Depression Symptoms & Antidepressant Side-Effects Assessed

It’s becoming very clear that despite taking twice as high a dosage of venlafaxine / effexor now, the timed-release capsules work much better for me. The nausea and vertigo vanished completely, and in the mornings I don’t go through withdrawals anymore either. I do feel quite drained from the experiences of the last three weeks, though, very tired and listless. I lost 6 kg (13.2 lbs) – 4 kg over the first weekend and another 2 kg since – and even though I would welcome further weight loss very much, it goes without saying that vomiting, diarrhea and skipping meals due to nausea is not exactly a healthy way to drop the kilos and at least partially responsible for the feelings of weakness. On top of that, venlafaxine also suppresses my appetite for a good part of the day, until it returns in the evening and I suddenly start scouring the kitchen for all the stuff I did not buy when shopping…
There has been no improvements of the symptoms I primarily started taking venlafaxine for yet, the cognitive impairments and lack of energy, but I do feel more emotionally stable recently. Next Friday I have a follow-up with the psychiatrist, when I’ll find out whether I’ll increase the dosage further or stay on it for the time being.

As for the welfare process and related paperwork, the main appointment at the job centre had been cancelled on Tuesday already because the lady had become sick, and the one who works on our case at the employment agency was replaced with a colleague due to illness as well. While being very friendly as well, this colleague could do little more than collect the forms we had filled out at home and the documentation we had brought. Other than that, we will have to wait for them to get back to us. I handed in the questionnaire on my medical complaints today; the question was: “Do you have medical conditions which influence your current job or have done so in the past? Please give a short description of your illness respectively your symptoms and tell us which kinds of occupation would be influenced by these.” The space left blank was less than a quarter or a page, so I could not go into much detail:

“Diagnosis: chronic recurrent depression with comorbid panic disorder.
– permanent / daily symptoms: muscle pain in legs and arms; social anxiety; slowed-down thinking; word finding problems; problems falling asleep (at least 2 hours / night); severe lack of energy; hypersomnia; decreased libido
– frequent symptoms (at least 3 days per week): stomach pains; digestive problems (diarrhea); back pain; memory problems; concentration problems; depressive emotions (sadness, emotional emptiness, hopelessness); headaches
– periodically appearing symptoms: insomnia
– under stress also anxiety attacks
– currently (since mid-March 2013) additionally vertigo, nausea and vomiting due to starting an antidepressant regime (venlafaxine)

Because of the diverse symptoms, I am physically, intellectually and emotionally affected with any kind of occupation.”

That is as accurate an assessment as I could give of my daily problems in such a small space, and each of my healthcare providers should be able to confirm them. I learned today that the medical service will first contact my general physician for information, which is a bit of a problem since at least 80% of my depression treatment has been done by my therapist; the general physician does get reports from my psychiatrist, but except for the fact that I have participated in the medical study he does not know anything about the psychotherapeutic treatment. I do hope they’ll get in contact with him as well – if our regular case worker had been present today, I would have asked her, but her colleague was not familiar with the protocol in such cases.

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On Discomfort & Comforts

After the drama at the beginning of the week, I had to pull myself together for the crystallography exam – successfully enough for passing. The results were in after 24 hours and thus I know that despite waking up to my head spinning with vertigo and my dysfunctional memory, I put that class behind me for good. The results for physics and mathematics still haven’t been put online, so in that regard I’m still biting my nails.

