My SSDI Story part 2

It was the additional weekend job that finally broke me. I could barely manage to go to work, and when I did go I was nervous and agitated. I fell down a staircase at the preschool and injured my knee, requiring arthroscopic surgery. At the same time my depression became acute and I was suicidal. I spent much of my time with a friend of mine because I was afraid to be alone.

One night I took an overdose of tranquilizers — just enough to make me sick. The next day my therapist found out, and she instructed my friend to take me to the emergency room.

I was in a severe psychotic depression by this time, which led to my first inpatient stay in a mental hospital (and my only involuntary admission). After a week in the hospital, I returned to my friend’s home and she helped me move out of my apartment. I was nervous about getting another job, but about six weeks later I started a temp job that ended up lasting about 16 months. The first half of that period I worked for the temp agency, then the company hired me directly.

I was the assistant to an administrative assistant, and she was a kind and friendly person. If she had not been patient as well, I would not have lasted a month. But it was summer before I had another manic episode and I was able to conceal it most of the time. It appeared occasionally in the form of unexpected insolence. I could tell she didn’t know what to make of it, but she didn’t question me.

Of course, as day follows night, depression follows mania, and once again I was suicidal. My boss had been depressed herself in the past and when I told her how I felt, she told me to go home and call the doctor. That was the last day I worked.

I went back to the mental hospital, then remained out on short-term disability, possibly a little longer than absolutely necessary. Meanwhile there were massive layoffs at the company and my boss herself was laid off. I returned from disability for only one day, so that they could give me my pink slip.

Bipolar Spectrum Research

It is almost inevitable that when people attempt to categorize anything they make the initial categories too narrow. Psychiatrists have know for some time that the diagnostic categories for bipolar in DSM-IV TR continue to be inadequate, in spite of revisions. Inevitably, people fall through the cracks, usually into the dreaded NOS (not otherwise specified) category. I say “dreaded” because a nonspecific diagnosis often results in lower quality treatment, especially if the physician is inexperienced with bipolar patient.

A recent review of the literature looked at the 4 recognized types of bipolar (I, II, III, and IV) and compared their symptom criteria with what is actually seen in clinics and hospitals. The author (Hagop S. Akiskal, MD) found evidence for five additional categories, as follows:

Bipolar _ , or schizobipolar, falls under a separate DSM category, Schizoaffective disorders. These are diagnosed in patients who exhibit both psychotic symptoms and mood swings, satisfying most of the criteria for each type of disorder.

Bipolar I is a well-known type that represents what many people think of as “bipolar”. The patient’s mood episodes cover the entire range from depression to mania (which often has psychotic features). Akiskal suggests that an additional category, bipolar I_, includes those who have frequent depressive episodes interspersed with a few manic or near-manic but not psychotic periods.

Bipolar II was first identified in 1976 by researchers at the National Institutes of Mental Health. In a nutshell (no pun intended!), these individuals experience recurrent deep depressions along with hypomania, often at the end of the depression. Mood shifts can occur quickly, and the delineation between the two moods is more clear. These are “typical” bipolar II’s.

Bipolar II_ individuals, according to Akiskal, experience greater mood dysregulation and frequent occurence of depression and an irritable rather than euphoric hypomania. Even between episodes they are considered “moody” by those around them. In fact, the moody person who develops major depression is more likely to shift to bipolar I or II in the future than is the person who is not normally moody. This is an important clinical consideration (although I have not seen practical application of it). Panic disorder and/or social phobia are also classified by Akiskal as indicators of potential bipolar II_.

Bipolar III is diagnosed when anti-depressants prescribed for a major depression produce a shift into hypomania. It most often occurs in patients with a first-degree bipolar relative, which reinforces the genetic link for bipolar spectrum disorders. The hypomania does not generally last long, and recurrs infrequently.

In Bipolar III_, the bipolar episodes are inextricably linked with substance abuse, such that it is impossible to determine which came first, the chicken or the egg. (My experience here:) These individuals are now termed “Dual Diagnosis” in hospital settings, based on the belief that it is depression that caused the substance abuse in the first place. However, it could just as easily be bipolar disorder — one reason why it is often better to treat according to symptoms instead of diagnoses.

Bipolar IV, as described by Akiskal, is a category I have never encountered myself. Apparently, sometimes people (mostly men) who have led successful and seemingly happy lives develop depression in the latter part of middle age. This quickly leads to an agitated depression or “mixed state” in which the person fulfills criteria for both depression and hypomania. The author suggests that this disorder may be the cause of unexpected suicides — “but he was so successful, I don’t know what went wrong.” An agitated depression is highly dangerous for anyone no matter what their diagnosis is, because if they are suicidal that have enough energy to complete the act, unlike typical depression with complete lack of energy (personal experience again).

