Cognitive Deficits Revisited: Coca Cola Addiction

Chances are, at some point during the last few days you came across the headlines claiming a link between the consumption of soda, especially diet soda, and an increased risk of depression. The idea itself is not new and has been circulating the media before, but surfaced again this week – even though at a closer inspection there is room for scepticism.
Most of the following text I had written almost a week ago already, but not quite finished the post yet when it suddenly became a hot topic.

Some of the most persistent symptoms of the chronic major depression I suffer from fall into the category of cognitive deficits: word finding problems, temporary inability to access memories, concentration and learning difficulties, generally slowed-down thinking and speaking. There is no doubt that I have improved in all those areas over the past two years, but the progress has not always been linear. The subjectively best I felt in September 2011, when according to the BDI-II my overall depressive symptoms were in the range of 10 points and lower, a score equal of euthymia (non-depressed, reasonably positive moods). That was also the time when I experienced the least cognitive impairment, in all aforementioned categories.
The biggest differences between now and then are that in September 2011, I was not yet back at university, and I had been on a number of short trips that year, providing both recreation and intellectual stimulation. Over the course of just a few short months, my cognitive capacities had improved greatly. In 2012, it was mostly classes, homework, written exams and office appointments instead. As a result, most of the cognitive deficits made a comeback or got worse again. The only exception is access to memories, at least concerning personal history. I remember a lot more now than I did back in May 2011.
It’s a vicious circle: the depression causes cognitive deficits, and I get depressed over those cognitive deficits…

Most days, it is as if I have a cloud in my head; every brain activity appears somewhat hazy. The closest approximation I can give is that feeling when you are just about to fall asleep and your thoughts start drifting, and then you are being forced to rouse yourself and do some task. Except that for me, this sensation can last for hours and is present at any time of the day, without being tied to sleepiness. Brain fog. Mental cotton-balls. A muddy pond in your head.
The only remedy I have for this is drinking Coca Cola – there’s something about the sugar-&-caffeine-rush that clears out the clouds and suddenly makes me more alert, more concentrated, more “intelligent”. Strangely enough, coffee does not nearly have the same effect. Nor do fresh air or anything else I tried. Only cola gets me out of the sedation.

I don’t want to drink coke on a regular base. I am worried about all kinds of negative effects this might have on my health, from diabetes to cavities in my teeth to osteoporosis (the sweeteners in diet coke severely upset my digestion, so that is no option). But more and more, I do crave cola due to the effect it has on my brain and thinking abilities. Nothing else lifts the psychomotor retardation as effectively. None of the blog posts of the last months was written without either a glass of cola standing next to me or having been consumed prior to typing.
I try limiting myself to two glasses a day, one in the early and one in the late afternoon, sometimes coupled with a cup of coffee. The results are about six hours of clarity. But there is no denying that occasionally, I drink more, and that on some days, I already crave cola before breakfast.

As I was going to wrap up this post and googled “cola depression”, I came across another fascinating blog post at Evolutionary Psychiatry, discussing the case study of a woman addicted to coca cola. Until very recently, I was much more worried about the physical consequences of my cola-consumption, and while my own intake is far lower than the quantities mentioned, it does make me wonder about possible influences on my mental health.
There is something of a dilemma: Either I give up Coca Cola and experience even more psychomotor retardation, accepting that the lowered intellectual capacities will depress me even more, and deal with the coke cravings on top of it. Or I will continue drinking soda, but risk possible negative effects for my physical and mental health, in the latter case even increasing the damage my brain has already taken in twenty years of major depression.
Maybe I’m fooling myself into a false sense of security by thinking that two glasses per day are permissible. Maybe I’m fooling myself by thinking that eventually I will get rid of the fatigue and brain fog for good, consequently not needing the cola-boost anymore. Maybe I’m a fool for thinking I will be able to quit the soda eventually. All I know is, right now I will take uncertain and abstract health risks over the certainty of daily psychomotor retardation.

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Forcing Myself To Post

This is not the first time that I’m trying to write a blog post, even though a couple of weeks have passed since the last attempt. The biggest hindrance being my continued inability to express myself – if talking about it poses great difficulty, writig appears an almost Herculean task. So I’ll just try to give a very fragmentary overview in the hope that eventually I’ll be able to express myself more eloquently.

