Under Pressure

My apologies for talking about myself so much, but it was probably inevitable (& if that kind of groveling annoys you, please keep in mind that I'm a Minnesotan, & we apologize like we drink: far too much, far too often).

That said, the saddest thing about bipolar disorder, from my experience, is the loss of a consistent ability to cope with stress.

It hasn’t been a total loss for me, but I used to be much better at it. That was a big part of the reason I started out as a newspaper reporter: the thrill of a deadline, the pressure of talking a reluctant source into telling you what he knows, the daily anxiety over what your readers & sources & editors will think of what you wrote.

But the stress eventually got to be too much, & I left journalism for law school. I knew that carried its own stresses (ridiculously competitive first-year classes, for one; ludicrously competitive second-year summer-job hunts, for another), but I also knew I could study at 4 a.m. & pull all-nighters before exams. I found that harder to manage with a day job.

Now I find it hard even to remember being as ambitious as I was when I graduated from college, or when I started studying law. I usually do what I can to avoid stress now, & I rarely look forward to it. I feel guilty about that once in a while – like I should contribute something to the world but never quite get around to it.

I suspect I’ll be that ambitious again, during one upswing or the next. I also know it won’t last.

My Medical History & Me, Part 1

On average, manic depressives wait eight years, & four doctors, from the time symptoms show up to the time the psychiatric world makes an accurate diagnosis. I got there in nine & six, but count me lucky anyway: I spent only 24 hours under hospital lock-&-key, received some relatively effective treatment for the depressive end of things, & got a chance to see the sausage factory that is American mental-health-care up close.

At the risk of becoming permanently self-referential, here's a bit of my experience with the insanity industry.

As I've noted before, my crazies struck early, but they waited until I was 23 before they started breaking to the surface (in the form of drunken antics unusual even for a drunk). They waited another four years to make their formal appearance.

When they did, they showed up first as insomnia: I went at least one night a week, sometimes two, sometimes two in a row, without a wink of sleep. Some nights I got in my car & drove around for hours; other nights I watched TV in bed (I firmly believe Homicide: Life on the Street reruns staved off insanity), gave up around 3 a.m. & brewed a pot of coffee; others I drove to my office at 4 a.m. & worked all night through the next day.

Next came the anxiety attacks. These weren't full-blown panic attacks, with all the physical symptoms, but they weren't far off. I typically ended up hyperventilating & dysfunctional, or pounding the holy living Christ out of my dashboard at every red light; driving during these things usually ended with my throat raw from screaming through the windshield at anything that moved.

My first stop: the endocrinologist who treated my diabetes at the time. He had nothing to offer for the sleeplessness, not even a psych referral.

A couple years later, during my first year of law school, I met with the student-health-service "shrink." She was a real psychiatrist (as far as I know), but student health-care in this country is an oxymoron. Campus clinics tend to attract bottom-of-the-barrel medical talent, & student-patients are treated as whiny spoiled annoyances. The urban legend at my undergrad college (& most others, I assume) held that male students routinely had to undergo pregnancy tests before they could get any medical help. The school where I met the shrink has a top-notch teaching hospital, but ironclad rules prevent university students from using it without a referral from the student clinic (which almost no one could get) -- whether or not their insurance would pay for hospital treatment.

So not surprisingly, this psychiatrist was a touch out of her depth. She agreed I probably suffered some degree of depression, but didn't think it was worth doing anything about it. She even suggested my insomnia (which by this point was chronic & repetitive) was a good thing because sleep deprivation is sometimes used to treat depression. It is, but typically only in severe cases, & even then only by psychiatrists who know what they're talking about.

My next try for help was in Manhattan, where I was a summer intern between my first & second years of law school. I happened to be there for the rainiest June in the city's history, & by the end of it I was loopy. I drank for the first time in three and a half years, and strong suicidal ideation crept in.

This time I decided to go with the nearest emergency room. Big mistake. The place turned out to be an assembly line for the sick poor who live around Columbia University. The triage nurse sent me for an interview in the psych ward, which could obviously handle only severe cases of mental illness -- the kind of cases that require cops, restraints & massive amounts of drugs. I could still walk & basically function, so they told me I'd have to wait at least a month or two for an outpatient appointment with a shrink. I didn't really expect to live that long.