Friday and Saturday I was on an excursion to local sites of geological interest. Since most of the geological outcrops didn’t offer enough space for huge crowds, we got divided into groups of twenty-something people, and each group had slightly different routes and sites to visit. Our guide was very nice, but unfortunately his tempo was so insanely fast that a few of us got close to a physical breakdown. My metabolism is very slow (as a result of both depression and Hashimoto’s) and soon my head started spinning with vertigo. Another girl had an asthma attack, and together with others we soon fell behind. After realizing the effect this had on us, our guide apologized and promised to slow down, but we still kept lagging behind, desperately panting uphill hour after hour. At one point, about ten minutes before reaching the highest peak of the day, I paused and stared into the forest stretching below me, thinking: “Why couldn’t you pick a different subject? Something where you do not have to go on field trips…”
The only thing which kept me going was that we were in the middle of a nature reserve and thus the only way “back to civilization” was to continue walking.
The second day saw us climbing up a mountain through vineyards; not nearly as long a walk as the day before, but so steep that we had to clutch onto the wires for the vines and descend sidewards to prevent falling down the cliff-like slope. In the early afternoon I had to admit defeat because of a black-and-blue toenail – I simply could not walk properly anymore due to the pain. I’ll have to wear open shoes for the next days – very inconvenient, since the weather is rather wet, but that is the only way I can walk without a severe limp – and somewhat embarrassing. I will be rather self-conscious about it tomorrow, but it is my only option.

The best aspect of those two days was coming home to someone. I got served dinner and could rest my legs on my boyfriend’s lap while he massaged my sore feet (and legs and back). Even though most of my body hurt, I actually felt pampered.
He helps me staying in the present, to not worry about the future or think about the past so much. He comforts me emotionally and mentally. I think I wrote in an earlier post already that my idea of happiness is spending an evening on the sofa with him – it might sound utterly boring, but I really enjoy this very dullness. There is enough drama in my life and I am grateful about every time I can just wind down and bask in the warmth of our shared life together.

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.

Depression Revisited

Those last few days my situation has been really bad; as mentioned before, I depend on financial support from my parents, and my mother has been urging me to get a job, even though I hardly have the time and capacities for taking a job on top of my studies. I tried handling the situation on my own, but when she threatened I had to move out of my flat (which would equal moving in with my parents again), I panicked and wrote to my therapist about the situation. He replied:
“My medical opinion is that a place of your own is very important. Moving out or getting a job at this time would put your health in extreme danger and further increase the risk of chronification. That’s a specialist’s opinion. Please stay calm and tell your mother that you are in close contact with me and asked for my medical opinion. I’d be happy explaining it to her personally in the new year.”
I am going to take him up on this, because I believe that he’ll be able to speak with much more authority to my mother than I could ever have. If I say anything, it might look like I’m unwilling to get a job, when in reality, that’s not the case at all. I wish I had the energy to handle both…

I don’t actually think my mother was going to kick me out – it’s more like a really inappropriate kind of hyperbole to steer me in the direction she wants me to take. But at that time, the idea really freaked me out: I do love my parents, but living with them permanently would drive me over the edge quickly.

I’ve had so much stress lately that the muscles in my limbs turned stiff and hurt so much that I can’t fall asleep until 4 in the morning. My eyes are inflamed again too. Those are symptoms I can handle, though. What unnerves me is how much my cognitive abilities are influenced by this: it’s harder to concentrate and doing my homework becomes more difficult. It started about two weeks ago already, but has increased since.

Physical Side-Effects of Depression

In the therapy sessions, we usually concentrate on the emotional and behavioural aspects of depression, since this is the area where we can work on change. The physical side-effects of depression, which used to even eclipse the emotional pain quite often, will go away too when the depression vanishes.
For a long time, however, I wasn’t aware that these two aspects – mental/emotional well-being and physical pain – were so closely related. I blamed my thyroid and the Hashimoto’s disease for feeling fatigued and for the memory problems I was experiencing, even if the lab results showed that my medication was perfectly adjusted. For all the other complaints, I saw three doctors in total who all diagnosed me with a variety of conditions which usually matched the most recent physical manifestations, but always ignored the full picture. Nobody suspected depression before I started having panic attacks, and even though I personally suspected a mental health problem earlier, all the symptom lists for depression I checked mentioned weight loss and sleeplessness, while I was (am) clearly overweight and slept much more than the average person: I always dismissed the self-diagnosis again on these grounds. Only at the hospital I learned that in chronic depression, weight gain and hypersomnia can occur too, as well as many other symptoms.