I don’t know how I made it through the semester, in hindsight maybe even less than at the time of living it. In the end, I was so burned out that I pushed all but one of the exams to October, because I wasn’t mentally fit for studying any more, but at least that one exam I passed with an “A minus”.

My husband’s appeal for a residency permit got granted for three years (after that, it’ll be a permanent one). We jumped through all the bureaucratic hoops and in December he can finally start the mandatory German classes, the way there being paved with many frustrations that will require a post of their own.

My old computer broke after five and a half years of faithful service. The power supply unit literally blew up (knocked out the living room’s fuse, smoke curling out of the computer’s back) and damaged not only the PSU, but also the mainboard and processors. It was only because of a financial donation from my mother-in-law that I could buy a laptop as replacement… All my personal data – photos, all my uni files, the templates for the blog charts etc. – still are on the old harddrive, but I hope I can get them back soon.

The last regular therapy session was in April. I had one “on the side” in late June, which my therapist had crammed in between hospital duties one morning, but following up on this, all scheduled appointments got cancelled due to the persisting staff shortage at the hospital, and then August rolled around, which my therapist takes off every year.  I was told to get in touch via email at the beginning of September, so I guess by Wednesday (when the first dust of back-to-work-stress has settled) I will contact him.

For about three months, I have argued back and forth with German Telecom over the cancellation of my landline phone back in February: because I couldn’t pay my phone bill all at once, I had cancelled my phone and arranged for payment of the remaining bill in four rates, due in March, April, June and July.  In May, I received a letter reminding me of outstanding payments on my landline and when I called customer service to clarify the mistake, the ladies I spoke to insisted that my phone had been turned off because I didn’t pay – never mind the fact that if one calls my old number, an automated message announces that the phone number is not available at the moment. It wasn’t turned off, it was properly cancelled. On top of that, they spoke of the fee due in May, when the payment plan I’d received in the mail clearly stated that no rate was due that month, and claimed that a sum equivalent of three rates was still due when I had already paid two rates out of four.
In the end, I got so worried that I even discussed it with my therapist the one time I saw him, even though his suggestion to take a lawyer to sort this out was rather unsatisfying to me – how would I pay the lawyer? I don’t have any insurance which would cover such a case either, and so I could only hope that one of my emails or phone calls would finally sort out the matter.

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These are, in a nutshell, the most important events of the past months. This is the third day I’m “working” on this post, just to give some kind of perspective regarding the difficulty of writing. By the end of June, I was at a score of a whopping 33 points in the BDI-II, which signifies heavy depression, and right now I’m still lingering at around 15 points on good days, or higher on bad days.
The most persistent symptoms are a lack of energy and “emptiness” inside. Not only am I  devoid of any kind of esprit or verve, but sometimes it’s even hard to tell what I’m feeling. There’s… just nothing I could put into words. Which is upsetting when my husband asks me what’s wrong, because I don’t want him thinking it’s something he did. It’s just our circumstances, I guess. We’re on a very tight budget and can’t really afford to go out, much less to go on a trip for a while. So I guess part of that emptiness inside is just boredom, being stifled by the ever-same routine. And part of it is pure dread in the face of having to go back to uni in a couple of weeks. Even though I know that I should take it as a challege and one day at a time, the memory of the last semester is too fresh to actually see it this way.
Around this time last year, I thought if I went back to uni, it would take a couple of weeks and then I would get used to it. I thought that if I did not manage 100% productivity, I would reach at least 70%. Right now, it feels that anything beyond 30% is beyond my capacity, and I wonder if I will ever become “normal”, ever be able to finish uni, get a job – and hold it down. How do “normal” people manage?

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.”

Old Routines

It’s amazing how we spent the better part of a year in different countries, yet settled back into the old routine so fast that it feels like my boyfriend’s never been away. It doesn’t feel like he’s been here for only 48 hours either, so there are moments when the ten months which passed in between morph into a slightly surreal memory which might as well have been an intense dream. He accompanied me to therapy too yesterday – one more reason to feel catapulted right back to last year’s winter, because he was my regular companion on those trips to the hospital.

