Frustration, Destabilization, and Behavioral Activation

My car broke down yesterday. It was a traumatic experience because I was getting on the highway and it suddenly started lurching and died as I pulled off the highway. That was enough to send me into a mild panic attack. Thankfully, I had cigarettes to calm me down instantly (I don’t recommend smoking to stave them off since it can make panic attacks worse, but it’s all I had since I forgot my xanax). Still, that wasn’t enough. I was hypomanic and frustrated.

For the past few days, my mood has been elevated, but trending back to normal. Yet, this frustration really got the better of me. It’s normal to be a little down as a result of having additional problems and being trapped in a small town for yet another night, but this triggered a mood swing. Today, I was agitated and depressed. I couldn’t sit still, yet I just laid in bed watching star trek, not wanting to do anything except for crawling away to a small corner.

But there were two things that I did yesterday and today that helped enormously. First of which was focusing on rationalization and alternative plans. My girlfriend was there for me to bounce ideas off of, but what really helped was me going over every possible contingency and planning accordingly. Focusing while using a small meditative technique and exploring alternative possibilities helped alleviate the frustration by showing it to be the only rational choice. Even if it wasn’t, I convinced myself that it was, which is enough to defy some of the frustration.

Secondly, I tried some of my behavioral activation therapy this morning. I listed off things that I could get done and ranked their difficulty. The easy stuff I rewarded myself with just a little tv. Calling the mechanic, getting out of bed, getting in contact with people to arrange plans, etc… Now I’m rewarding myself again by reading some blogs and browsing the internet. What’s amazing is that it’s working very effectively. I still have some big stuff to do, and I’m not sure if I can do them, but it’s raised my bare functionality considerably by getting the small things out of the way.

And now lastly, I’m drinking some coffee to get caffeine’s antidepressant effects out of it. The effects seem to be working. I’m getting bare stuff done, maybe will eat soon, and I’m feeling less depressed. Not great, but by getting some of the little things done, I feel an enormous weight off of my shoulders and a small sense of accomplishment. Which is not that bad considering that I was able to rouse myself in just about 2 hours with the above technique.

Losing One’s Mind – When Medication Fails

It would be impossible to talk about medication without talking about its failures. Especially since failure is more prevalent than success. I talked yesterday a bit about what I felt like before going on medication, so today I’ll talk about what it is like to have to stop medication.

In my opinion, medication is a real crap shoot at times. Over the past 9 months, I’ve been on a lot of drugs that do not work. There’s celexa (twice), atenolol, propanolol, seroquel, risperidone, xanax, and klonopin. Over this summer, I’ve tried three antipsychotics, with only one working, abilify. All the previous ones ended in horror shows. And at the end of each of the failures, I always had a similar thought, that I’m losing my mind.

One of the main ways that I’ve seen drugs fail is that they simply didn’t do anything. This was especially the case when I was given beta-blockers for my anxiety. Nothing happened. There weren’t any side effects either. I used to think that this wasn’t a horrible way for a drug to fail, but it still is. The beta blockers were supposed to control my heart rate and reaction to stressful situations so that I didn’t get a panic attack. And they seemed to work a little bit, but I couldn’t really test them out in any substantial form without really stressing myself out. So I marched right into an exam with high hopes that the drug of choice among performance artists for stage fright might work, and then promptly melted down. The failure of a drug to perform does two things as a result, first it is a waste of a lot of time in taking it, but the second is that it brings a great deal of uncertainty into planning my activities. Even when I was unstable, I knew my limits. I knew when I could or could not deal with something and planned accordingly. With the addition of a new drug, I need to find my barriers all over again. And if it does nothing, then I wind up in a lot of unpleasant circumstances that I could have avoided. Additionally, if it doesn’t work, then these situations might destabilize me without having the proper medication to bring me back. So I often find this failure to be the most exasperating way to fail since it’s just time and energy to do nothing.