Today, I wanted to take inventory of the physical side-effects which one would not necessarily relate to depression and which I experienced over the course of the years.

Permanent or frequent complaints:

• Muscle pain in the limbs: I’m not entirely sure when this started, but by spring 2009, I very often had severe pains in the muscles and nerves of my arms and legs. Sometimes it would feel like a “tennis arm”, sometimes like the kind of muscle cramps you get when over-exercising. I combatted the pain with ibuprofen, paracetamol or aspirin, which brought relief for a few hours.
  My second general physician diagnosed me with multiple sclerosis because of it.
  When I was put on an antidepressant in summer 2011, the pain went away after only four days. It returned after I discontinued citalopram; my therapist was the first person who told me that it was stress-related and caused by an inability to relax. Ever since, I lie down and try to consciously relax all of my body whenever I feel the pain. With the progress in therapy, the days when my limbs hurt become fewer and fewer.

• Inflammation of the eyeballs: This symptom first occurred in spring 2009 too, when my eyes became red, dry and sensitive to light. In the beginning, the intensity would be sometimes less, sometimes worse, but last year, it was permanent.
  My first general practitioner diagnosed it as hay fever – never mind that weather or seasonal changes had no influence on it at all. My sister and niece both have hay fever, so I am rather familiar with its symptoms, and I was very certain that the inflammation of my eyes was not allergy-related. The next doctor saw it as a symptom of MS, together with the muscle pain.
  As with the muscle pain, the inflammation vanished when I started to take citalopram and returned afterwards. Recently, the inflammation had come back, but as I try to counteract the stress, it gets a little better every day.

• Headaches: I used to have headaches very frequently; up to four or five times a week during the most intense periods. The most common form was a consistent, one-sided pain directly behind the eye, as if someone was relentlessly poking me into the eyeball from behind. In 70% of all cases, the left side was concerned. Rarely (once every couple of years), I will also have a case of migraines, when I can’t tolerate light and sound and have to lie down in a dark, quiet room with a wet cloth on my face.
  The headaches started very early, during my teenage years already, and currently occur on about two or three days per month.

• Digestive problems: Another group of symptoms that I had since adolescence – stomach aches / cramps, diarrhoea, a couple of episodes when I couldn’t eat anything but apples and plain rice, one episode of histamine intolerance that vanished after two weeks. Now I experience those problems about 2 – 3 times per month, but during the worst of it, that would be 4 – 5 times per week, for months on end.

• Backaches: For about twenty years, I used to have “typical” complaints like tense muscles around the shoulder and back of my neck, but in recent years, there have also been intense phases of lower back pain. The latter first occured early in 2008, about two weeks after I had started a new job that pushed me to the limit in regards to social anxiety. I didn’t make the connection back then, but in retrospect, it seems very clear that the job and the new type of backaches were related.

Infrequent or singular complaints:

• Vertigo: One morning in 2007, I woke up with such a heavy case of vertigo that I literally couldn’t get out of bed. Lifting my head alone brought such waves of nausea that I had to vomit. It took three days until I could leave the house and see a doctor for it, who was clueless and referred me to a specialist. I had my ears and head checked, especially the sense of equilibrium, but everything was fine. They sent me home, “If it happens again, come back.” So far, there has been no second episode of unexplainable vertigo.

• Chest cramps: This is a strange one. The first experience was the night after I celebrated my 18^th birthday with a party; I woke up in the wee hours of the morning with a feeling as if my stomach was starting to petrify. Since then, I have spells when it happens a couple of days in a row, just to stop again just as suddenly for about half a year.
  Very often, the cramps come at night and I wake up from the pain, but sometimes they can also occur during the day: the muscles around my stomach become hard and cramp; a very intense ache that I feel under the sternum and in the middle of my back. Sometimes, I can sense the muscles there going tense a few hours before the actual cramping, but usually it happens within minutes only.
  Heat helps as it relaxes the muscles. At my most desperate, I had hot water bottles on both chest and back and was drinking hot water to relax the muscles from inside as well, because the pain can get so intense that I can hardly stand upright anymore and feel like opening my chest with a knife just so I can reach under the sternum and massage the muscle.
  Some people have suggested that it might be heartburn, but it feels completely different and is not inside the oesophagus or stomach, but very clearly outside of it.
  It appears that the chest cramps have become less intense and more infrequent, but is too early for making a definite call still: I had episodes of up to nine months without them and experienced some chest cramps this spring, so it will need at the very least a year without them before I consider them gone.

