find it again.

This last weekend was Independence Day for us former colonials. I hope that it will be my last one whilst living here - I don't plan to move back to the states after grad school; I didn't want to move back in the first place and I get on better with my parents when I live on a different continent. Anyhow, because I'm off to London and two of my friends are off to Oxbridge and my very lovely ex-girlfriend but one is off to Missouri, all for grad school, we all four got together to watch the city fireworks from my back porch and discuss moving issues, house hunting and the fear of failure.

We've been friends as a group for three and some years now. The two going off to Oxbridge just got married last week; she's a classicist and he's literature with a classics minor. My ex-girlfriend but one - really now just a very, very good friend - is also a classicist and is going to study some very offbeat and interesting things about the classical tradition and classical urbanisation patterns. The Oxbridge classicist is going to work primarily on Greek paleography - she promised to take me to see the Oxyrhynchus papyri and I am unendingly excited. We are all a bunch of happy dorky people headed off to the promised land of graduate study. We've spent a lot of time together as a group, especially when N (ex-girlfriend who will henceforth be abbreviated because this descriptive reference thing is too clunky to be accommodated further) and I were still dating.

The Oxbridgers have been well known for hosting parties named after grammatical constructions in Greek and Latin. (Did I mention that we are all dorks? Is it necessary even to mention that?) There is a certain kind of construction for descriptive paraphrasis called an Absolute, so there was the Ablative Absolute party, the Dative Absolute party, the Genetive Absolute...recently we found out that there is a rarely used Accusative Absolute but we haven't managed to have that one yet. It could still happen.

Oxbridge boy and N have been best friends for years, since before either I or Oxbridge girl knew either of them. But it was at the time of the first Ablative Absolute that the Oxbridge people began dating each other and that N and I first got to know each other. She and I started dating near the time of the Genetive Absolute. Then at the Oxbridge people's wedding last weekend, N was Oxbridge boy's best man, which led to a fun discussion between me and one of the professor's small daughter who never has been quite sure whether N was a boy or a girl, which N gets a big kick out of. She finally decided that N was the best girl-man, on account of being a girl but the wedding program saying man and because she was standing with all the other boys up front instead of the other girls. That child is going to be very comfortable with gender queerness when she's an adult - it's great and it'll be an advantage if she goes into classics.

I do have a point to all this anecdote and it is this: between last weekend at the wedding with all those people who know what the intervocalic sigma is and this weekend on my porch, I noticed that I have a lovely group of friends. They have all done what they could to help me over the past few weeks, especially N, and I don't feel abandoned and rejected as I often have at the end of a relationship. (N actually sat there and listened to all the gory details - she has always been an above average ex but that really goes above and beyond). It hasn't been just these three either; it's been my Georgia friends and my across the hall neighbors and the rector at my church and some of the professors and even some of the people and the rector at my mother's church who've helped me.

Two years ago, when I had just got out of hospital and had the worst and most acrimonious break-up ever of my life, all of these same people were my friends. But two years ago, I felt completely abandoned. The difference this time is that I'm well.

I never did like the idea of borderline personality disorder and I still don't, nor do I think that I actually have it. But I looked it up a month or so ago and read what seems to me to be the calmest description of it I have ever seen, though it could just be that I was calmer, and something caught my eye. The 'borderline' in the name refers to being in a state of borderline psychosis. That much makes sense to me. It would explain the deep disjunct between my experience then and my experience now. Two years ago, everything and everyone felt hostile; I couldn't let anyone help me, especially with moving, because then they'd find things out about me and use them against me and come to hate me secretly if they didn't already hate me secretly. Every thing that anyone said was full of too much meaning, as though all words and phrases were talismans too inscrutable to understand but suggestive of grave consequences from the heavens to the depths for any reply in word or by deed. I couldn't understand what anyone meant when they talked to me and I was tongue-tied by the need to load my words with the right meaning, convinced that I needed to strike on exactly the right phrase, like a spell or incantation, that would tell them what they were asking so that they would stop interrogating me like that. I would be happy to take the suggestion that all of this was the result of a state of borderline psychosis; in fact, that does explain it much better than bipolar disorder alone. There would be no moral content in saying that I had bipolar II with concomitant psychotic tendencies - it would be a bit scary sounding, but it wouldn't have any moral content. Borderline personality disorder does, however, have moral content; it's in the idea of a disordered personality, a disordered self, which implies culpability and carelessness.

