… was better. I took the tablet directly after breakfast instead of during it, and that helped: the nausea was tolerable and I did not have to puke. Still cannot eat much, though. More vertigo than yesterday and a slight headache. When moving my eyes quickly, my brain starts “shivering” – those are not full-blown brain zaps, but it rather feels like my brain turned into jello and quivers with every eye movement.
Even though I didn’t do much today, I feel exhausted.
Tag: antidepressants
The First Day On Venlafaxine
Googling venlafaxine yesterday did not do me a whole lot of good. For a while, I was pretty scared, but then decided to judge it according to my own experiences with it. After all, the effect citalopram had on me was different from what the majority goes through as well.
Well, my first experience with it was rather horrible. The psychiatrist had told me to take the venlafaxine in the morning, with my breakfast, and so I had a banana, took the pill, and ate a sandwich afterwards. About 20 minutes later, I started feeling a little queasy and dizzy. I went to lie down on the bed, where I felt very ill very quickly. 45 minutes after taking the pill, I found myself in the bathroom, vomiting violently. I don’t want to gross anyone out by too graphic description, but it was so bad that while vomiting I thought: “This isn’t going fast enough! This stuff needs to get out NOW!!!”
Once my stomach was empty, I felt better instantly, but it was not over yet, because apparently my whole digestive tract was affected and I got diarrhea as well, while a couple more waves of nausea washed over me – those did not result in vomiting, though. In the early afternoon, the worst was over and I slept for two hours as I was completely exhausted.
After the nap, my stomach had calmed down and I only felt a bit of dizziness, but was left rather weak. I don’t dare eating anything but dry bread, plain rice and apples either, because I am afraid of getting sick again.
I just hope it will be easier tomorrow, because I don’t see myself lasting very long if I have to vomit that violently every morning. When starting citalopram, I got queasy too, but nowhere near as bad.
Originally, I’d wanted to cut the first pill (37.5 mg) in half and start with an even lower dose, but the pills are too small for that (I don’t have the extended-release capsules).
Back From The Psychiatrist
And thus begins the new treatment regimen with Venlafaxine (Effexor), starting tomorrow.
Everything went well; I was a little nervous first and not particularly in the mood for dealing with a stranger, but the psychiatrist turned out nice. He asked: “What leads you here?” I told him that I was in therapy for chronic depression for two years and generally was really satisfied with it, but couldn’t get a handle on some symptoms like concentration problems and energy, and wanted to see what medication could do for me in that regard. He knows my therapist and has a superficial idea of the CBASP programme I’m in, and I guess that was enough credit to not let me do all the lab tests and ECG again. I also gave him permission to send reports to my general physician.
I recounted a brief history of symptoms and the treatment I received so far: First depressive episode at 12, second at 16 (this time with suicidal ideation), since the age of 19 / 20 only oscillating between different stages of major depression; panic attacks at 30, treated with citalopram, then therapy; therapy major success, but then the start of a slow decline. The psychiatrist asked about living situation, family, family history of depression, school education, what I am studying. Whether I smoke, drink, ever did drugs, take any kinds of medications.
He performed some tests on my cognitive capacities, because I had complained about them:
– “Spell the word ‘radio’ backwards.”
– “What’s the difference between a river and a lake?”
– “What’s the difference between a ladder and stairs?”
He had me memorize the words “street, traffic lights, flower” and asked whether I remembered those in between other questions, and had me do a chain of mathematical exercises: 100 – 7, then subtracting 7 from the result again, and again, and again. I scored 100% and obviously am not demented.
Some questions on differential diagnoses: do I see or hear things nobody else sees or hears, do my thoughts race, do I think I am being watched or that people talk about me behind my back, etc.?
The most difficult question actually was, “How do you feel these days?” I honestly had to think about that, and answered, “On average days, I feel subdued. Pessimistic.” I told him about the insomnia, problems falling asleep and the stomach aches, that I like to withdraw from people, worry a lot and occasionally get anxiety attacks because of the worrying.
All of that took about half an hour, then he proposed that due to my previous experiences with SSRI in the form of citalopram, I should try out what an SNRI does for me. He explained that SNRI give most people more energy, explained possible side-effects and finally gave me a prescription for venlafaxine. Unless I experience really bad side-effects, I’ll see him again in four weeks.