Do It Yourself

Even though it appears that my BDI-II score lingered in the same area since March, there has been a great shift when looking at the individual topics of the assessment. The points used to be evenly spread over a lot of categories, but out of the 11 points I scored on Monday, 7 resulted from somatic reactions to stress: fatigue, lack of energy, hypersomnia, inflamed eyes and muscle pain. They will go away or at least get better if I manage to reduce the stress and relax, but are not related to negative thought patterns.
That means only 4 points are left where we need to work on the way I perceive myself and the world around me: the most persistent over all those months has been the self-dislike category, where it took the longest until any change occurred at all, and where I have never been down to a score of zero. Currently, I rate myself as 1 – “I have lost confidence in myself”. Which is pretty good in my book already, but my therapist thinks it could be even better… He knows that I have strong tendencies towards ruminating over the past and constantly reminds me of staying in the present, “I did not notice anything in the last months that you should blame yourself for.”

A lot of things that used to be very difficult or intimidating have become a lot easier: I am not constantly obsessing over the camera which records our sessions (for documentation and supervision purposes) anymore – though I hardly ever forget that it’s there for longer than a few minutes. I also write the situational analysis on the flip chart myself now, which I always avoided, and even the dreaded role-playing exercises are not quite that bad anymore. For months, my therapist would ask, “Would you like to write on the flip chart?” And I would reply, “I’d rather not.” But now he’s changed to, “Why don’t you write on the flip chart?” And so I did, and it was ok.

I told him about the nice feedback I had received from a former colleague last week, and he emphasized that it was me who had put the new batteries into me, nobody else. According to the theory that depression is “learned helplessness”, people get depressed when they feel that it doesn’t matter what they do, they’ll fail or suffer afterwards anyway – one of the main focuses of CBASP is making you realize that your behaviour does make a difference.
He’s right in so far as nothing we did in therapy would be worthwhile if I didn’t apply it to my everyday life. I have worked hard on myself, and I worked for therapy too: doing my homework, being prepared, being very willing to work with my therapist and not against him.
I agree that the progress has been my doing, but I couldn’t have done it without professional help. After almost a year of most severe depression, I was so depleted that I couldn’t have helped myself even if I’d known what to do, and I also think without guidance, I might have given up trying soon. It was necessary to hand over the planning to someone else and trust that they’d know what to do. For the first three months, I just followed the lead until I was well enough again to even start thinking about how to take my life into my own hands.

Disclosing Depression, Part 2

Last Saturday, I attended a meeting with former colleagues from my old job. It was nice, better than I expected actually; my personal criteria always are whether I start wishing I was somewhere else or feeling uncomfortable, and neither was the case.
Before leaving, I had not really been in the mood for going anywhere and the only reason I went was because I had missed my own farewell party back in February due to train strikes. I did not feel like I could cancel without a bad conscience, but the day turned out enjoyable.

I told them that I was undergoing psychotherapy for chronic depression, because I didn’t feel like hiding the fact and pretending everything was ok, always had been. The reactions were positive; I believe a few people were a little uncomfortable because they didn’t know what to say or how to react, but I didn’t mind as I can relate to that kind of discomfort, plus they were still nice about it. One of my former bosses even told me a friend of hers had been an inpatient at the same hospital last year.

Part of the reason why I mentioned it now and not when I was still working there, but already undergoing therapy, is that I do not see them as often anymore. I don’t have to deal with their awareness of my mental state every (work) day, so I can afford to disclose it since it’s not going to affect my job.