I was so much more ill than I knew. It's only since I've been feeling better that I've been able to see how far from well I was and for so long. It has only been nine months since I began to feel well, and only five that I have felt really well and I still feel better every month compared to the last. I have no memory of ever feeling well before, at least not in a longer-term, continuous, dependable way. It is a new feeling. I remember having the same trouble with talismanic sentences when I was seven.

It has definitely taken too long to find an adequate treatment and/or diagnosis but in a lot of ways it doesn't matter anymore, now that I have one. It's too late to do anything about the past now, and though I do wish it had been different, it is different now. Much like finally getting the bachelor's degree: it bothered me no end that I hadn't finished yet and so many years had gone by but now I have it and it doesn't matter to me that I got it this year instead of last because I have it forever from now on.

It's the same with my friends. I wish I had been able to understand that they were trying to help me and that I had been better able to accept that help two years ago. But it's there now and I still need it now and I can accept it and understand it now. Thank God.

So instead of spending this Fourth of July alone watching the fireworks from my back porch, we had a proper party with moderate drunken carousing and barbecue and I made my little pecan deadlies and there was bourbon and beer. It was a proper Southern celebration and the last any of us will see for years. There was even an illegal fireworks show that some people let off in the parking lot of the church across the street, which was better than the licit, city-sponsored fireworks. This time next year, it'll be time to stand in line at the Texas Embassy, which is a restaurant in London that's the hotspot for all the American expats who aren't invited to the party at Winfield House - it's a little cheesy but I have had some bizarre discussions about American foreign policy there over the years with junior VP's of various corporations so I still look forward to going. I'll be taking the Oxbridge friends with me.

And I Shall Sing as I Push the Rock Back Up the Hill

One thing that I had forgotten about feeling well is that one doesn't always feel well. I feel rather rotten most of the time, being stuck, as I am, in a corner of the world for which I am not suited among friends whom I love but with whom there is so much I cannot share.

This sounds like pretentious weltschmerz from the mouth of an ingrate but it isn't meant that way.

What I do mean is that I often feel almost as bad as I do when I'm depressed but the trick of it is that now I only feel that way for an hour or five minutes and not two months. I'll feel unbearably anxious but whenever the reason for the anxiety is removed, it fades away, quickly. It's amazing.

I have worried, as I know that others do, that the medication could only ever take away from me; that I would either be artificially happy and well or still miserable and sick with side effects. I thought that it could only be a compromise between how much depression I could stand and how much medication I could stand. There was, indeed, no reason for me to think otherwise. I had learnt from experience that medication would make me not-depressed, which is not at all the same as well. As it turns out, that's not what has happened this time.

I've not turned into a smiling shell of myself. I'm not a morose lump either. I seem to have as complete a range of human emotion as I ever have had. I think that this is what it's like when the medication works.

Good job it finally did.

It only took twelve years, two hospitalizations, three depressive episodes so bad that I had to drop out of school, two so bad that I had to stop work, three pronounced periods of hypomania, years of insomnia, years of horrendous anxiety, and more than a decade of seeing various psychiatrists, psychologists and so on. It's only taken up the past seventeen years of my life.

I'm laughing though, it's absurd, but I'm laughing like Sisyphus. I'm glad something finally worked.

Time for My Pills

Yesterday I did something I probably should not have done.

In the late afternoon all the anxiety that had been building came to the point of being unbearable. So, I took a klonopin. Half an hour later, no difference. I thought, well, take another and I did. Still nothing. So I took another.

Finally, everything began to ebb away and I could at least sit still and stop picking on myself. I finished up a few things and headed off to bed where I fell blissfully asleep.

I was more than a little hungover today, bumping into things and walking from one end of the apartment to another for reasons I couldn't remember. I made myself walk to church because I though that it wouldn't be a good idea to drive. I dropped my music at least six or seven times this morning; I'm glad none of it went sailing down from the choir loft onto unsuspecting parishoners' heads. I've been fatigued and wobbly all day but quite relaxed. I sang much better this morning than I usually do - less worried about accidentally squeaking on the high notes, I suppose.

