Introspection – Page 3

Another Clever Title

I never quite know what to do with myself when I’m like this. I know retreating from the world and everything in it is probably not the healthiest option right now but it’s kind of all I want to do.

I believe I mentioned previously, Dr. Psychiatrist is adjusting meds again which always seems to make me a bit unsteady no matter what is being adjusted, or by how much. In this particular instance I switched from just bupropion to a relatively new combo drug approved in 2022 that adds, of all things, dextromethorphan. The theory is the addition of DM will improve my anxiety symptoms. If I don’t have any terrible side effects, I’ll be increasing the dose of DM in a couple weeks.

Whatever the DM is supposed to do I wish it would get on with it. I’m certain I’m not terribly pleasant to be around when I’m this symptomatic and, as I mentioned above, I have increased difficulty doing anything other than sitting and moping.

I hope people will bear with me until I’m tolerable to be around again. Fingers crossed it won’t take too long.

Clever Title

Lead in paragraph that is long enough to make the drop cap work. I don’t care what anyone says, I like drop caps.

the difficult is, you see, days and months can go by when nothing changes. I could post endless variations of “I woke up, ate breakfast, then sat around the house doing nothing until it was time for bed again” but I don’t think that’s what my audience wants.

So I am forcing myself to write about something. This week has not been great. The symptom du jour is anhedonia which has meant I haven’t really wanted to talk to anyone about anything, ever. So of course this was the week I had three people reach out wanting to chat. Which I would love to do, if my brain could figure out how to break out of this funk.

I was going to write in a bit more detail about how the funk is hitting me this time but instead, I’m going to bed.

Somewhat More Verbose

Among the happenings over the last year was being denied social security disability benefits. In spite of opinions to the contrary provided by my actual care providers, SSDI felt there was no reason I couldn’t “adapt to other work”. The nature of the “other work” was not specified.

I had tried, over the preceding 16 months or so, to not count on getting disability benefits. I knew it was a long shot, at least the first time around, but I also didn’t have a long-term Plan B. This has not contributed anything to my peace of mind.

The Plan B I was pretending I had, and which I don’t think was really fooling anyone, involved me sucking it up and going back to work. What with my preexisting doubt there is anything really wrong with me in the first place (well documented in previous posts) and social security insisting I could adjust to other work, I tried hard to resign myself to the idea of returning to hospital nursing. Several incidents of greater or lesser significance over the last few months have persuaded me this isn’t realistic, in spite of any protestations I might make to the contrary.

As one might infer from the numbers in the previous post, I remain symptomatic. I still don’t know what to do with myself when panic-brain takes over, which happens much too frequently in spite of everything. Dr. Psychiatrist is still experimenting, trying to find some combination of meds to make me a bit more functional. which is a process I am trying to not get discouraged about as well.

Am I better than I was this time last year? Probably? But certainly not better enough.

Almost A Year Later

Oh look! This place is still here! I am not going to bother trying to summarize what went on over the last year beyond saying, things have continued to be a little closer to the “Dumpster Fire” end of the scale than I’m happy with.

I am, as we speak (read? type? communicate?), unemployed. I left my non-patient care job at Swedish and started an actual clinical education job at the University of Washington hospital. Unfortunately, the environment was still much too hospital-y for my anxiety and I was having almost daily panic attacks at work again. I’m not at all sure what this bodes for my future employment, but I’m still looking. I’m branching out to non-hospital jobs but the one offer I’ve had so far paid less than I was making 10 years ago. So no. I could write a great deal about the experience of applying, and being denied unemployment benefits, but that may be for another day.

The other big development over the last year has been an increasing difficulty being out and about in the world. It seems that people with PTSD and other panic disorders are prone to develop symptoms of agoraphobia. Who knew?

My symptoms aren’t so bad that I can’t leave the house, but they do kick in when I’m around crowds, especially if I have to stand in a line and wait. The checkout line at a busy grocery store is just about guaranteed to make me go sideways.

I’m not sure what this means for the future. I’m not sure if this is a permanent thing. I do know that it’s kind of a pain in the ass.