After having to cancel on me twice in a row, yesterday’s appointment was only 20 minutes long and not counted as a proper session. The situation at the hospital is rather chaotic at the moment, worse rather than better compared to the last weeks. My therapist usually is very neatly groomed, but this time I noticed that he was not properly shaved, probably because of a lack of time.
My boyfriend and I were waiting in the visitor lounge, talking, when my therapist walked by – he knows this is where I am waiting until it is time to go to his office, and he wanted to tell me that he would be a few minutes late. It made me happy to see my therapist and boyfriend exchange a few sentences – they become a little less abstract to each other this way.
I have a new appointment for early February, the first regular one in over two months: the session in December counted as an informational meeting only. Due to the restricted time frame we had yesterday, we only discussed which kinds of behaviour had a positive influence on my depression indices: the BDI-II score is down to 14 from previously 20. It was only just enough to give a rough overview, but for me it was more important to have the personal contact with my therapist, however brief that may have been. Very early into the meeting, when I was just sitting down, he said: “You are looking well!” And I believed him; he doesn’t make insincere compliments, and I felt happy enough to believe it possible that I was looking good too. Not to forget that the last time I saw him, I was so mentally and physically exhausted that it showed on the outside – so that was a valuable feedback for me that I was back on the right path.

Slaying A Dragon

Yesterday was a very significant day for me – one I had worked towards since April last year: I told my mother that my boyfriend and I wanted to get married. This was problematic in several respects, not only because of the generally difficult communicative patterns in my family, but also because my mother is decidedly against marriage (never mind the fact she’s been married to my father for over 30 years). At her most irrational, she claimed she’d “outlaw” it if she ruled the country. My sister’s failed marriage didn’t do much for swaying her in a more favourable direction either.
In most families, the news that their daughter wanted to get married would be regarded as happy news, but I wasn’t so sure about that and thus the topic had been fraught with a lot of anxiety. The range of possible reactions just was too broad to predict a likely outcome.

To make you understand the scope of this, I’ll have to go way back to spring 2011. My boyfriend and therapist actually met ever so briefly once – hardly more than a greeting and shaking hands – at the visitor lounge at the psychiatric hospital, so my therapist was able to put a face with the name. After my boyfriend had to leave Germany at the end of March because his tourist visa expired, my therapist had assumed a quasi-parental role and questioned me on our relationship in the first therapy session after the separation.
I summed it all up in an email to my boyfriend the next day:

Each of our sessions start with him asking me about my depression index – whether it went up or down, and what I did to get there. The philosophy in CBASP, my treatment programme, is that your mood always is a result of things you do or don’t do (when usually, one tends to assume it the other way around).

I told him that you had to leave again and that my points probably would be lower if not for that. And he said with a major change like this, we must have done a lot of things right or else I would probably have bounced back quite a bit, to 20 or possibly even higher.
So I related to him everything that went down since my last session – how we had looked into ways to get an extended or permanent visa, how we found out that you had to leave again and still tried to make the best out of the last week. I told him about the trips we made […] and he asked what the goodbye was like, whether we cried – whether we *could* cry, because the inability to cry signals deeper depression than bursting into tears. If you cannot cry even though you feel like it, it means your access to your emotions is disrupted: crying always is a good sign in their books.
He went off on a little tangent here, explaining the differences between “primary emotions” like happiness, sadness, fear, anger etc. and so-called “social emotions” to me: the former are understood by all humans in the world and elicit the same reaction, and they are also “contagious” to the people around us. Every time we display one of those, we radiate it off to other people, too. That is why being around happy people can make you feel happier and why sometimes one person can get a whole group down. “Social emotions” are defined by culture. He gave me an extreme example: a member of a cannibalistic tribe will have no problem eating human flesh, while we would have to torture ourselves into it and endure very strong feelings for doing so.

My therapist proceeded to ask about our contact and very much approved of daily Skype sessions, then went on another tangent by telling me that he had a short relationship with an American girl from New York City when he was a student and that the costs for phone calls almost ruined him back then. He even did an internship in New York City and got an unlimited visa for the States then (that was during the early Clinton administration – wouldn’t happen anymore today, and his is not valid anymore because he left the States again). That’s also part of the CBASP programme, that you get to know your therapist on a personal level, because it helps you discriminate between different people’s reactions instead of just assuming that everyone will reject you.