Then, too, I've had the less fun side effects. They don't always pop up when I take klonopin but they did this time. I kept getting tearful over all manner of things in the afternoon. I felt leaden and a little depressed for a few hours. I don't know why that will sometimes happen with klonopin and sometimes not. Most times not, really, now that I've been taking it a while.

When I was first out of the hospital I took 2.5 mgs a day, spread out. I could hardly walk but for the first time in years I wasn't eaten up by anxiety and self-loathing. Since then I've weaned off to the point of taking a half milligram every now and again. I take it in bursts, usually. I took one every day for the first week and a half of school to stop myself building up place-associated anxiety. Now that school is familiar again and not full of fearful recent impressions, I've stopped taking it.

When I took three of them yesterday (ssh. . .don't tell my psychiatrist I did that) I reasoned to myself that I used to take more than that on a daily basis and that therefore it was unlikely to have too much of an effect. I was so wrong. My tolerance did slip away; very, very far away. I will not be doing that again in a hurry. I suppose I might if I really enjoyed the 'stoned' feeling of it, but then, if I did enjoy such feelings I would probably have continued to take seroquel or geodon!

Was it worth it? I don't know. I did run through most of my first response anti-anxiety activities: bath, mint or other herbal tea, walk, pleasant errand, and the usual cure-all of distraction by dvd or NPR. However, I was too distracted to be distracted and I let the kettle boil over. I also tried the phone a friend option but it being Saturday night, I hadn't much luck with that.

It was worth it in that I didn't get to the point of a full blown, banging on the walls, decorating my legs with insults in ink kind of panic attack. It was too much hangover/side effect-wise.

Now I just wish I could figure out where that one came from.

The Best Thoughts Come While Bathing

Thank goodness for hot baths. Nietzsche said that the best thoughts come while walking and he certainly has a good point but when it's 29F outside and you're feeling a little fragile and anxious, I have found that the best thoughts are more likely to come in the bath.

While I was basking there, my toes finally warm, it occurred to me that all my histrionic "I'm going to die homeless on the street having alienated everyone I know on account of the foul unreasonable moods of bipolar disorder and, for the same reason, on account of never having been able to hold down a job and thus becoming an indigent, hallucinating old lady" rants have their origin in something relatively small that just has a tendency to snowball.

It's not the worry over going back to school, it's not the worry over what seems at this moment to be likely to be a rather bleak future: I'm really worried about the stress itself. The other things are things I can only deal with on a day to day basis. There isn't anything I can do about my future indigency at this vary moment. I know this but once my mind leaps its merry way down this track the very fact that there isn't some concrete action I can take today to guarantee that this won't happen is very distressing and helpless making. What I was missing was a consideration the mechanics behind my illness.

There are several things that will set me off. Sleeping badly, travel, letting others down, not finishing homework and so on. The sleep is a different matter but the common root of nearly everything else that sets me off is stress itself.

Following from that, it easy to think 'oh, well, I just need to avoid stress,' which is true in its own way. However, it is highly unlikely that I will ever be able to eliminate stress from my life entirely. (!) What I really need to do is focus on how best to handle it.

For years I have had overwhelming anxiety, the kind where putting on shoes is too stressful, let alone fixing something to eat. All that accumulated anxiety seems to have burnt out (metaphorically speaking) the circuits in my brain than process anxiety. Now I seem to have three experiences of anxiety: none, extreme anxiety and stark raving mad.

I haven't had the stark raving mad kind for quite a while, thank God; not since I was in the hospital and given some very helpful drugs to deal with it. Taking them, clonazepam mostly, for about four months put me back in the realm of normal. I still have them as a PRN. (That's medication-ese for 'when I think I need them')

It's quite possible that going back to school will send me far enough up or down that I will have to drop out again. But it's a very helpful thing to realize that it's not having to show up at a certain place at a certain time each day or the homework or being around lots of people that's going to throw me. It's the stress of having to do all these things with my lovely broken mind that goes from zero to 260 in less than half a second.