And best of all: The "social worker" who interviewed me in place of the on-duty shrink actually asked how often I masturbate, in a way that suggested I should do it as often as possible because that would make me feel better. I don't know about you, pal, but a good wank isn't quite enough to get me down from the window ledge.

There's more to come in a later post . . .

My Crazy Family & Me

I'm way too fascinated by the crazies in my family history. Whenever I read about the debate over heredity vs. environment, I instictively jump to the genetic side of the argument. No doubt that's in part because I'm no fan of self-blame, but it's also because the statistics support the hereditary position.

And damnit, it just makes sense. Does it really seem likely that bipolar disorder appears repeatedly in the same families solely because of environmental quirks? Mood disorders generally, maybe: Your childhood & family life are fucked up, odds are good that you will be too, someday, & odds are good that your kids' childhoods will be fucked up, etc., etc. But something as specific as manic depression? That's kind of like chalking cystic fibrosis up to shitty luck.

My family's bipolar branches include a grandfather who drank himself to death years before lithium hit the scene; probably a grandmother, who's undergone electroconvulsive therapy (ECT); probably a sibling; an aunt; at least one first cousin; at least four first cousins once removed (first cousins of my parents on both sides); and probably a great-great-grandfather, who killed himself 26 years after he fought in the Civil War (his family covered up the suicide, so I can't be positive, but it's the only explanation that fits).

Personally, I think the fact that the debate continues has a lot to do with magical thinking: If we wish really, really hard, we'll make the world a place where we're all individually responsible for every aspect of our circumstances in life, or at least a place where we can blame specific people for their misfortunes. The only alternative is to believe that our lives are almost entirely outside of our control -- & that thought scares a lot of people shitless.

Obviously some number of fruitbaskets stand out as the only crazies in their families. But those could be families where the disease just lay dormant, genetically speaking, for enough generations that its presence is lost to memory. They could also be families where the illness is especially hard to trigger. Or they could be families where bipolar disorder expresses itself mildly in most cases -- too mildly to land anyone else a diagnosis or even suspicion.

And clearly environment plays some role in bipolar disorder, but is it anything more than a trigger that sets off sleeping manic depression?

My personal theory of life (for what little it's worth) is that far more shit happens to us than we make happen. Call it the Moby-Dick school of thought: The harder we try to shove fate into the boxes of human philosophy, the more slippery fate becomes. Life does whatever the fuck it wants -- not what we think it should. And that includes sticking us with hereditary ass-pains that mock our need to believe we live in a meritocratic world.

My Problem with CBT

Saw a new shrink today. He was very good, very empathetic, very sharp, & he made his diagnosis based on my narrative history & recollections rather than on the standard bipolar checklist. This helps, since I tend to answer "no" to most of the classic bipolar trigger questions (did you ever believe you were King Henry VIII? Did you ever drop $50,000 on lawn ornaments? Did you ever try to break your way into the porn industry?).

He seemed to peg my diagnosis as bipolar not otherwise specified (NOS), that funky-ass catchall category that acknowledges you can be manic-depressive without drawing up plans to build a nuclear power plant in your backyard. This reading certainly makes sense. Like I said in an earlier post, I worry that I see manic depression where it doesn't exist. But this shrink pointed out specific symptoms that do suggest a bipolar-spectrum disorder: My depressive episodes often involve some sort of high-stress trigger (Kerry losing in 2004, for example); my mood changes tend to be seasonal, at least when they're relatively stable (OK in the summer, up a tick early in the fall, then noticeably down around January, & back up again in early spring); and my sleep patterns fit, at least at their worst (staying up later & later every night until I'm sleeping during the day, then crashing & snapping back to a pseudo-normal-human schedule).

I switched to this guy mainly because I was getting tired of the behavioral dreck I was getting from my therapist. It helped for a while, but I keep seeing cognitive behavioral therapy (CBT) as a kind of modern-day blame-the-patient approach: It's not your fault that you never learned to behave properly, but we'll fix that. As much as I appreciate the need for personal responsibility, you won't get very far telling me the reason I'm crazy is that I failed to grow up. My therapist never went so far as saying he didn't consider bipolar disorder a real disease, but he always seemed to lean in that direction -- taking medicine is a good idea, & you shouldn't stop, but our biggest concern is making sure you learn how to behave like a responsible adult. More than a little condescending, frankly -- I doubt many therapists who've actually lived with mental illness would feel that way.

