Tuesday, November 11, 2008

How Well is Well Enough?

Today's post was a toss-up between two topics:
  • Existentialist ideas in psychotherapy and their role in my becoming well
  • Medication and wellness

I'm going to write about Medication and wellness first, because it seems to play a big role in my becoming well.

Contrary to what some of my readers may think, or I suspect my pdoc sometimes thinks, and I know my husband and family think, I do not believe medication is the end all, be all for my becoming well. I recognize there are numerous factors that need to come together for me to achieve anything close to wellness.

In fact, the first thing I recognize is that for me (...I am only talking about me and my experiences in this post), for me I likely will have some symptoms throughout my life. I think even if Dr. X and I find the best combination of medications for my mood is such that there will always be underlying cycles that require medication changes, increases, decreases etc. Also, my symptoms seem to fluctuate..from extreme depression, through to anxiety, anger and sometimes rage.

I am beginning to see that these fluctuations of symptoms may, in part, be why my depression is hard to treat. Sort of like that old cliche: "You can't please all of the people all of the time, but you can please some of the people some of the time". Exchange the words "mood states" for "people" in the sentence and you pretty much can see where the difficulty lays.

Part of my theory is that anxiety is on one end of the spectrum and depression on the other. Given that almost consistently I have both mood states at the same time it makes sense that my mood is hard to treat.

With the depression ALWAYS comes fatigue...a huge and cumbersome symptom. The problem is if I take any dose of a stimulant, or stimulating medication, that is strong enough to help with my fatigue, it increase my anxiety. If I take a high enough dose of an anti-anxiety medication to treat my anxiety, it always increases my fatigue. On top of that it seems every antidepressant I have tried has increased my fatigue. The only one that I can think that didn't (Moclobemide) made me intensely agitated.

So, what are my realistic expectation for medications, which symptoms are the most important for me to address, and which symptoms might I need to accept, and learn to live with?

My Realistic Expectations for Medications (vs. Psychotherapy and my motivation/actions to change):

  1. A decrease in mood cycling by 50% (which I think would decrease anger/rage and mood fluctuations
  2. An increase in mood by 50%
  3. A decrease in anxiety so I have NO anxiety attacks

The Most Important for Me to Address:

  1. I would like my mood, at the very least, to be such that I am not severely depressed most of the time (say 75%). I believe some of my depression will not be addressed by medication, but by my becoming a more active participant in my therapy. I'd say approximately 50% of my depression is caused by my inability to become the person I want to be. (an existential struggle...more on that in another post)
  2. I would like to stop having suicidal thoughts. Especially the violent imagery of stabbing, shooting and hanging myself. I would like to WANT to live...so not just stop having suicidal thoughts, but also I would like to stop wishing I would die. (although some of these may need to be addressed by my working harder in therapy to create a life I believe is worth living)
  3. I would like to have enough energy to work at least the equivalent of 4 full-time days a week.
  4. A reduction in my feelings of guilt would be good. I suspect working again would remove a large part of my feelings of guilt, but some of that is either genetic, learned, or biochemical.
  5. I would like to be less apathetic/amotivated to do my own art, my housekeeping, and work a job. It would be nice to have the energy to do other things like exercise and garden, but I am willing to have some inability to do some things.
  6. I would like to stop having anxiety/panic attacks. I am willing to put up with all the worrying I have done my whole life. To me that is normal, but I cannot manage the not being able to breathe, the chest pains, the fear and discomfort of the actual anxiety attacks.
  7. The huge mood cycles...where I go from high and unstoppable and crash into suicidal depression.
  8. I'd like to have at least a bit better memory/cognitive functioning....enough to both be able to read a book and to be able to remember it.

Symptoms I Need to Accept:

  1. Some fatigue...I am getting older and it has pretty much been 10 years since I really felt well. A decade can add to a person's fatigue. I think I need to accept that I may have some fatigue (say needing an hour nap a day).
  2. Some depression...25%...I lived with that before. I can live with it again. As long as most of the time I want to live, and feel my life is worth living, I can put up with some really bad days.
  3. Worries/OCD stuff (except my obsessive suicidal thoughts), but things like like checking my doors to see if they are locked over and over, or freaking out that I left the iron on, washing my hands many times a day etc. I have been like that most of my life.
  4. Insomnia...I have never slept well. I have almost always had a pattern of waking in the middle of the night and having difficulty getting back to sleep due to excessive worry, anxiety etc. I survived until now without sleeping that well. I can live with not sleeping that well.
  5. Some mood cycling. Maybe the cycling can be addressed by increasing/decreasing Tegretol/Antidepressant/Stimulant based on the cycling? (i.e. Decrease or Increase doses based on my cycling?)
  6. Some anger/irritation. I think part of this is attached to a hyperthymic temperament(genetic), and/or is learned behaviour. Both my Dad and my paternal Grandma had high expectations of those around them, and for themselves. They had go, go, go personalities. I see most of my Dad's relatives have the same kind of "frustration intolerant" personalities.
  7. Some memory problems/cognitive functioning problems....I need to learn ways AROUND this (e.g. day timer, notes to self, set alarm etc.