Part of the reason is that the whole team had been aware of my health problems for years – they saw me cycle in and out of severe depression without anyone having a clue what was causing the problems, including me. I was good at my job and got an excellent reference letter, despite all my issues (to be fair, they always were understanding of people being sick; not only me, but everyone) – however, I wanted them to know that I finally had an idea of what was wrong. I had never mentioned the emotional distress to them, but they were cognizant of some of the physical complaints: the muscle pain, the cognitive impairment, the insomnia alternating with hypersomnia.

Four days later, I still don’t regret disclosing that I am undergoing psychotherapy for chronic depression. The particulars of it aren’t any of their business, but I feel relieved that I won’t have to lie about what I’ve done during the past four months.

Stressed Out

This week has been tough so far. Now that the depressive symptoms have lifted, I’m feeling raw. Vulnerable. With the perpetual haze of pain – both physical and emotional – gone, I get really aware of all the “holes in the road” that need to be patched up, badly. I’m confronted with a lot of problems, some of which have been causing the depression, some which were caused by it.

Part of me daydreams about taking a long vacation together with my boyfriend: quitting everyday life and problems for a while and enjoying myself instead, with no more serious questions than what to have for dinner on my mind. And then come back with recharged batteries and lots more energy and tackle the problems.

The reality, however looks like this: no money, dependent on financial support from my parents, trying to get a new job. Arguments with my mother. Lots of bureaucracy as we are working on transfering my boyfriend from the United States to Germany permanently. I still haven’t told my family that he’s going to live with me and I still have to ask them to sign a legal document that makes them “invite” my boyfriend, because I don’t earn enough money to do it myself. Then there’s the whole question of what to do with university and starting the transfer to a different subject. And all the while paying attention so I don’t slip back into depression.

Cognitive Deficits

Looks like I came down again for good – no further euthymic phases during the last 48 hours. Which does not mean that I’m doing poorly; quite the opposite. My legs hurt earlier, but I managed to relax them and went for a long walk outside.

Yesterday, I borrowed a text-book for students of psychology from the library, because I want to understand what’s going on better. My therapist always explains everything to me, but if I asked every question which pops up in my mind in between, we’d never actually get to work on my problems.
I’ve always collected as much information as possible about topics that are on my mind a lot, but only now I find myself actually able to do it. Just a few weeks ago, I still lacked the ability to concentrate sufficiently, not to mention the energy. If there is a drop of regret, it is that I was not able to chronicle the whole therapy properly due to those reasons; I’ll have to depend on my unreliable memory for that.

Cognitive deficits are among the most scary symptoms of depression. It is one thing to lie on the sofa without moving for hours on end, and an entirely matter if suddenly you cannot remember facts you usually knew, if your memory gets clouded and you cannot carry on the most simple conversation without frantically searching for words. My brain always had been the one part of my body that I could count on, and suddenly that started to fall apart. More and more often, I would feel like having a wall of opaque glass in my head – I could still tell there was something behind it, but there was no way to access it.
There were days when I was scared about this, especially in the beginning – if your grandmother has Alzheimer’s, that can make you worry quite a bit. Later I had started to accept this state as a given, but still mourned the lost capacities. I could hardly believe it when not too long ago the first cracks appeared in the glass wall, and ever since the impairment has slowly started to crumble away.
Before starting therapy, I had tests done at the hospital where I did not perform too badly, but sitting through exam-like tasks is different from losing personal retention, because on the former you get concrete feedback immediately, but the latter you do not notice immediately. You only know that the recollection of an event, for example, is gone if someone else mentions it and you cannot recall it at all, or if you are asked to name certain situations and draw a blank when searching through your memory for it.
In the very first therapy session, we did an anamnesis of my depression history and I actually had to look through old diaries to get this right, because in my head it was a huge jumble at best. Five months later, this has become a lot easier; I have access to a lot of memories again that were temporarily lost.