Medical Service Appointment

The worst part is over now that the appointment with the medical service is behind me. It went by no means great, but at least I did not cry afterwards like last time.

The physician took a little more time to ask questions, about 15 minutes, which was the one positive aspect of the appointment. On the negative side weighs in that she tried putting phrases in my mouth that I didn’t mean to say, kept interrupting me, and generally had a brash demeanour.

I wasn’t feeling my best to begin with: slept badly the night before because of anxiety about the appointment; kept confusing words; couldn’t remember which dosage of escitalopram I take, etc. And the doctor’s behaviour made everything even worse.

For example, I had tried to explain why I had not gone back to psychotherapy – that I want(ed) to, but for reasons already discussed on this blog haven’t. She tried to twist it into me saying that because I’d had such a positive experience with my first therapy, I was resisting seeing someone else now and idealising the first treatment. Absolutely not true. If health insurance wouldn’t limit the number of sessions I could have, I’d be way more willing to try things out. And even if, ultimately it was my psychiatrist who suggested to wait with that – and she knows me a helluva lot better than someone who judges me based on a 15-minute-meeting.

The doctor also had never heard of CBASP and when I said that the general consensus is that chronic depression is largely treatment-resistant with standard behavioural therapy, she called bullshit. Whatever, I don’t really care. It’s what the scientific papers say, not my personal opinion. Not trying to convert anyone, least of all her.

Also, she said I was “talking in diagnoses”, not how I felt. Well, last time I tried that with her colleague, he wouldn’t even let me finish. Also, it’s really hard for me to open up to strangers about such personal stuff. There’s a reason why my therapy sessions worked out so well, and that is that he took the time to make me comfortable. I realise the medical service was never meant for that kind of in-depth, trust-gaining discussion, but I had told her half a minute earlier that I suffered from social anxiety, and how at uni I would devote 75% of my energy to not freaking out and 25% to following lectures. It’s kind of a low blow to hold “talking diagnoses” against me after I just divulged that strangers freak me out.

Seven hours since I got out of there, and the knot of anxiety in my stomach only slowly starts dissolving.

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Jobcenter Updates

The jobcenter sent us two forms as part of a „hearing“ regarding why they paid us too much money. Two separately mailed letters containing the exact same forms and the exact same letters, except that one was addressing my husband with “you earned income” and my letter read “Mr. Layara earned income”. So I explained for the fourth and fifth time respectively in those forms that the jobcenter pays in advance, but my husband’s salary only comes in about six weeks later since he gets paid retroactively the following month. I also asked for our monthly allowance to be reduced, to avoid having to transfer back hundreds of euros later on. We’ll see how that goes.

Tomorrow, I have an appointment with the medical service to assess my mental health. Last time was pretty bad; my one comfort is that with just a few more months to, the result of tomorrow’s appointment will only matter short-term. I was supposed to bring ALL my files from various doctors, but they gave too short notice of the appointment to get anything from the psychiatrist, and anything from the clinic / therapy is not available as it is part of a medical study and thus confidential. For the latter I still have a statement written by my therapist from the last time I had to see the medical service.
Also, I need to bring all the medication I take. Not sure why – to prove that I’m not making anything up? Shouldn’t they already have my medical records on that from the psychiatrist? And how would showing them a bunch of blisters prove I am actually taking that stuff? Seems rather stupid to me.

On Tuesday I have an appointment with my caseworker at the jobcenter. I am not sure whether I mentioned that before, but we got a new caseworker a year ago. She is nice enough, but I miss the old one. She was bipolar, so actually understood how mental health problems can influence your everyday life. Also, she would get in contact before setting the actual appointment. They don’t have to do any of that, but it was a courtesy she extended to me that made me feel as if they took me into account as a human being, not just a file that needs to be processed.

To say that I am afraid of the appointments would be overstating it, but they make me terribly nervous. I feel pressured, and “faulty” to boot. I understand that the state needs to check who they give money to, but this arrangement is not contributing to my recovery.

Misfortunes Never Come Singly

Over the past few days, I’ve had to deal with a number of frustrations and disappointments.