Basically I would like to go back to at the minimum, the functioning level I had before this MDE started. Which is probably a "Worry filled Dysthymia". I'd accept that.

I know medication will not help me reach that goal 100%. I have to work harder and do the work I talk about in my therapy sessions. I have to somehow get on track, stay on track and build up my abilities to do more and more.

This means:

  1. Continuing to teaching classes at the Art Clubhouse I teach at, despite my really wanting to stop
  2. Eating more balanced meals, taking vitamins, and eating way more vegetables than I do
  3. Cleaning the house EVEN when I feel tired and unable to
  4. Taking the dog for at least one LONG walk EVERYDAY (at least an hour) and two smaller walks everyday too.
  5. Taking on MORE, not less responsibilities, maybe by volunteering to teach somewhere else (after school programs, or seniors programs etc.)
  6. Going off Valium and staying off it
  7. Stop drinking alcohol...period.
  8. Do the things I say I will do in therapy.
  9. Work on my art EVERYDAY for at least 1 hour.
  10. Become more social, and increase my social activities.

Getting "better", (more resilient, achieving at least my minimal requirements for a life worth living) will take more action than I have taken these past 7 years. Approaching my life with a more active role in my destiny is partly a medication finding struggle, but more than that it is an existential struggle. I need to somehow create the will, the desire, the ability to become the person I want to become. To do that I need to define that person, and begin taking steps towards implementing changes in my life to become that person.


Border Life said...

As my tdoc says, no one ever recovered from depression by staying in bed. I was listening to Phillipe Goldin, and he pretty much said the same thing-- that is, recovering from depression required doing-- you are spot-on about things such as cleaning the house, keeping up teaching art and being social. My only thought is to add in things slowly, baby steps-- too much expectation placed on yourself could make it hard to succeed, and then, ick-- bad feelings. My pdoc and I have the same issue, trying to treat depression and anxiety, so far the symptoms are...rounded off...hopefully enough so that the tdoc and I can take care of some of the rest. Tdoc and I are looking at ways I can accept my anxiety and function, rather than eliminating it. Doesn't sound so great, anxiety, well, sucks. I want it gone, gone, gone. I'll start some ACT in the next week or two I think... I look forward on your post on existentialist ideas in psychotherapy. Thanks for sharing. <3 BL

Jazz said...

I agree with border life, you want to add these things in slowly so as not to overwhelm yourself...if you overwhelm yourself, you'll end up giving up before you've started.

Another thought--I found that some the medications I was taking were real motivation killers. Is it possible that some of your lack of motivation/apathy/fatigue is coming from the medications themselves? It's a tough balancing act, finding something that helps you and doesn't debilitate you with side effects.

I, also, am looking forward to reading your thoughts on existentialism.


Aqua said...

Hi Borderlife and Jazz:
I agree, slow baby steps is how I need to approach the "doing things". I still remember the first time I met my pdoc he told me it was going to take work to get better. I always took that to mean I had a personal responsibility to be active in my treatment and not just lay around waiting to get better.

I don't think I have just "laid around", but I have had huge periods in the last few years especially of being extraordinarily amotivated. Dr. X says that is a symptom of my depression, but I also think my fatigue, while a depressive symptom as well, is caused in part by my meds, and the fatigue is extremely hard to overcome.

Thanks for the comments and take care,

Anonymous said...

Another well thought out and reasoned post Aqua. Were then any things on your list that you want to do for pleasure as apposed in view of recovery? If that makes sense...aside from sleep that is! I know the meaning of pleasure changes with depression, but make sure you fit in some time for things which you find good to do, in exchange for the achievements you have made.

I'll jump on the interest bandwagon regarding your next post. I am hoping that you have come up with answer which solves the problem of an existential crisis :)

Lola x

PS when your done with sorting out the existential crisis problem, can you get a move on with the issue of world peace, third world poverty, and the hole in the ozone layer? Ta very much :)

Graffiti said...

Wow, That is a very extensive statement!