I can't change the way school is run but I can do several things about how I approach the stress of it all. I can go back to the clonazepam on a daily basis for a week or so, I can make sure I take a bath every night, I can go to weekday mass, which is something I should do more often anyway, I can have hot chocolate every night. Knowing that the difficulty lies in the stress itself rather than school itslef (which I cannot change) makes all the difference.

Symptom, Sin, Circumstance or Psychology: I lost the thread on the way out of the labyrinth.

I have been having a great deal of trouble with motivation lately. I can't seem to get past it and I'm not sure where it's coming from.

I first taught myself back in 2002 to like cleaning my house, which was a big leap for me. That was the same year that I started looking after my eating habits. Then in 2004 I finally got a handle on keeping my clothes tidy. I got television watching under control in 1999. I have long had good spending habits. I developed the discipline to finish sewing and knitting projects somewhere along the way, I think in 2004, maybe 2002. Perhaps it just took a couple of years for it to really take hold. I learned how to talk to people, that is to overcome my shyness - I still come off all wrong sometimes, in 1998 and again in 2003 and again in 2006. I made a good habit of timely bill paying in 2003. I learned how to keep up with schoolwork in 2005. I seem to be developing a new understanding of how to give and receive help as I write, which feels like the only thing I have going at the moment.

Everything else seems to have slipped out of control. I have piles of unsorted clothes on my closet floor. I have two outstanding bills. The television seems to have taken me over. I have one unfinished sewing project and one unfinished knitting project. I've gone all shy again and my spending habits need reform for the first time I can remember. I haven't been able to properly keep up with the housekeeping for a good six months now. I cannot keep up with the schoolwork nor feed myself properly.

It took me a long time to develop good habits, which is a bit embarrassing. Some of that is due to never having been prepared to look out for myself once I no longer lived at home. Some of it is due to the disproportionate anxiety due to the bipolar. There are assorted secondary reasons for it as well. But bit by bit I pushed myself past it.

Now I seem to have lost it all and that is very discouraging.

Part of the current problem is that I'm not sure what has brought it on. One possibility is that I need an additional 100mgs of Lamictal. Another is that my routine is so loosely scheduled that I can't use my time effectively because it feels like there will always be time tomorrow - acres of time in front of me. The possibility that worries me most is the dreaded akedia. (Also known as accedie and accedia but I have done too much Greek to bear with the badly pronounced Latinate form of the word: it grates.)

I've had some rather flummoxing moods lately, the kind I look back and fret about. It's odd, though, because I am by and large on an even keel. I have been since September 6. (I know the date because I keep somewhat meticulous track of these things. That was the first day I felt well since October 2006.) Now the eveness has lasted more than three months and I am beginning to trust that it will stick around. So where has this deep lack of motivation come from? Why do I abandon all these good habits now when I was able to keep them up while I was severely ill?

If I were to tell my case worker or therapist about this they would immediately be on my case, saying that I should go to the hospital. But I'm not ill, not in a way that a hospital can help. Going to the hospital when I did is one of the best decisions I have ever made: it helped me to find appropriate medication quickly; it got me away from friends who didn't understand what depression is and were doing their level best (one of them, anyway, whom I was sharing an apartment with at the time) to make me feel incredibly guilty for not being able to behave as they wished I would; it kept my family at a distance; it stopped me having to do things like cook my own meals; it cured my insomnia for a good five months; and it gave me a chance to be around a whole bunch of people who were going through the same problems, so that I no longer felt as weird and isolated. But there's no opportunity for sustained counselling there. It's not the appropriate place for me to get to the bottom of whatever it is that has demotivated me.

This is the difficulty with the psychiatry/psychology part of things: they read everything as a symptom and automatically assume that the sufferer is having an irrational reaction to external circumstance, an attitude that has been shown to be distinctly unhelpful in several well conducted studies over the past sixty-odd years. It seems more likely to me that the cause lies in some psychological difficulty that would require some time for discernment or in some reaction to external circumstance, neither of which would be solved by playing around with medication.

If only I could figure out how to start figuring this out! Any ideas?