Another bothersome way that drugs might fail is by having intolerable side effects. This personally happened to me when I was taking risperidone. I was planning on dumping it rather quickly, but then it started up with paranoid hallucinations (that’s for the next section). Sometimes, the drugs do help, but the cure is worse than the disease. The difficulty with this is that it’s hard to tell what’s worse. Sure, I had fatigue and lower sex drive and felt just rather apathetic, but is that better or worse than swinging around every 6 days from manic to depressed with a mixture of suicide and mixed states thrown in? Add in the fact that it’s hard to remember what I felt like 6 weeks ago, and there’s a recipe for a difficult decision. Our brains are not wired that well to handle such evaluations, it’s like deciding between a strudle that will make you nauseous and a bowl of ice cream that will make you constipated. The choice is neither! But that’s not always an option. The tug of war between these two options is enough to drive one mad in its own rights. My own experience has taught me to just choose the neither and try going for another option. But it took a long time to figure that one out.

Finally, the drug can cause a complete mental break. Seroquel caused a mixed state with paranoid hallucinations, and risperidone just caused the paranoid hallucinations. Sometimes the drugs really do drive me to be a little insane. It’s exhausting to go through this. Not only is it time and energy wasted, but the destabilization and trauma of the episodes is enough to leave me bed ridden or completely out of touch with reality for weeks. And the after effects do not necessarily go away. Seroquel disrupted my memory to a significant degree and caused me to restart 3 of my classes since I could barely remember anything from the previous few months. Failing in this way doesn’t just reset to normal, it makes things worse than before.

These three ways that drugs can fail are exhausting and an everyday reality of taking new drugs. What can be even more exhausting is that medications might fail at one point, but work at another time. So there is no final say in whether the drugs in fact do work. It can be maddening. But not all is despair and failure. Tomorrow I’ll talk about the two successes in my life, lamictal and abilify. The success is relatively new, and I’m not that used to it yet, but I’ll talk a little about the hopefulness that comes with finding what works.

Caffeine and Hypomania, A Dangerous Mixture

Something brand new happened to me today. I was mildy hungover and sleep deprived (from 1 small beer too! grrr) so I caffeinated heavily today. Something fascinating happened, it triggered a hypomania. At first I thought it was just the caffeine making me energetic, but there was no crash, no sugar low, no nothing. It just kept going and going. And for the past few days, I’ve had fatigue and sleep issues around late at night where I couldn’t stay awake past 10 and I would sleep till 9am. It was troublesome to say the least, but not a horrible depression. Still, I’ve swung out of it into the exact opposite, rather than a hypodepression, I’m hypomanic.

Why is this? Two factors in my opinion. My psychologist pointed them out to me a while ago, but it’s taken until now to really put it together. The first factor is the alcohol. He stated that it has a kindling effect, meaning that it causes mood instability. If I’m swinging down, it’ll make me go further down; going up, it’ll make me go up. For a long time, I thought that this only worked while the alcohol was in my system. So whatever mood I was in previous to the drinking would in fact be what is kindled into a stronger phase.

Now I find that it simply causes instability in general. This morning I wasn’t feeling that great, but the coffee acted as an antidepressant and swung me up. Now, for the record, I’m particularly sensitive to antidepressants. Celexa took a whole 48 hours to put me into a full on mania. So it doesn’t surprise me now to say that I must be sensitive to the effects of caffeine. But I am surprised at the fact that it triggered a hypomania. This hasn’t happened before when I drank coffee. I felt better in the past and had more energy, but nothing that was sustained.

And while I am hypomanic, so I’m not really that concerned, my more rational mind is pointing out to me that this might be very dangerous. I tend to drink more when manic which will only make it worse. Additionally, now that I’ve put two and two together, it seems that I might be trying to trigger manias using this combination. This is particularly dangerous since the stable me doesn’t want manias. They’re dangerous and heavily disruptive to my daily life. It also means that I have to pay special attention to my coffee intake for the next few days to prevent me from going any further. This, however, will be more difficult because I can already feel my impulse control slipping. For all I know, tomorrow I’ll just chug a pot of coffee to try and get the high back. I can’t tell what I’ll do, that’s the scary part of having manias.

Furthermore, while I’m feeling great now, there will be a crash. I don’t get manias without a coup de grace ending of depression that is equal in magnitude. That means that the marathon of stability that I’ve been running, with only mild depression here and there, might be over. And it often takes a while for me to stabilize again after having a quick mania-depression combo.