Edited to add: Yikes, maybe I shouldn’t have googled venlafaxine / effexor, because the results sound pretty bad… “The antidepressant everyone loathes to have taken.” Sounds like I am in for a bumpy ride…
Help Me, Zopiclone
I did not think it was possible, but the last night was almost worse than the one before. It started promising: Got tired and went to bed at 10.20 PM, read for half an hour and switched the lights off at 10.50 PM. Fifteen minutes later, I was asleep – until 1 AM, when I woke up and was so alert that I could not force myself back into the realm of dreams. Got out of bed for a couple of hours, then back into bed, where I read until 6 AM. Lay awake for another hour and finally dozed off just after 7 AM again.
At least I did not cry this time, but it was even more confusing than simply staying awake. So for tonight, I asked my sister for one of the zopiclone pills she got prescribed for her insomnia last autumn. A definite first, as I never took any kind of hypnotic agent before, but I just cannot go on like this. I have tried everything to rectify my sleeping cycle and it only got worse, and even though I am generally not keen on using pills, I feel like I am going to lose my mind if I don’t get back to normal hours soon.
In other news, I have an appointment with the psychiatrist in four weeks. As the psychotherapy is covered by the fundings of the clinical trial, he has pretty much free reign to do with me whatever he deems fit, because with the exception of the citalopram two years ago, the health insurance did not have to pay for anything yet.
I’m not quite sure how I feel about all of this yet. I would have prefered to see my therapist as the psychiatrist as well, because nobody else knows my mental health history as well as he does, and quite frankly it would save me the hassle of having to get to used to another “stranger”. However, I have hardly any right to complain, and maybe it will even be good for something to keep the two treatment fields separated.
A Bad Day
And I do mean bad: not-sleeping-until-5-AM-and-crying-after-waking-up-bad. I have been talking to my therapist about starting antidepressants again; even though he is also a psychiatrist, he must not treat me as such because legally therapy is “aftercare” for the clinical trial I was part of, and he is only allowed to see me as a CBASP therapist. With the kind of health insurance I have, I cannot see him as a regular patient, and I don’t have the money to cross over to his regular patient pool.
He said the antidepressants will not be able to replace the psychotherapeutic work (which I did not mean to do anyway), but might be able to aid it. He also recommended a psychiatrist to me, which makes things a lot easier as I do not have to do research and worry about whether I made a good choice or not.
Going Back On Antidepressants?
(For the past couple of days, I have been under the spell of a virus infection which is currently on a rampage in my neck of the woods – sneezing, coughing, sinus pains, yadda yadda yadda. Not that I really dare complaining; having suffered through a real influenza two years ago, I know how bad it can get and how far away I am from that still.)
For a little while now I have considered going back on antidepressants. Taking citalopram was a mixed blessing, which I have written about in one of my first blog posts and in the Pre-Treatment Diary, and for a long time I was adamant to not go back on medication. However, my perspective on it has changed since: To begin with, I believe I was too depressed in 2010 that antidepressants alone could have “cured” me – even on medication, I still was severely depressed. After two years of psychotherapy, I can feel and tell apart varying degrees of depression, even within the same category of “severe”, “moderate” or “light” depression, but was not attuned enough for doing so two years ago. I can also tell where citalopram worked for me and where it did not, and it undeniably helped with the panic attacks, even if it could not eradicate the depression enough to make a difference.
Maybe a different brand or class of antidepressants will work better than the citalopram did.
The reason why I am even considering going back on antidepressants is that I feel myself slipping – very slowly, but it is happening – into another episode of depression. My energy levels are getting lower; concentration lapses; the cognitive deficits are becoming worse; insomnia. I just want to curl up on the sofa, hide from the world. (And none of that has anything to do with the cold; it has been going on for a much longer time than this.)
What worries me is an unpredictable sadness flooding me out of nowhere, making me tear up from one minute to the next. It is so difficult to explain to other people… sometimes, it is as if I am in a bubble, and inside it time goes by much slower than for everyone else. I am too slow, too lethargic to keep up with the rest of the world….
Due to my husband’s integration class finally starting and me being unable to fall asleep, he has gone to bed earlier than me all week long: I would just stay in the living room and join him a couple of hours later, so that I would lie awake only one or two hours in bed instead of four of five. Sitting around at night all by myself has somehow emotionally transported me back to the times of my deepest depression, and I always had a pattern where my mood would tank over the course of the evening. The sadness increases with every hour, and I feel more and more lonely until I fall asleep. It is like being the only person in a vast, empty land, with nothing to distract or occupy the mind, where only bitterness and desolation thrive. Everyone around me is asleep.
I went to bed at two o’ clock in the morning, hoping I would be able to sleep. Instead, I found myself falling into sadness again – so badly that it cost all my self-control and restraint to not wake up my husband. I knew it was silly; after all, I was lying right next to the person I had married, no reason to feel lonely. And yet, there was this strange sensation of being completely isolated from everyone else in the world.