Frustrated keyboard-pounding noises

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A couple of things I don’t think I’ve mentioned here have cropped up again today. Among the reasons I took the job I currently have was the medical benefits kicked in on my hire date. None of this “the first of the month after your first full month of employment” nonsense, sign to accept the job; get benefits. At least that’s what I was told and, to be fair, that was probably the intention of my employer. Unfortunately it didn’t exactly work out that way.

I’ll spare the reader the blow-by-blow details of what happened but the short version is, for reasons that no one can adequately explain, Shannon did not get added to my medical and dental coverage. It took three weeks of fighting with the benefits people and me turning in my resignation for it to get fixed. I did withdraw my resignation after being promised the insurance would be fixed (by sheer coincidence this promise came almost immediately after me submitting my resignation). Anyway, as of yesterday it was supposed to be all fixed.

Imagine my surprise, then, when we got a message from our pharmacy saying there was a problem with the insurance, which is exactly what they said when we found out about the problem in the first place. Fortunately it turned out to be a relatively common and easily corrected SNAFU with the pharmacy’s records but the situation still put me very much on edge again, which is what I really came to talk about.

I have previously talked a fair amount of shit about trigger warnings. It isn’t that I object to their use, nor do I have any doubt that trauma-related disorders can result in certain otherwise normal everyday events and topics to be distressing for people. What I object to is the use they have commonly been put to in discussion forums and the like, which is to put responsibility for one person’s mental health on to someone else – “OMG I am so triggered right now! How dare you not put trigger warnings on your completely ordinary and generally uncontroversial content? Now my triggers have been triggered and its your fault for triggering me because you didn’t use trigger warnings which has resulted in me being very triggered by the triggers you failed to warn me about“.

So this is the difficulty I’m running into. It is hard to talk about the things that escalate my stress and anxiety, “triggers” if you will, without sounding like a complete choad. This gets right back to my baseline difficulty with mental health in general; the overwhelming majority of my professional experience with mental health has been with people ostentatiously using a, usually self-diagnosed, mental health condition as an excuse to behave like a raging asshole. This is a particularly sensitive topic for me right now because my own mental health condition has resulted in me behaving kind of like a raging asshole over the past few weeks.

I don’t know what the solution to this is. My worst fear… among my worst fears is becoming one of those people who may as well have their diagnosis tattooed on their forehead and who use it as a central piece of their personality and all their social interactions. Meeting someone for the first time? Better make sure you work the fact that you’re neurodivergent into the conversation in the first few sentences, no matter how tangential it may be to the topic at hand, to make sure everyone knows you’re different and interesting. On the other hand, if simple things are going to elevate my stress and anxiety it might be a good idea to let people know.

It’s a conundrum.

My very own To Err is Human

In 2000 the Institute of Medicine published To Err is Human: Building a Safer Health System, a landmark work that shone the light, really for the first time, on the incidence and severity of medical errors. Why do I mention this? Because I’m pretty sure I had one.

As seen in the previous post, for the last few weeks I’ve still been having panic attacks and was quite symptomatic with depression and anxiety which prompted Dr. Primary Care to start me on sertraline. While I was seeing Dr. Primary Care I also got a refill on my bupropion since I was nearly out. I started the newly refilled prescription yesterday and noticed something kind of odd.

I want to take a moment here to mention I am aware of the difficulties and pitfalls of identifying pills by sight. Pills from different manufacturers will look different even if they are the same drug and the same dose. That said, I’ve seen quite a few pills in my day and I can generally spot things that are different because of manufacturer and things that are genuinely off.

So I started my newly refilled prescription and noticed that the new pills were markedly larger than the ones I had previously been taking, in spite of appearing to be from the same manufacturer. By chance I have access to examples of 150 mg XL tablets in addition to the 300 mg XL tablets that I am supposed to be taking and I am as certain as I can be without any physical evidence that the pharmacy filled my last prescription for 300 mg XL with 150 mg XL.