The only good part of this is that I get to put abilify to the test of stability and depression control. I’ll see soon how deep I go down and how quickly I go there, and then how quickly I bounce back. It should be an informative few days. And the only reason I’m not too worried is that I’m starting to get that hypomanic “I’ll survive anything” feeling. Which is great for now, but my mind is screaming at me to stop this before it gets out of hand.

Self Medication – Caffeine as an Antidepressant

I abuse caffeine. It’s my drug of choice next to nicotine. Nicotine is for some other time, but caffeine is for now. The past 2 days or so, I’ve been mildly depressed. Anhedonia, easily fatigued, excessive sleeping, etc etc. It’s almost ridiculous how quickly I can detect depression. So how do I cope. Well, I turn to stimulants mainly. And caffeine is a readily accessible and delicious one.

What does it do that is so appealing. First it gives me a pick me up. Which is readily needed since I get so fatigued. In fact, this might be one of the most important things. Usually when I’m depressed, I lie around all day and watch tv. I don’t even have the energy or focus to read much when I’m depressed more than usual. Caffeine gives me a restlessness and need to move around that may not lend itself to doing cognitively heavy tasks, but it gets me into needing to do chores and at least moving around. It’s strange, since I hate being restless, but when I’m depressed I’ll take anything that feels different.

Second is that it seems to improve my mood. This is substantiated by some medical research. It acts as an antidepressant that increases both serotonin and dopamine. So in addition to giving me a kick, it also works as a minor antidepressant that helps kick start my mood. It’s no zoloft mind you, but I’ll take whatever works. Along these same lines, it does make me feel better and happier. It’s strange to think of a beverage as doing this, but it perks up my mood and makes me feel more congenial.

Third, it helps with creativity. The increase in the rapidity of my thoughts is beneficial to making the connections for some creativity. When I’m manic or normal, this may not be the best idea. But when my thoughts are slowed down by a depression, this gives me enough of a boost to start thinking again.

So in the end, caffeine is not necessarily the enemy of bipolars or being depressed. In fact, it has its uses in moderating the depression episodes and relieving some of the symptoms. For years now I’ve used it as a pick me up for my depressions. But it’s only been recently that I’ve consciously chosen it to really help me out. And for the past two days, it’s transformed me from a couch bum into a semi-productive member of society. That’s enough for me to get some of my days back from the cycles that abilify is still not powerful enough to stop.

Keeping the Mind Sharp on Drugs

I am always cautious of cognitive side effects of drugs. It is imperative that I retain my cognitive performance for two main reasons. First and foremost is that I am a student that is looking at grad school. It would be disastrous to have my cognition impaired in any significant manner since I rely on my mind remaining as sharp as possible in order to excel. This is not to say that in other lines of work one does not need to use one’s brain. But being at peak performance is critical at this stage of my life, so I’d rather not be fighting off the feeling of being drugged or have memory problems.

The second reason is that cognition is important in controlling my moods. I need to be sharp to identify mood changes and subtle changes in my body’s feelings so I can get on my mood swings quicker. This is almost more important than my school work since being unable to identify my mood swings in time will lead me to destabilize and in essence negate any value of the drug’s benefits.

I don’t think that this just applies to me, I think that cognitive side effects are of primary value to everyone with bipolar. As I said above, having the mind dulled will in essence negate the value of being on the drug to begin with. Every day one monitor one’s mind to see if it is working properly. Without the mind properly functioning, one might as well throw away the drug unless it stabilizes one’s moods significantly. At that point, it’s personal preference. I’ll usually opt for less stable and better cognition since I can handle minor mood swings with cognitive-behavioral methods.

So one needs to keep their mind sharp. Measuring this is incredibly difficult, if not impossible, from a purely introspective stance. To determine my focus, I need to actually try to focus on something. So to determine my mental acuity I need something that’ll actually stress my mind. I can’t do this through paper writing or anything that does not challenge me significantly, but if I try to do something difficult in logic or philosophy, then the reason I’m coming up short may in no way be my mind’s lack of sharpness. To properly measure my mind’s ability, I need something that is objective, sterile, consistent, and behavioral.