Finally, he asked what we had planned for the future and I told him that you wanted to come back and that there were basically only two ways for you to stay here other than a tourist: either by job offer or by marrying me. He asked a lot of question about you to get a better picture, and I told him that you had worked as a historian and then, recently, for [international company]. He said you must have incredible skills to handle the [international company] job and was very impressed. He wanted to know what social climate prevailed in [my boyfriend’s current location] and when I said “Bible belt” and that originally you came from [city in New England], via [different state], he said he couldn’t blame you for having difficulties. He is very familiar with [city in New England] and called it “my city” – I think he has been there quite a few times on business trips and for workshops, and also said that it was rather European compared to other places in the States he has been to.

Eventually, my therapist came to the conclusion that I already communicated to you yesterday. He thinks that we have a very healthy relationship and that in his opinion, the key for lasting relationships lies in how well you get along in everyday life, and how well you support each other there. Everything else is secondary – no matter how good you are as a couple on holidays, for example, if everyday life together does not work, there’s nothing you can do.

That is only a rough overview; strewn in between were always small “lessons” for me. For example, when I said that our goodbye at the airport was very teary, he asked if I could have cried in front of my mother, too, and I said I wouldn’t. I’d try to hold it back there with all my might.
Or we compared and contrasted our situation with a hypothetical situation where we would not have sorted out all the legal stuff and lived in uncertainty.
In his opinion, we made the absolute best out of what we were dealt.

Anyway… just so you know what we were talking about yesterday. I personally feel very glad we spoke about all this in therapy, because it helps me process, and I am also glad that we had a whole session just for “understanding” what has happened here.

Unfortunately, I don’t have access to the first email I sent my boyfriend directly after the session, so I might have forgotten details. I do remember that we focused on behaviour a lot and also that my therapist asked about my boyfriend’s language skills, job perspectives, health management  etc. And I do remember that he advised me to not suppress or try to conquer emotions, and to cry when I feel like it, for example, because “trying to be strong” and suppressing costs too many resources and too much energy. In the end, he came to the conclusion that there were “no pathological structures” in our relationship, with an emphasis on the fact that he’d tell me if he detected anything like that.
Over the following weeks, we roleplayed me telling my parents about it, and he assigned me the task of making a list with reasons why I’d want to marry my boyfriend – because I’d been dumbstruck in the session when he’d ask me that question. “Because I love him” wasn’t enough of an answer, and so I started writing down arguments and categorized them into topics: “Because he respects me as a person: my sexual orientation; my feelings, opinions, ideas and wishes; my personal belongings; my privacy.” [On physical appearance:] “He likes me the way I am and doesn’t expect me to conform to some ideal standard.” [On depression:] “He can handle my depression and endure it, even if I’m feeling significantly better or worse than he does.” I had close to 50 reasons when I stopped.

Another email I sent my boyfriend, about two months after the one mentioned above. In the session, we’d talked about some unexpected news my boyfriend had received and how they’d influenced me:

We had some administrative stuff to sort out then, but at the very end – I was already half out of the door – he asked: “Can I say something about you and [your boyfriend]?” I stepped inside the office again, closing the door once more: “Of course you can!” Inside, I must confess, I got a little nervous at that moment, wondering what he possibly might want to say.
“I don’t know [your boyfriend] personally, even though he has been very ‘alive’ in our sessions through the way you spoke about him. I mean, I have seen him, but I don’t know him from personal contact. Still… I just wanted you to know how very deeply I am touched by the relationship between you and [boyfriend]. In my profession, I see so many relationships every day, but…” – he shook his head here – “…what you two have… this is what is important in life.” At this point I was just stammering ‘thank you’ and how much this meant to me, taken completely by surprise and once again speechless, so that I repeated the same two phrases at least three times. We said goodbye again, and just before I opened the door once more, “I believe [your boyfriend] is a really good person. I don’t know him personally, but I have a feeling that this is the right stuff.” And he smiled.