Of course, these categories can still be further refined, but I think this work is helpful in recognizing the various stops along the bipolar spectrum. In the end, though, I think the symptoms are what’s most important. It’s nice to have an “umbrella” designation to give the physician a place to start. On the other hand, the inadequacy of the categories in the DSM can fool them into a simplistic view of bipolar (“are you I or II?”) and likewise, a simplistic method of treatment.

Reference:
Akiskal HS. The Emergence of the bipolar spectrum: validation along clinical-epidemiologic lines and familial-genetic lines. Psychopharmoacol Bull. 2008; 40(4):99-115.

Music Therapy II

In a previous post (July 21), I wrote about my interest in self-prescribed music therapy, specifically entrainment CD’s. Entrainment is just a fancy way to say that the CD presents a sequence of music designed to train the emotions. The ones I have been making bring me gradually from depression to happiness. I think my latest one, #3, is the best so far.

1. Crush — Dave Matthews Band

A romantic song that is associated with a depressed time of my life.

2. Losing My Religion — R.E.M.

This song isn’t about religion, as you might think, but about frustration and depression. According to lead singer Michael Stipe, “losing my religion” is Southern slang for “fed up” or “at the end of my rope.”

3. Ordinary World — Duran Duran

Popular during a drastic change in my life, in which I was desparately seeking that “ordinary world.”

4. My Immortal — Evanescence

Almost any song by emo band Evanescence would do, but this is one of the most depressing songs I’ve ever heard. It is, therefore, the peak of the “depressed” portion of the CD.

5. One Headlight — Wallflowers

Although “One Headlight” talks about a suicide, it is one step up from #4. Believe me.

6. I Let the Music Speak — ABBA

Rich in a variety of emotions, the words and music in this somewhat dark song are a nice transition.

7. Eyes Without a Face — Billy Idol  &  8. Baker Street — Gerry Rafferty

Both are melancholy, but the sadness is not depression because there is still hope.

9. Turn! Turn! Turn! — the Byrds

Self-explanatory I think! If you are not familiar with the song, here are some of the words (adapted from the Bible book of Ecclesiastes):

To everything (turn, turn, turn)
There is a season (turn, turn, turn)
And a time for every purpose, under heaven

A time to be born, a time to die
A time to plant, a time to reap
A time to kill, a time to heal
A time to laugh, a time to weep

10. I Made It Through the Rain — Barry Manilow

We’re now in positive territory, but this is not just a happy-go-lucky fun song. It’s a tribute to victory over grief, depression, pain, and struggles of all types.

11. Waterloo — ABBA, 12. When Smokey Sings — ABC, 13. Walk of Life — Dire Straits, 14. You Get What You Give — New Radicals.

These are the fun songs! Listening to them always makes me smile, but they work much better when preceded by the rest of the CD. The first few songs acknowledge my feelings and maybe even help me express them (sometimes I cry). Gradually I’m led into hope and empowerment, and the final four are the icing on the cake!

I highly recommend this technique to anyone who has a mood disorder.

Off to the hospital

Yesterday I saw my therapist and, after I told her of my depression and its extent, she suggested I go to the hospital for stabilization. Probably only a week or a bit more. I have been going to Timberlawn Hospital Trauma Unit for almost 4 years now. This will be the 4th time. In my opinion, the Trauma Unit is excellent and targets my needs very well. They treat symptoms, rather than disorders, which I think is a good idea since disorders are just attempts to categorize the wide variety of emotional symptoms. It’s easy to get hung up on exactly what someone’s diagnosis is, and also to make judgments about treatment based purely on the Dx and not on the person’s symptoms as a whole.

In fact, I like Timberlawn so much I wrote a review of the Trauma Unit and posted it to Associated Content:
Review:Timberlawn Trauma Program

I can’t say I’m glad to go though. I’m actually reluctant and dreading it. There is always the fear of people I don’t know, and the fear associated with being locked up and losing control over some aspects of my life. The fact that I’ve chosen to give up the control for my own good doesn’t make it any less frightening.

I’m fortunate to be getting a lot of support and encouragement. I really need it!

where next?

I have known I was bipolar for 11 years and I’ve had a lot of good therapy, beginning even before that when I thought it was just depression. I’ve been hospitalized numerous times as well. I know my disease intimately and I’m familiar with many, many strategies for alleviating symptoms.

But I feel there’s no point in all that anymore. I don’t want to try because it is just hopeless anyway, and I don’t have the energy. Trying to keep a positive outlook just makes me look like a fool, I think. It’s not going to change. It’s not going to get better, ever.

I feel I have an obligation to my family to keep trying, but it’s so painful. I just want to run away. I think to myself, I will just walk out my door to the highway and hitchhike to someplace far away. If I end up getting murdered, so much the better. I won’t really care.