My Daily Affirmation

I really shouldn't find this reassuring, but I do. I've been reading Francis Mondimore's Bipolar Disorder: A Guide for Patients & Families, & came across this nugget toward the end:

"Stress doesn't make people manic or send them into a major depression unless they have bipolar disorder. Neither does drinking too much or sleep deprivation or the loss of a job or the end of a love affair or the hundred other things that you can convince yourself explain your symptoms better than a diagnosis of bipolar disorder."

My bouts of denial usually show up in a weird-ass kind of way. I don't worry so much that non-crazy people will think I'm repulsive because I'm nuts -- I worry they'll think I'm being melodramatic by declaring myself nuts. I've had the same anxiety over declaring myself a drunk: I hear the war stories of other recovering alcoholics & fear mine will sound lame (though when I tell mine in detail, I usually get a few gasps & "you're-still-alive?" looks that ease that concern a touch).

What often gets me (especially, for some reason, right before psychiatrist appointments) is the thought that maybe I'm not really bipolar. Maybe I just had a few bad depressions & drank myself into situations my shrink sees as manic. Maybe I talked myself into a bipolar diagnosis just because it seems sexier than straight depression (does that make me a pervert?).

Which is why Mondimore made me feel better. Apparently sane booze hounds don't typically drink themselves into situations that end with 4 a.m. paddy-wagon rides to a hospital suicide-watch room.

Who knew?

My Moody Circles & Me

Why start another bipolar blog? Especially a bipolar blog that no one in his right mind would ever willingly read? Well, I’m not in my right mind, so I can do whatever the hell I want.

I’m a Minnesotan, a lawyer & ex-newspaperman, a fruitcake, a recovering soak, a diabetic, & still alive, & on most days I’m at least a little proud of all those things. I’m an unabashed liberal who was raised in the congressional district currently represented by Michele Bachmann, protégé of Joe McCarthy (though hopefully that will change after November 4). My hometown has a population of 17,000, & it’s surrounded by miles of right-wing farm country. I prefer big cities, Danish cigarettes & socialized medicine. So I’ve got something of an inferiority complex about my origins.

The crazies started their invasion at least as far back as high school, but they didn’t make their presence fully known until I was a year into law school in 2003. If I can offer just one piece of advice to anyone bored enough to read this: Go nuts before, or after, but never while studying for a professional degree – especially if you’ve ignored common sense & passed up scholarships in favor of the most expensive school you can find. I’m ass-deep in debt, with poor long-term job prospects, three law schools on my transcript, & grades that scream “nervous breakdown!”

So anyway, here’s a basic outline of how I became acquainted with insanity:

Bipolar disorder runs in most of the recent branches of my family tree, though I didn't know it until a few years ago. I grew up with a vague but constant sense that I didn’t see the world like most other people: In high school, the lumps of life-related shittiness that other people put behind them seemed to stick to me, to gnaw at me long after I should’ve forgotten them.

I bucked family tradition & went to college out of state, where I figured I’d have better luck. It seemed like I did for a while, but eventually I started taking everything – every rejection, every failure – too personally. I had a habit of building up fierce ambitions, then dropping them for no good reason. I also started drinking, & by the time I graduated I’d developed a nice cozy relationship with the sauce.

About a year after graduation, I had an episode that was probably part suicide attempt, probably part manic episode, & definitely part alcoholic blackout. I can’t remember most of it, but I almost died, which scared the living Jesus out of me, & I quit drinking, for a while. The emergency room doctors assured me my problem was purely liquid, so I had no reason to suspect I might have been driven to booze by genuine clinical madness.

I survived the next few years working as a newspaper reporter. That was fun, at least until anxiety attacks & a long run of insomnia convinced me I should try something else, maybe law school. So I took the LSAT (talk about the benefits of hypomania: I managed to pull off a high score despite getting not a minute of sleep the night before the test) & went back to school.