I remember leaving the therapy session that day, feeling like I was walking on clouds. I was just utterly touched by what he’d said, and the fact he did say it at all. In CBASP, one of the therapist’s roles is to heal emotional-behavioural damage in the patient through making them experience healthy behaviour in sensitive situations, and that was one the most important moments I had together with him. I knew I could completely trust every word he’d uttered to be sincere, that he had no reasons for bullshitting me, and this kind of openness was one of the great “healing moments of my therapy.” There was a lot more going on at that moment than is visible on the surface – every person in love likes hearing nice things about their relationship and partner, but apart from the content of the sentence, I felt being taken seriously and listened to. I felt I and my future happiness were important enough to someone that he’d trouble himself with examining it closely.

With so much support in my back, it should have been easy to just tell my parents – after all, I was in the unique position of being able to cite a mental health professional’s opinion. Nobody could accuse me of being deluded by my own romantic feelings. However, it wasn’t easy for me at all. I made a couple of attempts, but at the last moment, the words just got stuck in my throat.
There was one notable Sunday which I’d looked out as the date when I’d tell them: I’d be alone with my parents in the afternoon, with plenty of time for talking. I bought a cake for us and wanted to create a pleasant atmosphere. Everyone was ready when I noticed I’d forgotten something and ran out of the room, returning literally a minute later, but those 60 seconds had been long enough for my parents to get into a petty argument over something really insignificant. Frustrated, I ate my slice of cake in silence and retreated without bringing up the subject.
Weeks went by, turning into months. Stuck with waiting for some important document on my boyfriend’s end, there was no imminent pressure to come out with the truth – it was something present in the background, but I didn’t feel any need to act immediately, and thus the anxiety prevented my saying anything at all. Only when said document was suddenly approved and I received an express-delivery of my boyfriend’s paperwork, I knew I had to get moving – yet it took almost another four weeks and the flight to Germany getting booked until I could finally realize it. Fortunately, my boyfriend was cognizant and understanding of my difficulties and didn’t push me; he appeared more confident than I ever felt that eventually, I’d manage.

It happened on the way home from a farm shop where we buy most of our vegetables. My mother doesn’t have a driving licence, so I chauffeur her there, and it looked like a good opportunity: we were not going to be disturbed in the car and, in order to ensure the security of all passengers, my mother couldn’t have a complete melt-down there. Still, my stomach slowly twisted into a tight knot and nausea started to rise up. I was only a heartbeat away from breaking into a cold sweat, and there was this imaginary voice screaming in my head: “Stop as long as you still have a chance to do so! Just don’t say anything! Abort mission!”
We were literally two minutes from home only when I swallowed all of the silent terror, took a deep breath and said: “Mum, I need to tell you something… [Boyfriend] and I want to get married.” The rest is only a haze and I do not remember it very well – as I wrote in previous posts, stress and anxiety tend to wipe the memory out. I do recall that my mother said something like, “I thought so, I was kinda expecting that.” And, “You two need to know what you want.” Which I answered with a simple but convinced, “We do.” She asked a few practical questions about finances, health insurance; she was rather anxious about us wanting a huge celebration (which, considering the facts that we’ll get married on short notice whenever the paperwork goes through and that our finances are limited, is not the case at all). What I remember very clearly is that I parked the car in front of our house and that the last thing she said before getting out of the car was: “After that I need a cup of coffee now.” And I replied, with full emphasis: “Me too!”

After I was back at my own place, I updated my boyfriend, therapist and some friends via email. I have to credit one of my friends especially: we had been emailing back and forth this past week and also that morning, talking about my problems opening up to my mother among other things, and she had reasoned with me that the situation couldn’t really get any worse than what I was already experiencing. And she was right.
The huge wave of relief one might expect did not come, at least not so far. Maybe it will take a little longer until I really feel it, maybe that’s not going to happen. That was a huge dragon to slay and a lot of personal angst I had to confront – really one of the most difficult things I did in my life. Intellectually, I’m just glad to be done with it finally, the emotional reaction might or might not come still. Right after talking to my mother, I was in some turmoil as a direct result of the stress: shaking knees, slightly trembling hands and a little agitation, but none of it too violent.