The aquafit class got cancelled after local authorities closed the pool and adjoining gym. Apparently there’s fault with the ventilation system, and fixing it will be so extensive that it won’t re-open before summer 2017. A number of schools and seven different sports clubs have now suddenly lost their training locations.
As for the group I was part of, any vacancies at aquafit classes held at different pools are first going to those who joined as part of their physical rehab. Anything that’s still available afterwards will be offered to the “prevention group”, or you can simply get your money back.
Financially it’s no loss, but I was so happy with everything concerning this: the group, the instructor, the time slot, the uncomplicated drive… On Friday I’ll find out if I can at least finish the last four weeks before the summer break.

Then, we are having jobcenter problems. My husband has a fixed salary per hour, but there are additional boni for night shift, Saturday or Sunday work. So he never gets paid the same and the difference can be several hundred euros in extreme cases.
As I mentioned before, welfare is slowly phasing out; we are still approved until the end of September and only get substituted right now to make up the difference between the threshold-income and his actual income. We have to hand in a copy of his payslip every month to prove how much he made.
Well, the first month, when my husband’s actual income after taxes was still lower than what we got from the jobcenter, they paid us too little and the missing rest came three weeks later. The second and third month, they paid us too much (way too much this month) – which wouldn’t be such a big problem if we wouldn’t get into trouble for that down the road. We basically have money sitting in the bank that isn’t ours, that we can’t touch because they might ask it back at any given time, and all attempts to contact them have been fruitless so far. They don’t react to emails, phone calls end in the holding line…

On top of all of this, the jobcenter ordered me in Friday morning to discuss my medical report. It makes me nervous as hell, because I don’t know the result and what they want to do with me. Worst case scenario, we would have the means to terminate welfare support on the spot. Last month we were just 60€ below the threshold and this month we’ll be over it, so the jobcenter would have (or should, at least) stopped giving us money anyway – we only wanted to stay until September because we could have used the “mobile pass” still, which gives you percentages off public transport fares, and as a security net until my husband’s probational period at the new job ends at the beginning of September. Last but not least, terminating now would be a nightmare of bureaucracy, whereas just waiting until it runs out does not require anything other than NOT requesting a renewal.

Logically, I am aware that no matter what they are going to say on Friday, they can’t do anything to me. I could just walk out saying “So long, suckers!” if shit hit the fan. But being the unconfrontational person that I am, it already stresses me out.

Cola Addiction Revisited

Long-time readers of this blog may remember the post about Cola-addiction I wrote over three years ago. Even though I was fully aware of how unhealthy it is, I couldn’t go a day without it. When I noticed recently that my cola consumption had been comparatively low for several days in a row, I decided to attempt kicking the habit. It’s been over 48 hours since my last glass now and, to my surprise, easier than expected. The cravings are manageable, and the headaches I’ve had over the past two days may or may not be related to withdrawals. They are nuisance rather than a huge problem anyway.

Why now? The biggest factor in this is the valdoxan: since I’m sleeping better, I don’t feel as groggy anymore and thus don’t need the coke to “wake up” my brain. Plus I was ready for it – right now, I feel like I can handle making lifestyle changes and sticking with them. I am motivated by my weight loss; my depression index and anxiety are low, and I have a moderate amount of energy. Why not seize the chance?

Floating On Top

The first aquafitness class was thoroughly enjoyable. As I wrote before, it’s a course dedicated to overweight people and / or those who haven’t exercised in a long time, so everyone but the instructor is quite large. That alone really helped me to be at ease, because I didn’t worry how I’d look compared to the others.

The group is lovely too; not all the new people on the list showed up, and more than half of the participants already knew each other from previous classes. The instructor made everyone introduce themselves to everyone, no matter whether you were a first-timer or not, which was a little awkward, but I managed. And as far as I can tell, everybody is genuinely friendly and nice. I liked the rapport the instructor had with the regulars. The general setting was non-threatening enough to keep my social anxiety in check.

From what I understand, there are two different kinds of aquafitness: the one where you can stand on the ground, and the one where the water is so deep that you can’t reach the floor. I’m doing the latter. The exercise is pretty similar to aerobics, just modified to fit the environment, and a little slower. Since you’re working against the water resistance, it’s just as exhausting as a normal aerobics class, but without the sweat and running out of breath.

I’m probably going to be sore tomorrow, but tonight I am feeling a good kind of heaviness in my arms and legs – the one that comes when you have exerted yourself. And my back ache already is a lot better after one hour only. Mentally / emotionally I am feeling rather well, too – just what I wanted to get out of this class.