Two additional pieces of evidence that could add weight to the theory; once I started taking my new 300 mg XL tablets I immediately started feeling better. My mind has not been this calm in weeks and my overall mood has improved a great deal. Also when I started taking my new 300 mg XL tablets, I was struck with a serious case of insomnia which is a common side effect of bupropion. It hasn’t really been a problem for me¹ except for a couple of days after a dose increase.

There are potentially confounding factors to consider however. As mentioned above, I don’t have any physical evidence. All I have is an empty bottle that says 300 mg XL, and a comparison of my mental image of the pills I was taking to known samples of 150mg and 300mg tablets that appear to be, but can’t be said for certain to have, come from the same manufacturer. There is also the addition of sertraline to my regimen. I’ve been on it for a week and, while usually SSRIs take a bit longer to really take full effect, the possibility that I’m just feeling the benefit of the sertraline cannot be ruled out. Finally, the insomnia could very easily have resulted from me working my first full week on night shift after being on a “sleep when you want, wake up when you want” schedule for a couple months.

Pretty sure but not certain.

The thought of the difficulties I’ve been having with my mood over the past few weeks being the result of a medication error is actually reassuring to me. I was feeling distraught because I thought I’d been making all this progress in therapy and introspection and self-analysis and all, but here I was feeling like shit most of the time again. Additionally, if this was a medication error, any doubt about the benefit of being on medication that I may have had is gone. Being on a half-dose was all kinds of no fun so I don’t even want to think what being off it entirely would be like at this point.

¹ I know, I know. But there is my baseline insomnia and then extra insomnia gets piled on top of it. Insomniaception. A couple of days after my last increase in dosage I was back to my baseline insomnia.

What progress feels like

I spent most of the time between Tuesday morning and Thursday night last week having what felt like one, very long panic attack. Of course I didn’t recognize it as a panic attack until it was over. I seem to have two flavors of panic attack but neither of them have the precise textbook presentation I learned in school; a feeling of impending doom or a fear of death, frequently physical symptom similar to a heart attack, etc. What I seem to get are a sense that everything in the world in general and my life in particular is broken and nothing will ever be able to fix it, or a sense that everyone in my life either hates me or is angry with me about something. The one under discussion was the former and I spammed several friends, family members, and my therapist with texts and emails about how it wasn’t fair how badly my life sucked and now we’re going to have World War III thanks to Putin.

The thing is, at the time I did not feel irrational and, in my defense, it really has been a few pretty rough years and the nature of my reaction wasn’t completely unjustified. The problem started when my (perfectly justified) dissatisfaction with the state of the world turned into an out of control semi barreling downhill with no breaks. On some level I knew something was wrong. I knew I didn’t feel like myself, I couldn’t think clearly. It felt like my brain just wasn’t working right.

At this point I would like to pause for a moment and talk about brain anatomy. In broad terms, the human brain can be divided into three sections, the brainstem, the limbic system, and the cortex.

Generally, the brainstem tells you that you’re hungry and need food, the limbic systems tells you to go find food, and the cortex decides whether you want Thai or Mexican. Or, more importantly, tells you that you can’t go look for food right now because other things are more important.

That inhibitory function of the cortex is the key. The brainstem starts shouting about how there’s a big problem here (whatever it might be, probably a saber-tooth tiger), the limbic system agrees that this is a big problem (whatever it is and we certainly can’t rule out the tiger theory) and we’d better do something about it right fucking now. It is at this point where the cortex is supposed to step in and remind everyone that saber-tooth tigers have been extinct for a really long time now and all that happened was some jerk cut us off in traffic.

Problems start because under enough stress, either intensity or duration, the limbic system kind of stops talking to the cortex. It decides that the big problem (whatever it is) is important enough that we have to deal with it and we don’t have time for the guys at headquarters to get back to us. This effectively removes the filter between thought and action which frequently results in people doing stupid things like spamming their friends with apocalyptic text messages.

Or punching a wall.

What I’m learning is it’s impossible to think yourself out of a panic attack because the thinking part of your brain is quite literally not at the controls anymore. Of course the goal would be to not have panic attacks in the first place which is why I’m also trying very hard to learn the warning signs so I can do something to change the situation before the lunatics take over the asylum as it were. Unfortunately I am really bad at recognizing the warning signs, partly because I’ve spent the overwhelming majority of my life not just ignoring them but desperately pretending they didn’t exist at all. Since nothing my limbic system could do would get the attention of my cortex to have it fix the problem, my limbic system decided it needed to turn things up to a point where they couldn’t be ignored anymore.