When I turned 30, I looked at the decade behind me which supposedly defines what kind of person you are, and all I saw were missed opportunities, failures and loneliness. Years lost to depression. I don’t want to do the same when I turn 40, and so I try to push myself – no matter whether it takes 2, 20, or 200 attempts to realize my goal. The only way I can ensure a better future is to change something in the present…

Almost There…

One more day, and it’s Christmas break. I am really running on reserve fuel now… and apparently it shows. One of the students I spend some of my classes with asked me today, “Are you doing ok?” I replied that I was being tired and needed a break, but this was quite the understatement. I was touched by the sentiment of him asking, though – how easy it appears to be for some people.

We got back two physics homework sheets today, one I had done when I was only halfway on the decline, the other I had submitted last week. The old one came back with a result of 31.5/32 points, the other with 8.5/34 points. Both were of comparable difficulty and length and I put equal effort and time into them. The difference is that the first one I did while not suffering from cognitive deficits, the second clearly shows that I could hardly think logically.
Once I go past a certain point, it’s not only fatigue and stiff muscles, but an increasing inability to articulate myself or recall memories. With each point my BDI-II score rises, learning becomes harder. My therapist, who has a background in neurology, actually understands this kind of symptom and takes it seriously. When we were talking last week, I couldn’t remember a word I was looking for and gave him a few others until I finally found the one I had meant to say. He replied, “Good that you remembered!” and nothing more, but from the way he looked at me (and from former conversations), I knew that he was aware of the struggle behind it.
This kind of problem usually starts out very unspectacular, you merely have to concentrate a little harder. But as time goes by, the concentration you have to bring up for understanding the text grows increasingly out of reach. Eventually, the level of your reading skills just isn’t up to it anymore – as if you gave a young child of 6 or 7 years a text written for adults. At the worst stage, sentences just stop making sense. You look at them and it is as if every word is written in a different language, and if you try to read one of them, they start moving over the page and never hold still long enough to actually see them properly.

I know that getting rest and sleep and doing recreational activities will “fix” this again, just as those symptoms disappeared during spring and summer before. I will not touch any of my uni stuff before January 2 – classes start again on the 9th.

Last Session Of The Year

Last therapy session of the year; the next one is on Friday the 13th (January 2012), to which my mum will accompany me. Apparently, my regular therapy is also coming to a close – I’ve had 31 sessions so far and if I recall correctly, that means only 4 more in the normal rhythm before drawing them out. Not sure about the time periods between them, but I do know that session 40 is definitely my last one. I’ll part with a laughing and a crying eye: laughing because my life improved so vastly, crying because I will be sorry to say goodbye to my therapist for good. The whole purpose of our relationship was that it would end again eventually, but I’ve grown fond of him… but, I guess that’s a bridge I’ll cross when I get to it.

We took a look at my uni schedule today, trying to find out what I can eliminate – all contact hours, homework and commuting time added up, I had a 50-hour-week and a BDI-II score of 20, with a tendency for the worse. Friday was crossed off the list completely and I’m supposed to figure out what I can do without until I reach a point where the work load does not push me into a depression anymore.
“We are pulling the emergency brake now,” my therapist said. “And if it gets too much,” he smiled, “just scratch another class off the list and go to the cinema instead.”
Eliminating classes wasn’t the problem, I didn’t need help for that. The huge difference is that if my therapist “allows” me to take it easier, I feel like I’m actually doing something pro-active and taking care of myself, whereas without discussing it in therapy, I’d have suffered from a bad conscience and felt like I was only procrastinating. That’s clearly something I still need to learn during our remaining time together: that I have a right to take care of myself and that I’m allowed to set limits.
A job is only possible in summer, because I’m going to have exams and an “en bloc” course and an excursion (probably followed by another protocol) during the upcoming semester break, and during the second semester my situation will hardly be any different…