Signed Up For Aquafitness

I’m not a “sporty” person, quite the opposite: about 50 pounds overweight – not morbidly obese (anymore), but in the area where my weight will most likely lead to health problems down the road. The last big check-up was five years ago when I applied for the clinical study. Back then I was physically healthy, but I am aware that it doesn’t take much to change that.

Since November 2014, I lost 8 kg/ 18 lbs. Not through dieting, because going on a diet flips some kind of switch in my brain which causes me to think about nothing but food all day long. Instead, I practice moderation, and thanks to the escitalopram, I am a little more active than I used to be. It’s a slow process, just a pound lost per month on average, but it’s trending towards the right direction.

My all-time maximum weight I had in 2003, when I was 17 kg / 37 lbs heavier than today. It was mostly due to the untreated hypothyroidism that I gained that much, but if I thought taking the appropriate medication would melt the fat away, I was mistaken. Even during my most active times, I would shed the pounds very slowly only.

A few weeks ago, I decided to sign up for an aquafit course – one especially for overweight and/or unfit people. Even though I loved the Tae Bo class, it was so physically demanding that I don’t think I’d be able to do it anymore, and even at the best of times it made me very self-conscious about my body, because the rest of the people were really toned… That definitely shouldn’t be a problem anymore.

Even though I talked a lot about weight, losing it is not my main motivation: I want to be healthy. At almost 36 years old, it is for the first time ever that I feel like my body might fail me if I do not take care of it. I don’t want to get rid of the physical symptoms of depression just to suffer from the side-effects of ill health. Thanks to Facebook I know that somebody I went to school with suffered two heart attacks last year, and even though his lifestyle was a lot unhealthier than mine, I don’t want to be next in line.

Apart from the physical benefits, I also hope for a positive effect on my mental health. I do not believe that an active lifestyle can prevent depression – it was from my most active period ever that I crashed into one of the bleakest phases of my life, and there are too many amateur and professional athletes suffering from it – but that it can help prevent a rebound. Especially since the biggest anxiety factor (being the only fat person among a group of slim people) is being eliminated.

Class starts the first week of April; just an hour once a week. Not a massive programme, but it’s one hour less of sitting on my butt.

Thoughts On Psychotherapy

Last autumn, the clinic contacted me regarding a follow-up evaluation for the medical study. Actually, they had first contacted me in summer, but my family and the paperwork for the renewal of my husband’s residency permit kept me so busy that it got pushed out of my mind. After their last reminder, I offered to drop off the questionnaires in person – I had an appointment with the psychiatrist anyway, and it’s less than five minutes driving distance between the two locations. That way, the clinic would have them faster than via traditional mail, and I’d feel a little less guilty for making them wait so long.

The evaluation mostly consisted of self-report questionnaires like I had filled out so many times before in therapy. The most difficult was a section where I was supposed to rate the difference between summer 2011, when the clinical trial ended, and autumn 2015. On paper, my situation sometimes didn’t look all that different, but on the inside it sure felt like a world apart.

So one dark December afternoon, I was knocking at my therapist’s office door again. I felt a lot more nervous than I had anticipated: I hadn’t seen him in three years, and still didn’t know what medical problems had caused him to terminate back in 2013, whether he’d be visibly altered.

When he stepped out of the door, he looked maybe a few pounds heavier than I’d remembered, but definitely healthy. There was an emergency meeting going on in his office, so I couldn’t go inside, and he had only a minute, but “didn’t want me to leave without saying hello”. He showered me with questions, of which I managed to answer less than half, and we agreed to meet again in January after my next psychiatric appointment.

I wasn’t any less nervous about the January meeting than I had been about the December one. It was scheduled as a follow-up, because strictly speaking he was not allowed to see me outside the medical study – the clinic has stopped outpatient treatment completely, with the exception of clinical trials. Which buried my hopes for ever going back to therapy with him for good. Since he had already received my questionnaire, he was somewhat in the loop of what had happened in my life over the past three years.

“What would you say is the biggest difference between now and then?”
I had to think about this one for a moment, then replied that I felt like I had grown up. That I didn’t let people trample all over me anymore, that the person I used to be just a few years ago seemed like a stranger now.

It’s true in many respects. I don’t have that crippling feeling of worthlessness anymore. Not that I think about how awesome I am all day long – I just don’t bother with that topic at all, neither in the positive nor in the negative sense. It’s just become irrelevant for my life as it is now.