But the insomnia & anxiety didn’t stay behind, & I keeled off the deep end during the summer after my first year, in 2003. I’d been depressed before, but not like this. This was the kind of depression where the color fades out of buildings, where you stop seeing anything more than 10 feet away (you know it’s there, but your eyes are too tired to focus), where every approaching subway train starts to look like a decent way out. I repeatedly stuck my head out of my ninth-floor apartment window, estimating how badly I’d scar my neighbors if I jumped. I wrote a suicide note on my laptop, deleted it, then wrote it again.

So I ended up in the psych ward of a New York emergency room, if only for one night. They diagnosed me with major depressive disorder, & I started taking pills & seeing a shrink. Later on someone added a side dish of generalized anxiety disorder to my psychiatric menu, along with a prescription for Klonopin. I knew benzodiazepines were addictive, but I figured they weren’t alcohol, so who cared? I didn’t know that Klonopin is esentially hooch in pill form.

I eventually moved back to Minnesota & finished law school, but it took an extra two years, & I spent a good part of that time back inside 110-proof bottles of bourbon (along with scotch, vodka, 151 rum, & the occasional splash of 160-proof almond extract). I finally quit the juice again a little more than two years ago, went through outpatient rehab, (re)joined a 12-step group, & remain as sober as a judge – a judge who doesn’t drink, anyway.

In February 2008, my diagnostic status was upgraded to bipolar disorder type 2 vs. other. The “vs. other,” as I understand it, indicates that my current shrink suspects I really have type 1. She told me during my last appointment that she thinks my personality tends in that direction. I took it as a compliment.

I presently see the shrink & a behavioral psychotherapist. I’m not terribly hot about either. The doctor is good at her job, but she only does medication management, & she keeps appointments disappointingly short (medication management my ass: I try to squeeze in talk therapy wherever I can get it, as more than a few relatives, friends & telemarketers can attest). My therapist is also pretty good at what he does (cognitive behavioral therapy). I just don’t take to it very well. At the moment I’m aiming to move to more traditional psychotherapy, with a psychiatrist who actually talks to patients, but that shit’s expensive, with or without insurance. And what with being manic-depressive, prudent financial planning isn’t exactly my strong suit.

I still take pills, obviously, but I draw a very serious line in the sand on this issue: I refuse, ever, under any circumstances whatsoever, to refer to my medications as “my meds” (well, OK, besides in this sentence). I can’t really explain it – there’s just something about it that pisses me off. It’s too hip, too apologetic, too obnoxious. It sounds like the aging ponytail hippie who won’t shut up about “toking reefer.”

That said, I started Lamictal earlier this year. Before that I was on a relatively short roster of other drugs: Celexa (worked for a while), Lexapro (sucked ass), Remeron & Wellbutrin (couldn’t really tell), & Prozac (can’t really tell, but I still take it). My psychiatrist put me on the Lamictal – an anticonvulsant mood stabilizer – after several weeks of bizarre sleeping patterns last winter: I was switching back & forth, every two weeks or so, between sleeping at night and sleeping during the day. She told me that can happen with bipolar disorder; I haven’t seen anything in print yet that confirms this, but a few books come close.

I’ve been extremely lucky with side effects since the very first pill: some GI issues & a touch of dry mouth, but that’s about it. Given what I’ve read from other manic-depressives, I’ve gotten off easy on this front, but I like to believe I’d stay compliant even with side effects. I’m a staunch believer in aggressive treatment of mental illness – with the caveat that the treatment should never cause problems as serious as the disease.

Lately my moods have been pretty consistent. But it’s hard for me to judge. My episodes of severe depression (I’ve had at least two more since 2003) stand out – clearly something was fucked up. I can’t pinpoint much mania, though. There are certainly stretches that look like hypomania in hindsight, & my shrink says she suspects my blackout/suicide attempt involved full-blown mania. But I have a hard time tracing distinct mood cycles. I hope that’s partly because of the medication, but I also suspect I have some less-than-classic symptoms – maybe some mixed states, maybe some mania that involves more irritability than expansiveness (I have, on a few inappropriate occasions, become more than a little snippy).

Anyway, that’s me & my crazy. Make of it what you will. I may run out of things to say too quickly to keep this joke of a blog going very long. But I obviously like the sound of my own typing, so maybe not. I shall remain semi-anonymous, at least for now – if only so this blog's abject failure won't trace directly back to me.