The point to all this is I will almost certainly have more panic attacks in the future and people may very well see me behaving somewhat erratically. Be assured that in a matter of hours, or a couple days at most, I’ll be fine so just strap in and hang on.

The benchmark for stupidity

Back in the early 2000s (by which I mean 2000-2001) I worked as a nurse in the emergency department at our local university hospital. Among the injuries we saw on a semi-regular basis were adult men (and it was always men) presenting with a fracture of either the fourth or fifth metacarpal bones (sometimes both) and no other injuries.

what the fourth and fifth metacarpal bones might look like

This particular injury is known as a boxer’s fracture and results from, as one might guess, punching a hard, unyielding surface such as a human skull or, much more frequently, a wall.

In my mind it did not get much dumber than punching a wall. You start off with a bunch of problems, something makes you lose your temper and you punch a wall. Now you have all the same problems you had originally plus a fractured hand (and it was almost always their dominant hand because that’s the one people tend to throw the first punch with) and a bill for an ER visit on top of it.

With that all said, this is how I spent my Thursday evening:

ulnar impaction syndrome is a degenerative joint disease similar to arthritis

I knew what I’d done as soon as I did it, although I did spend a couple of hours trying to pretend I didn’t.

So, as the man said, how did it come to this? The short(-ish) answer is that I am having an increasingly difficult time arguing that the PTSD-like symptoms that I’ve been having aren’t actually real¹. The longer answer is that I really can’t point to anything specific. I’d been feeling off since the Tuesday of that week; more irritable, harder time concentrating, more than usual sleep disturbances, etc. and by Thursday afternoon I was moderately dysfunctional. I really can’t remember what I was doing right before. I was upstairs actively falling to pieces and went downstairs to try and get somewhere quiet. I went back to my office and then I was back out in the hall with a fractured hand.

I have to revise my opinion of at least some of the boxer’s fractures that came through the ER. This is, I think, a perfect example of that “toxic masculinity” you hear about these days. Men in America, certainly men around my age, were still acculturated into fairly traditional gender roles, especially when it comes to emotional intelligence. There comes a point where the only way one knows how to express and attempt to manage the intensity of emotions that one is experiencing is through violent rage because men have traditionally been actively discouraged from experiencing negative emotions in any other way.

I hope that others can maybe avoid these self-destructive patterns and learn a lesson from my experience.

And that lesson is: punch something softer than a wall.

¹ This is not to say that my brain isn’t trying to tell me this is just an example of how serious I am about sloth and malingering; that I would go so far as to injure myself just so I could better fake mental health issues shows real dedication

Or maybe I don’t?

Bessel Van Der Kolk is a professor of Psychiatry at Boston University School of Medicine and president of the Trauma Research Foundation in Brookline, Massachusetts. He has been studying Trauma and PTSD for decades. His book The Body Keeps the Score was written pre-pandemic but has absolutely exploded in popularity since the whole thing started (I’m trying to wade through it myself right now).

Van Der Kolk was on All Things Considered on NPR this afternoon (his bit starts at around 6:18):

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He makes a very compelling argument that, while the pandemic and it’s associated disruptions of every day life are deeply troubling and are, without question, causing an uptick in mental health complaints, those complaints most likely are not exactly “trauma” related. He takes the position that this is an important distinction to make because if you are treating people for pandemic related mental health complaints, and you treat them like they have PTSD or other trauma related issues when they don’t, they may not be receiving the best, most effective treatment for their condition.

I intend to discuss this with my therapist, and the psychiatrist I was referred to by Dr. Rando, but I think Van Der Kolk’s thinking is correct and it is much more likely that what I’m suffering from is garden variety stress and burnout rather than PTSD. I view this as good news because it means that, after my appropriately lengthy time away from work (it will be close to two months by the time I start my new job in February), and the addition of clonidine to my medication regimen, I should be able to get back to work without further issues.