Both the therapist and I agreed that I had responded extremely well to psychotherapy. I am convinced that a lot of the positive developments that were planted in therapy only came to full fruition two or three years later, when I was not having sessions anymore. I don’t even know how to describe it properly, other than that my brain got rewired.
He used that phrase a lot when I first started, but I only came to understand its true meaning now: in situations where everything happens too quickly to think about the best strategies, my brain defaults to different reactions than it did in the past. I stand my ground, I defend myself when attacked. All those hours of roleplaying these scenarios during the sessions are paying off.

I also have the situational analyses internalized, so when I find my mood tanking, I ask myself where I did not behave the way I wanted to, and what I could do better next time. I may sound like an infomercial that tries really hard to sell its product, but psychotherapy was the best thing that might possibly have happened to me.

Here’s the catch: it takes a long time to become fully effective. It only happens when you master a situation you would have failed previously – even when you don’t consciously register it, your brain notices that the new strategy was successful and is more likely to try a similar approach next time. So it takes a row of successfully averted crises for the new behaviour to grow roots. If you are like me and try to avoid adversity, it might take a while until you had enough exposure to such “opportunities”.

Of course, CBASP does not change your personality. I am still introverted and shy. But it gave me the tools to fix the holes in the hull that would have made my ship sink in the past.

The meeting with my therapist was over too quickly. I miss him – or maybe not him as much as what he had to offer (that sounds horribly selfish, but essentially what a therapist-patient relationship boils down to): a safe environment to try out new behaviour. Somebody who asked questions that opened up fresh perspectives. Especially the latter.

Of course, I could just start looking for a new therapist, but regardless of who I’d see, that person would never know the “old me”. The Layara who showed up on the clinic’s doorstep in 2010 was so afraid of everything that I’d never be able to properly communicate this to any other psychotherapist.

Then, there’s the question of familiarity. He is “tried and tested”, I know what to expect from him. With any new caregiver, a lot of time and effort would go into reaching that same degree of comfort.

Time is the third problem. Health insurance pays for 26 sessions every two years, and I always wanted to keep that option as my safety net. I don’t want to use them up and then be left with nothing to fall back on if disaster strikes!

And even if I decided to do that, there’s only one CBASP therapist left in my area, with long waiting lists.

When discussing this with the psychiatrist, she basically said she thinks my development over the last six months was promising enough to not necessitate any further psychotherapy right now – that I should see where the new medication and new circumstances (my husband’s new job) take me, and then make a decision. I agree with her – I certainly feel too well to use up my 26 “emergency sessions”. And for paying out of my own pocket we are too poor.

Maybe it is for the best. It took me more than a year to come to terms with the sudden end of therapy, but it also forced me to stand on my own feet. Ultimately, I was ready to do so. And in January, we parted on the promise to keep in loose contact, so unlike 2013, I did not feel like I had to say goodbye for good.

How Welfare Saved My Sanity

One of the biggest contributing factors towards my mental health improvement was getting on welfare. Or rather, not having to worry about how we’d be paying all those bills and the rent. There’s a lot to be said for financial stability, even if it is only the state-defined minimum. No more letters threatening to turn off the gas or electricity, no more anxiety attacks when checking the mailbox.

The public image of welfare-recipients in Germany is just as bad as it is elsewhere, but I learned long ago to tune such things out. Most of those who are judgemental don’t really know what they are talking about – and they certainly don’t know my husband or me.

And it looks like our “leeching off the system” is coming to end. My husband landed a respectable full-time job a few weeks ago which should see us completely independent of state support by the end of the year. I had paid off my old bank account within a year and thus by summer my name should get deleted off the “financial offender” list and my credit rating be ok again.

What the occupational future holds for me, I don’t know. Right now, my husband is the breadwinner, and I do all the paperwork that comes with his job. I don’t plan any further than six to nine months ahead anymore – none of the long-term plans and goals I held in the past came to fruition. I’ll deal with that topic once I actually become capable of holding down a (part-time) job.

I will forever be grateful to be living in a country where a welfare-system even exists. It wasn’t always easy – you sign away a lot of privacy and become the employment agency’s little bitch in exchange – but that is a thousand times better than what we went through before.

The relationship with my mother has gotten a lot better once it was not strained by financial dependency anymore, too. There are different factors playing into this other than money, since her hospital stay very much became a game changer that altered the way we interact, but there is no denying that money used to be a contributing factor to the tension between us.