Exhibit B: A (Not So) Hopeless Case
Exactly a week ago I appeared in front of a group of 19 psychology students as an example for chronic depression, but was (still am) so swamped with homework that I didn’t have the opportunity to write it down yet.
I went to the hospital straight from university, so I was a good half hour too early and had plenty of opportunity to get nervous. It was a part of the hospital building I did not know too well either, so I did not dare going to the restroom out of the irrational fear I would miss my therapist. Fortunately, we had about ten minutes to spare when he came to pick me up…
We spoke a few minutes outside – about how I was doing in general, and about being nervous and how curiosity got the better of me. We also discussed which personal information my therapist was allowed to disclose (he was very discreet, though, and spoke only of my “significant others” instead of naming a person, and he did not talk about anything personal). I gave him free range on whether he wanted to wear his white coat or not and on whether we’d sit at a table or not, so my therapist decided to recreate the therapy setting – no white coat and no table.
As mentioned, the group was rather small, creating a somewhat intimate setting – as far as that is possible given the circumstances. My therapist acted as a moderator, introducing me and my diagnosis, and I smiled a hello into the round. They had already learned about the characteristics of depression before and seen an in-patient earlier that day, who had also volunteered to talk about her depression. The in-patient, however, had been an example for biological reasons behind depression: a disturbed transmitter chemistry and psychiatric treatment with cipralex. I had come in as a representation of environmental and character-related factors, with the biological components playing only minor roles.
I started off recounting how I got misdiagnosed by my former general physicians, how I suffered from panic attacks in summer 2010, got on citalopram but could not shake the depression, and finally got in contact with the hospital. My therapist elaborated on the importance of behaviour in medical caregivers – had my first contact not been such a positive one, I might never have followed through with everything that followed.
There was a sheet with the results of all the clinical tests I did during the first 48 weeks of therapy – BDI-II, IDS-SR, MADRS and possibly some more I forgot, plus the results of the “therapy cards”. My therapist was not supposed to know the results until recently, because they evaluated the level of trust between him and me, but from the beginning of their evaluation (from therapy week 4 on), they had shown I trusted him. All the other tests showed the same pattern: a very high score in the beginning, then a steep decline over the course of a few weeks only, and a long phase of slowly fading out. Towards the end, my scores went up a little again, when I decided to go back to university.
We spoke about how important it is to trust the therapist and I listed some of the irrational fears the therapy setting could have evoked – fear of being ridiculed, getting yelled at, not being taken seriously, or cancellation of therapy as a punishment for increasing depression symptoms, for example.
I did surprisingly well during the presentation. My biggest fear had been to just freeze or being unable to get proper words and sentences out of my mouth, but I spoke with a loud and clear voice, looking at all the faces around me and also taking in their reactions. Everyone looked friendly, some even smiled encouragingly, and I found it easier to open up than expected. Of course, we did not discuss anything private, but considering that in university I have not told anyone anything that is even remotely close to the truth, it was a pretty huge step for me. Part of what kept me calm was that I knew no matter the outcome, the people would learn something from my appearance. If I could talk about it all, they’d learn from my report, and if I froze up completely, they’d get a demonstration of what depression can cause.
Today, I had a regular therapy appointment, and my therapist said he could tell the very moment I relaxed during the presentation just from observing my body language. He gave me quite a lot of praise and also thanked me for doing this: “Half a year ago, I wouldn’t have asked you. Not that you couldn’t have done it back then, but the risk would have been too high.”
There are several reasons why he asked me: for one, I’ve been long enough in therapy to know the process very well, to have recovered enough for being able to reflect, and something he has been stressing a lot over the last weeks is the fact that I went back to university. Last month, he told me about a colleague’s patient who had a similar diagnosis as I do, and she actually quit her job – whereas I went back to a place that terrifies me quite often. On about four days per week, it gets so far that I think I can’t take it anymore. I fantasize about quitting. But, there’s no realistic alternative, and so I struggle from week to week. My therapist knows this – he gets to hear plenty about that, of course. University was one of the catalysts which propelled me further into depression, so he thinks that it is of utmost importance now that I confront those situations and master them. He never influenced my decision on whether I should go back or not, but clearly approved of it afterwards.