I could be wrong but there is really only one way to find out: wait and see what happens.

In praise of 2-(2,6-dichlorophenylamino)-2-imidazoline hydrochloride

More commonly known as clonidine. Clonidine is an alpha-adrenergic agonist, and should not be confused with clonazepam (Klonopin) which is a benzodiazepine. As was previously mentioned, I had an appointment with Dr. Rando and among the things she recommended was adding a medication for anxiety to the antidepressant I’m already taking. Discussed options included benzodiazepines (which are not recommended for use in PTSD¹), beta-blockers (which she was hesitant to put me on since I had been having issues with fatigue), prazosin (which is also an alpha blocker but is only indicated to treat nightmares associated with PTSD²), and clonidine.

TL; DR – I started on clonidine and I feel like it’s working really well. My baseline level of nervous system jangling has dropped noticeably. You are now safe to skip the rest of this post which consists of some rambling about how clonidine works, why I was positively enthusiastic to try it, and how irrational the distinction I have in my head between “psychiatric” medications and “physical” medications is.

My reaction to the suggestion of more medication highlights again my physical medicine bias. I resisted being on an antidepressant for a long time, and even after I started one initially my goal was to get off it as soon as possible (and then resisted going back on one when it looked like it was going to be required). However, when Dr. Rando suggested clonidine I was positively enthusiastic for a couple of different reasons. First, I am well familiar with clonidine. It was a mainstay medication for our ECMO program because it (at least theoretically) has beneficial effects on pain control, sedation, and blood pressure, it is available as a pill that can easily be crushed, dissolved, and put down a feeding tube if the patient can’t swallow, and, perhaps most importantly to the Powers-That-Be, it is dirt cheap. I understand how it works and, because I know how it works, I could see how it would help with the difficulties I have been having. The other reason I was enthusiastic to try it was the opportunity to see first hand if it really did work the way it was supposed to.

I want to talk a bit about exactly how irrational it is that I would resist adding, say, an SSRI to treat PTSD while not only accepting but being enthusiastic about trying clonidine. As I mentioned above, clonidine is an alpha-adrenergic agonist, which means that it inhibits some of the fight-flight-or-freeze response that our nervous system does when it feels threatened. In past times this response was a great adaptation because it allowed our progenitors to run away from saber-toothed tigers. In modern times it can be maladaptive because modern life is very good at creating stress that one can’t fight or run away from so the stimulation of our nervous system doesn’t turn off. Ever. The practical effect of using an alpha-blocker to moderate the activation of our nervous system is to reduce the hyper-alert state, resulting in improvement in tension and anxiety. Clonidine can do this by having the ability to cross the blood-brain barrier³ and by being structurally similar to norepinephrine, one of the main neurotransmitters in our nervous system. In terms of it’s mechanism of action, it is essentially indistinguishable from most medications that have primarily psychiatric indications.

Of course none of that matters to my brain. It’s a medication that I have used and am familiar with, and it has primarily physical indications which means it’s a real medication and not one of those woo-woo brain drugs (that work in extremely similar ways to achieve similar effects). Totally irrational.

This is one occasion on which I will not complain about my brain behaving irrationally. Whatever the reason I was able to persuade my brain that this was a necessity, I’m very pleased with how the medication is working so far. It has settled my nervous system sufficiently to make every day life a great deal less challenging.

There is more to catch up on but I am taking advantage of the reduction in mental clutter to enjoy doing things. What kind of things? Almost anything really. Even doing chores around the house is less troublesome when you aren’t spending an excessive amount of energy trying to keep from having a complete breakdown.

¹ I’m not entirely sure why benzodiazepines aren’t indicated for PTSD. I suspect it has something to do with benzos having the potential to be disassociative which, based on my extremely limited understanding, is probably counterproductive.

² I have no idea why one alpha blocker (prazosin) is only indicated to treat nightmares and another alpha blocker (clonidine) is indicated for general symptom treatment. Seriously, no clue.

³ I also don’t know enough about the blood-brain barrier to even attempt to explain it, so here’s Wikipedia.