Our roleplaying exercises were a little different today: not the usual dialogues acted out, but instead my therapist challenged me to defend my position. After I told him that I preferred learning at home over learning at the library, for example, he said: “Convince me! Why should I believe you are learning more effectively at home?” So I listed my reasons – that I felt more relaxed at home and could concentrate better because I wasn’t constantly aware of the people around me, that I didn’t have to watch my stuff if I walked out of sight of the desk, that I had more freedom on when I wanted to learn…
Later he made me stand up while he remained seated (a position I hate, because it causes me to feel vastly overweight – even though he doesn’t get that impression and it exists in my head only) and voice the effects the depression has on me as if talking to my mother: “I have troubles falling asleep and wake up in the night; the muscles in my arms and legs hurt, my joints too. I have headaches and backaches and stomachaches. My eyes are inflamed and hurt and I can’t always see properly because of that. I can’t concentrate very well either and doing my homework gets really difficult because of that. There are cognitive problems which make me forget words and sometimes I don’t even understand my homework anymore because of this.”
Only when looking back I realize I listed exclusively physical symptoms, but didn’t mention the sadness, crying and despair descending upon me. Had I spoken to my therapist directly instead of him acting as a proxy for my mother, I would probably have mentioned this, but since we hardly ever discuss intimate feelings in my family, I didn’t speak about this in therapy either.

One aspect I forgot about and which my therapist highlighted today was exercise. There is no room in my current schedule for any kind of physical activity. He described a scientific experiment to me, in which hamsters had been exposed to stress over a long time, leading to the hamsters becoming depressed. The source of stress was removed then and the hamsters got divided in three groups: group A had a nice cage, plenty of food and social contacts; group B a nice cage and plenty of food; group C a nice cage, plenty of food and an ergometer. Everyone suspected group A to show the fastest recovery rates, but in fact it was group C which was the most successful within the given time frame…
Exercise is supposed to be light and fun – no pressure to achieve any results, but regular periods of physical movement. I certainly remember how beneficial my Tae Bo classes were, even though I have nowhere near the energy for that now. But I’ll try to reserve a fixed time for swimming or cycling or something like that.

Personal Boundaries

This post comes more than a week late, but I simply didn’t have time or the mental capacity (or both) for summarizing the last therapy session any earlier, even though it was a rather important one. I hadn’t seen my therapist for five weeks at that time because he’d been forced to cancel the previous appointment due to serious staff shortage at the hospital. Even when we met, I could immediately sense that he was under a lot of stress and appearing more tense than usually – fortunately he told me about the reasons behind it, so I could put everything in context and didn’t start believing that I was causing this tension…

We started out with a short discussion of the reasons behind my BDI-II score rising up to 16, which basically was poor stress management. Too many different demands that I tried to satisfy and subsequently hardly any time left for myself or activities I enjoy. My therapist has a good metaphor for this. “If you’re running out of ink, it doesn’t help if you try writing faster.” You can’t give more than 100% in the long run and if you’d need, say, 150% of your current energy levels or available time to get everything done, you need to prioritize and drop the least important points off your list.

After this, which took up only a few minutes of the allotted hour, we moved on to the situational analysis and the topic connected to it, personal boundaries. Some people have too few boundaries, some too many, some struggle indirectly with boundaries because they can’t communicate them effectively. I personally can keep strangers at distance, but have a hard time preventing people whom I’m emotionally close to from “infiltrating” me – as a result, I’m prone to neglecting my own needs in order to please the other person if they press me to do so. When I first entered therapy, I felt I could attend to my own needs only because my therapist had given me “permission”: it seemed an entirely selfish act, especially in the light of my relative lack of productivity. My therapist still reminds me every couple of weeks to not forget doing something I enjoy, because otherwise I probably would, and that I need to defend my own position.
Then, there are personal boundaries of a different kind, where a violation would cause not merely stress and exhaustion, but where a person’s entire well-being or even existence is at stake: physical, emotional or sexual abuse; being manipulated into doing something dangerous or illegal, or something diametric to one’s moral beliefs. Those are not problems I’m confronted with very often – fortunately! That doesn’t make discussion of them any less important, though.
The first reason for respecting personal boundaries which comes to my mind is self-protection, and obviously it is a very important point. But my therapist also highlighted another aspect: you need to establish and defend your boundaries in order to protect your relationships with other people as well. The moment you “allow” another person to go beyond your limits, the seed for that relationships demise is planted.
[Disclaimer: I am aware that in some cases, there has never been room for making a decision in the first place. Victims of sexual abuse, rape or physical violence, to just name a few, certainly didn’t allow such a crime to happen. These scenarios are expressively excluded and the reason why I used quotation marks.]
Close relationships can only be healthy if boundaries are mutually respected. Without them, a power gradient is introduced into the relationship that will more likely than not destroy the personal bond, or at least damage it. To facilitate an example: if I let myself being talked into making money illegally by a partner or close friend – maybe because s/he is in serious financial distress – I put myself not only in danger of being found out and facing legal consequences, but I also give others the power to manipulate me further down the road. “If you don’t help me, I’ll report you to the authorities!” – “Just this once more! You can’t say no, you’ve done it before!” – “You’ve done it for your ex, why not for me?”
Too often, we have a hard time saying no because we fear negative reactions. I certainly do, and that is why my therapist went on talking about how a refusal might temporarily anger another person, but as a long-term consequence establishes respect. They’ll know you as a person of integrity and as dependable, which in return is very desirable (at least to me).