This is where Brain Workshop is incredibly useful in two respects. First, it provides a graphing feature so that you can see progress as well as how you compare to previous days in terms of your mental abilities. I’m a huge fan of graphs since my mind has a hard time putting together trends from raw numbers, I need visuals to really make sense of it all, along with trend lines and other things (thank you Descartes for that contribution).

So it gives you some good visual data and numbers, but it also does more. It’s also shown in a study and two repetitions to improve general fluid intelligence. As I’ve stressed earlier, empirical verification is of the utmost importance to me. I don’t like trying things based on claims, I want evidence. If you’re wondering, as I did, fluid intelligence is the kind of intelligence that one uses in figuring out problems without an experiential basis to help out. If you’ve ever done an intelligence test with weird geometric shapes that you have to find out what will fit the pattern (the Raven’s Progressive Matrices test), it is this type of intelligence that it improves. It’s useful in everyday problem solving, so it’s also good for coming up with unique solutions to bipolar problems. It also helps counteract some of the negative side effects of drugs on cognitive performance. So not only can one improve one’s side effects, one can also improve their brain’s performance.

Brain Workshop also compliments my general philosophy on bipolar. It’s not an illness in the usual sense, it only means that one’s mind has emotional hurdles that it needs to overcome. With rigorous discipline, one can find ways to not only counter act some of these hurdles (which can include accommodations), but I think that one can even surpass what is usually seen as “normal” by taking advantage of the different moods and custom tailoring the life you’ve been given in a way that most people will never get around to. I eat healthier than most people, I take advantage of my moods to do reading and things that I enjoy (when possible), I know how to take breaks and when to work myself to the bone without red lining my mind and body, and I’ve searched out new means to keep myself sharp and on top of things. I still have my obstacles, but I’ve also found things that enrich my life through the process of dealing with bipolar that I would never have done if I did not have it or take it seriously. And that’s my outlook, which is that with creative solutions, bipolar can become a strength instead of a weakness. It only means that one needs to do things differently than most people.

Deadly Drugs

I’m going on new medication Abilify. Like many drugs of these types, there is a possibility of suicide. When one hears these facts, it sounds really scary. Seriously, you could take a pill that could cause you to kill yourself. That’s REALLY scary. But like most things that sound scary, one must take an objective point of view on it. Now I don’t have the statistics on the prevalence of suicide due to antipsychotics and antidepressants, but I’ll focus on the perspective of these risks from the viewpoint of suicide in bipolar.

I’ll be lazy, I’ll use wikipedia. But it states the reported suicide/mortality rate of bipolar at 0.4%. That’s much higher than the standard population, but it gets scarier. There’s another measure called SMR, or standardized mortality ratio. This is the ratio to convert the reported numbers into what to expect in the general population. Wikipedia has this number set at between 18 and 25. This puts the prevalence of suicide at somewhere between 7.2% and 10%. This puts the suicide numbers at between 1 in 13.8 and 1 in 10. Those are HIGH. Really frightening high numbers.

To put this into perspective, let’s look at some of the cancers out there with a five year survival rate. These come from the SEER report at cancer.org. Here we see prostate cancer with 100%, thyroid at 97%, testicular at 96%, melanoma at 91%, and breast cancer at 90%. All of these having as high or higher 5 year survival rates than bipolar. These are the big killers because of how often they occur, but still, bipolar out performs them. And the point that I’d like to get across is that bipolar is often overlooked as being a deadly disease rather than just a mental illness.

Returning to the antipsychotic, let’s say that a pill I have puts me at a 2% risk of suicide. That lowers my risk of suicide substantially, by an order of 3 to 5. It sounds very scary at first that a drug may cause someone to kill themselves, but in a dangerous diagnosis like bipolar, these drugs actually make it less likely to kill yourself. This doesn’t mean that one shouldn’t try to exhaust safer routes first, but if one ends up taking them, one should look at the bigger picture of how serious their mental illness is.

This is also not to say that it is not horrible when someone dies do to taking a drug. But when one takes a step back and looks at the big picture of just how deadly bipolar disorder actually is, these pills actually offer hope, substantial hope for people battling this every day. So mourn the dead as they should be, but embrace those who are still alive due to these drugs.