The Year Wasted On Venlafaxine

The venlafaxine debacle certainly deserves more attention than just the few lines I’ve allotted to it so far.

The first few days have been chronicled by this blog, but fact is that the side-effects never got significantly better. Nausea, headaches, muscle pain, and paraesthesia became my steady companions. Very often, it made me so sick that I had to lie down two or three times during the day. At every appointment I told the psychiatrist about it: he would either dismiss my complaints as “I’ve never heard about anyone having this problem with venlafaxine before”, or claim that those were not side-effects, but withdrawal symptoms because my dosage was still too low to last all day.

About fifteen months down the road, he finally cranked the dosage up – and that is where the heart problems started. Actually, I was in the early stages of serotonin syndrome, and it felt like I was on the verge of a heart attack. Before the next appointment was up, I had to lower my dosage again without even consulting him, because I just could not take it anymore. Finally he decided that maybe venlafaxine wasn’t for me and that I should try escitalopram instead.

The idea was that I would reduce venlafaxine over the course of three weeks and then start escitalopram. The withdrawal was so terrible that even though I gave myself six weeks instead, I still became bed-ridden. Other than expected, the most difficult part was not when I first started lowering the dosage, but the second to last step, which made me hallucinate.

Imagine lying in bed, sweating, your heart beating fast. Your head hurts, your teeth hurt, your back, your legs… every single muscle is in pain. Lights are too bright, sounds too loud, everything you eat makes you queasy. Your thoughts race and you cannot do anything to calm them down. And just when you think it cannot possibly get worse, you start hallucinating that the walls of your bedroom, the furniture around you, the ceiling above you are pulsating, bending in and out as if they are breathing.
I knew it was the withdrawal – that it wasn’t real – but that didn’t make it any less unpleasant. I cried like a little child: “I want it to stop! I can’t take it anymore!”

I do not want to badmouth venlafaxine, since there are many people who take it with few or no problems. I wasn’t one of them. By now, I am aware that I have problems with every drug that influences the noradrenaline (norepinephrine) cycle; that I am genetically predisposed to react that heavily to them.

However, I harbour resentments against the psychiatrist for letting me go through this for such a long time. He was friendly, but I feel like he did not take me or my complaints seriously – whatever it was, you don’t drag out a treatment that doesn’t help and causes so many problems for a year and a half. And I was too afraid that I wouldn’t get my sick note for the jobcenter if I complained too much, so I didn’t dare protesting too loudly. Even when giving the drug the benefit of the doubt, he should have stopped after six month. Instead, I wasted a whole year of my life on top of that trial period.

Coincidentally, just as I made the transition from venlafaxine to escitalopram, the practice was also taken over by a new psychiatrist. The options were to either stay at the old location and get a new caregiver, or migrate to the new location and stay with the old psychiatrist. I chose the former, and have been very happy since with the lady who took over. She’s friendly, competent, seems to genuinely care about her patients, and I find it easier to talk to her than her predecessor.

Escitalopram is a walk in the park in comparison. It really helps with the anxiety, and also has reduced the depression by 80%. What was left fell into three categories:
– problems falling / staying asleep
– lack of energy
– lack of motivation.

The psychiatrist’s suggestion was to try a second antidepressant as a booster. Initially I was very hesitant to even consider this option, because I did not want to go through an ordeal like the venlafaxine-regimen again. She promised that if it didn’t work, I could stop any time, and so I started with bupropion – which is how we discovered that I cannot take any SNRIs. It basically felt like a toned-down variety of venlafaxine to me. After three weeks I stopped.

The second booster I tried is valdoxan (agomelatine), which comes with zero side-effects. It’s slower to show results than other antidepressants I’ve taken, but after five months and experimenting with the dosage there is a definite positive trend: fewer days with sleeping problems, gradually increasing productivity, more motivation. There’s still room for improvement, but I am feeling better than I have in over a decade.

This Blog Is Still Relevant

Last night, I did something I had never done before: I read my own blog. During the past weeks, I had been wondering whether it was worth keeping “Lugubrious Layara” online – after all, I had not published regular updates in almost three years, and it did not seem to serve a purpose anymore.

But as I worked backwards through my own timeline, from the most recent post to the earliest ones, I realized how important this blog was for myself. Not only as a chronicle, but especially as a measurement tool for how far I have come since.

And that is why I need to keep writing and updating. I probably will never be able to close the gaps, but at the very least, I can make a fresh start right here and now.