It certainly was an intense and rather serious session, but I’m glad we had it. I’ve been focusing too much on the guilt I usually felt when not obliging, as if I wasn’t allowed having my own opinion and principles. The desire to please (more on this here and here) is very strong and I have to stay conscious of the fact that I am not only allowed, but under any circumstances must have my own personal boundaries.

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.

I Lucked Out

Thursday was the last session before my therapist’s vacations; the next one is going to be in three weeks. It doesn’t worry me, though, because I think I have sorted out everything in regards to starting university, and everyday life – as it is right now – doesn’t pose any insurmountable challenges anymore. And if something really bad happens, I can always call the psychiatric ambulance as I did back in May.
At the beginning of this month, my therapist going away would have been a problem; I really needed his support and expertise to keep me on track when I had to decide about my future. We role-played a scenario in which I had to defend myself and my credits in front of the docent, so that I’d be better prepared next time, and afterwards we went through a situational analysis of me telling my mother that I wanted to go back to university.

My newfound confidence is mirrored by my BDI-II score, which at 9 points was the second-lowest I’ve ever had. As always, my therapist started off by asking about the points, and when I told him, he commented that I might find him in the same area that day. It already is in the range a non-depressed person experiences during a stressful time (and for my therapist, it had been a very busy day) – the goal is to bring me to ca. 5 points and stabilize me there. Zero points are rather utopian even for people who never experienced depression; an ideal state that one might reach during moments of utmost optimism and bliss, but it does not pose any realistic long-term level of symptoms.

I asked how therapy is going to continue: the programme consists of 48 sessions, of which I have completed 26 so far. Usually, we would switch from the current rhythm of one session every other week (except for when either of us is away – then we try to have the session before the break) to one meeting per month around session 35. Optionally, one could ease the transition by drawing out the periods between appointments to three weeks from session 30 on. Towards the very end of the psychotherapy, the gaps become even longer.
If I followed the programme as intended, it would mean that by the end of the year, I’d switch to monthly sessions, but due to my return to university, we will probably opt for a different plan as I will need more support during the time of my first exams (ca. February – April). My therapist proposed an extracurricular meeting in October for figuring out an alternative treatment plan, so that I might go on longer intervals from November to January and then switch back to a tighter schedule for exam time.

It was a lucky coincidence that I found the programme at the hospital and that I actually qualified for it, because if I had undergone psychotherapy at a private practice, this week would have been my last: in Germany, health insurances usually only cover “short-term therapy” consisting of 26 sessions, anything beyond requires a special permission and is only granted if the client/patient still exhibits grave symptoms. Given my progress, I would not have qualified for additional treatment anymore: the extra-time, however, is something I need badly, because only this way I can make sure that I don’t relapse during the first semester back at university.
Health insurance is obligatory for university students in Germany (and the fees are lower for them): paying for sessions is completely out of the question for me, so without health insurance, I could not afford any of this. I am very, very grateful and feel extremely lucky that I can enjoy the luxury of such an extensive psychotherapy with a highly competent therapist with whom – most importantly – I get along very well.