One reason why he asked me might have been that the outlook for me without CBASP would have been pretty bad: “Early-onset chronic depression with life-long co-morbidity of panic disorder.” He called it a “horrible, horrible diagnosis” which without this special therapy programme would be pretty much treatment-resistent. CBASP actually works on both a personal and an environmental level, whereas other schools of psychotherapy concentrate on one aspect onely: classic Freudian psychoanalysis operates on the personal level only, classic cognitive psychotherapy on the environmental level. Neither of them would have been sufficient for me.
They didn’t even put me through pre-treatment self-evaluation as they usually do, because they thought it would trigger my flight instinct and drive me away. Yet, despite the very bad odds, here I was – more or less functioning now, and definitely able to talk to a bunch of strangers without running away.
At the very end of the presentation, everyone clapped and I blushed and looked down to the floor, until my therapist told me: “Look up and take it in. This situation will be over soon, so this is your only chance at grasping of how well it went. You need to take this memory home with you.”
A Severely Disturbed Patient
My therapist wrote an article together with a colleague, which was recently published as part of an anthology / publisher’s edition on psychiatric disorders and different treatment approaches. I have reason to believe that I am featuring as a case example in it: of course, everything is anonymized and no personal information is given other than that the patient is female, but there’s nothing in the case example which doesn’t match my diagnosis and specific problems, so unless he has another patient who is very, very similar to me, there’s no doubt about that.
I can’t quote the article or example here because it would reveal my therapist’s name and location, but the “severely disturbed” patient with double depression is described as emotionally distant (meaning the patient expresses no emotions towards the clinician) and detached (i.e. making no emotional connection to the clinician in order to deal with anxiety that’s triggered by other people), as well as exhibiting behaviour predominated by submissive characteristics. Interpersonal avoidance is cited as well as social fear. All of this could still be coincidence, but what makes me as certain as I can be without actually asking him is that the case example features “rules” describing my (pre-treatment) behaviour which we worked out in the beginning of therapy. Detached or submissive behaviour are part of the standard features for chronic depression and could be detected in quite a number of patients, but those rules were personal….
I have nothing against this – quite the opposite. When I signed up for the programme, I knew my data would be used and I knew they were doing clinical research even when I first picked the hospital as a possible treatment facility. I gave blood for a worldwide clinical research project which tests how genetic factors influence the efficacy of antidepressants, so that in the future psychoactive drugs can be tailored to measure the patient’s individual genetic disposition – since citalopram caused a lot of side-effects for me and left much to be desired, chances are that I am someone whose response to such medication is rather poor due to genetic reasons. Actually, before I started therapy and was completely ruled by depressive thinking still, I thought by myself, “You’ll probably never manage to get a university degree and do scientific research, so it would be cool to contribute your part to science as a ‘test subject’ instead.”
However, I’m uncertain whether to flat-out ask my therapist about it or not. It’s not like the article is a secret project; he links to it under his profile on the hospital website and the full text is accessible for reading. The reason I read it in the first place is because he told me about the results of an US-American clinical trial cited in the article and I was simply curious about it and wanted to know more details. So I started reading and after a couple of pages suddenly saw myself confronted with a very familiar case example.
Given the date of publication, he must have written the text early this year; it quotes other works from 2011. So it is very well possible that this is indeed my case, and I would understand why he didn’t mention it to me then, because quite frankly I might have felt even more “defective” than I already did. CBASP works under the premise that chronically depressed patients are stuck or get set back to an earlier developmental stage of thinking because of adverse conditions they endure repeatedly or over very long periods of time, and when I first learned about this in therapy, I felt ashamed for “having an immature brain”. So, had I read phrases like “severely disturbed patient” about myself back then, it would indeed have caused me distress. These days I can look at it and accept it for what it is, though. I wouldn’t have ended up in therapy had it been any different – or at least not in this programme – and my therapist gently gave me feedback on behaviour that made me figure out my deficits over time without being crushed by the realization.
I’d like to have certainty about this. One can only change if aware of what’s wrong with oneself, and over the last year I have often been in situations where I had to realize that my own perception of myself differed quite fundamentally from the feedback I received from others. If anything, the knowledge that this is indeed a professional description of my condition would be an additional source of feedback, because here nothing is sugar-coated. And if I’m a case example in a book on psychiatric disorders, I want to know, out of sheer curiosity alone – which means I’ll have to write him an email.
Update:
After bringing up the courage to ask him, I received a very nice email back, explaining that this was actually written in 2009 already, but published only now. The case example is based on a CBASP patient from “long ago” and it’s pure coincidence, “even though you’ll certainly find yourself in that too.”
So apparently there’s a former patient who had made up the same rule for herself – because there’s no reason I shouldn’t believe my therapist. He wouldn’t lie to me about that.
All of this made me think about how, even though I know my therapist has treated and still treats quite a number of other patients with CBASP, I have never met anyone else – neither personally nor online – who was diagnosed with chronic depression and did a CBASP therapy.
Pre-Treatment Diary
Since it’s been almost exactly a year since my first psychotherapeutic session (the anniversary will be on Tuesday), I added a new section to the blog, a “Pre-Treatment Diary“. Originally a collection of messages written for a group of friends, it gives some insight into the process of seeking help, the side-effects citalopram had on me, how my moods kept crashing time and again as well as various clinical tests, interviews and my first MRi-scan at the hospital… Unfortunately, I lacked the energy to describe those first CBASP sessions in greater detail – something I rather regret now – but it helps giving a more complete picture of my recovery process prior to the existence of this blog.
Exam Grades & Misguided Sense Of Duty
Friday’s session was a little different – my therapist wrote a letter to my health insurance (which wants to “promote” me from student fare to their standard fare, because I’m “too old” for being a student), stating that I had substantial health reasons rendering me “unable to study at all times prior to September 2011” and that it is very important for my recovery to not put obstacles in the way of finishing my education. I also have a letter from my general practitioner documenting the treatment with antidepressants, so I’m fairly optimistic that this will come to a good outcome.
The rest of the session we just talked: usually, we focus on situational analysis and solutions related to the problems in relation to the SA, but this time we just sat there and had a conversation – I could provide more than ample material for that. I am very much aware of the limitations of a therapeutic relationship and do not think of my therapist as a friend – but there’s no denying that I like him and that I enjoy talking to him beyond the fact that he cures me of an emotionally painful illness this way. He is very easy to converse with, both because he is professionally trained to “say the right thing” and because I stopped worrying about coming across as awkward – he knows I sometimes can’t find a word right away and expressing myself sometimes proves difficult, and we two are aware of the reasons behind that. But apart from the relative effortlessness of our exchanges, I find it interesting to discover his perspectives on life and the world in general.
As I said before, CBASP actually utilizes the therapeutic relationship as a tool for achieving the patient’s recovery, and you get to know your therapist’s background this way. Friday, we spoke mostly about university and the challenges going back poses to me. Knowing that I put a lot of pressure on myself, he warned me to not focus on grades too much and burn myself out again quickly in the process, and told me about his time at university and his grades in the final school exams (called “Abitur” here in Germany):
“Do you want to know my Abitur grade?” he asked.
“If you’d be willing to share it,” I replied.
“You know what you need to do,” he responded.
“Yes, I do – I need to ask you. Would you please tell me what your Abitur grade was?”
That’s how these conversations are used as short training sessions, because one of my “hot spots”, my areas of major problems, is that I retreat into myself and have a very hard time coming out of my shell. By making me ask, which happens very frequently, my therapist also makes me practice becoming more visible and active, and because I experience that nothing bad happens when I express interest in another person, I become more courageous outside of the sessions too. The third effect this exchange has is that by revealing his grade – which is good, but by no means as inhumanly good as I most likely would have assumed – he illustrates the fact that indeed good grades are not everything, and leaves no room for assumptions about my own perceived inferiority.
It’s already become apparent in the emails that I had temporarily slipped back into behaviour and thoughts which are typical for chronic depression – globalized thinking like “I will never succeed” or “I am not good enough for this”. It had not played much of a role anymore during the summer when I wasn’t facing as many challenges as I do now, so this is something where I definitely need to pay more attention. My BDI-II score had already risen to 12 points and doubtless would have gone up even more had I not pulled the emergency brake chain and stayed at home Thursday and Friday.
My next appointment is in three weeks, but afterwards I’ll be on a tighter schedule again for a while, to give me more support. And in between, I am to report via email about how I am doing every week.
My therapist strongly advised me to stay at home and recover properly from the sinus infection instead of going on the excursion which was planned for Saturday: “You belong in bed with a hot water bottle, not in a cave or quarry. If you’d broken your leg, you wouldn’t think twice about going…” I was hesitant, even though of course he had a very good point, but eventually cancelled my attendance. It’s going to create some complications and I’ll have to ask if there’s something I can do as an alternative, but in the end health goes first. The worst case scenario would be that I have to repeat the excursion next year.
What tipped the scale in favour of cancellation was that if I had gone, it would not only have meant an entire day outside when being sick, but it would most likely have affected my performance in the written protocol afterwards too. I’d have laboured – for months, possibly – on the fact that the result would not have reflected my true potential: it’s an open invitation for depressive thoughts.
Lugubrious Layara 