Panic Attack

Last night I suffered an anxiety/panic attack over the upcoming exam. I saw it coming in the afternoon already, but tried to ignore it – not that ignoring the early signs did much good. Around 1 o’ clock in the morning I started crying and woke up my boyfriend, who tried calming me down and get me to sleep. When I finally drifted off, I had very unpleasant dreams and woke rather early, being completely cramped – my left hand was so tightly clenched that I had to open my fingers with the other hand.
I’ve also had increasing cognitive problems over the last days, with the ability to memorize going downhill really fast, word-finding problems and slowed speech. All very familiar symptoms, but it is scary how fast they can come back once I am really stressed out. So I emailed my therapist about this and he wrote back that the panic attack is enough for him to give me a doctor’s note which will allow me to not participate in tomorrow’s exam, so that unlike on Tuesday I won’t lose one of the precious three attempts. I see him briefly tomorrow morning, and for Monday I had a regular appointment scheduled anyway.

I think I probably overestimated my mental capacities and, trying to cram as many facts into my head as possible, eventually buckled under the pressure. I guess I should only have registered for two exams in the first place…

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You Better Watch Out, You Better Not Cry…

Christmas usually is an especially difficult time of the year when it comes to family relationships. The stress prior to the actual holidays brings out the extremes in our behaviour. My mother regularly explodes on December 23rd because she has problems delegating tasks, but gets overwhelmed by the load and vents her frustration and stress violently…

Thursday, December 22nd

Twelve minutes into Christmas break on the way home from university, I slipped on the escalator leading down to the tram station and twisted my right leg, while simultaneously tearing my left arm (which was still grasping the handrail). I could still walk, but only with a heavy limp, and had to have my sister pick me up from the tram station in my home town so she could carry my bag.
Over the course of the evening, I got rather upset because while my mother was rather worried, it was over the fact whether I would be able to drive her and my grandmother to the supermarket the next morning, and she didn’t express any concern regarding the pain I might feel. Functionality trumps pain – her problem with my depression was that I didn’t function anymore, too. Now that I appear functional again, my feelings become secondary once more.

Friday, December 23rd

At 9.30 in the morning, I found myself at an overcrowded supermarket. Finding empty space in the parking lot had already been a challenge, especially since my grandmother uses a rollator walking aid and wants to park as close to the entrance door as possible. The situation inside was worse rather than better.
With the need to pull myself together for uni temporarily suspended, my mood had started tumbling down quickly, and the longer we were inside the grocery store, the worse I felt. My swollen foot pulsated with pain and the constant bickering between my mother and grandmother – who were both affected by the general atmosphere as well – grated on my nerves.
After about half an hour, it took a really insignificant event only to push me over the edge: I was waiting for my grandmother to finish her business in the butcher’s section and just biding my time, when suddenly I felt the gaze of a middle-aged man on me. As he noticed that I caught him looking at me, he winked at me. No idea why it upset me, but it did. I wanted to yell at him to stop looking or winking at me.
I hid in the only empty aisle I could find and actually started crying. Because of the limping, I was always behind my mother and grandmother anyway, so nobody missed me, but in order to not rouse suspicion, I couldn’t stay there for long. Managing to pull myself together until it was time to queue at the check out, where people were standing in long lines already, I excused myself and went to wait in the car: officially to rest my foot, but really for calming down. I switched the radio on and concentrated on the music, so that by the time my mother and grandmother had finished their shopping, I had regained my composure.
In the late afternoon, I got once again into my mother’s crossfire when she repeated her threat that I had to move out if I didn’t get a student loan, which caused me lots of anxiety again.

Saturday, December 24th

Christmas Eve is the main event of the festivities in Germany, with big family dinners and the exchange of presents in the evening, and it started even worse than the previous day for me. I was already crying in the shower, with no clue how I was supposed to get through the day, and poured it all into an email to my boyfriend, which I felt guilty for later – waking up to your girlfriend’s hysterics doesn’t make for the most relaxed Christmas either. (He was utterly lovely about it, though.) Somehow I managed to dry my tears and leave, though, so I could help my mother with the preparations for dinner, but what happened then took me by surprise:
The conversation turned to my 10-years-old niece, who had exhibited rather ill-spirited moods that morning too. I remarked that I’d occasionally wondered if she didn’t suffer from the same condition as I do, but had never said anything because that was a hunch rather than something I could back up with solid facts. And that’s the truth – there are certain gazes or the way she holds her head or looks at people that feel utterly familiar to me, like the seed of all that avoidant behaviour, but I cannot present any evidence.
My mother nodded, then asked: “Where does this come from? Is it me?” (My mother looks after my niece when she isn’t in school.) I was completely flabbergasted and utterly at a loss. There are basically three reasons which cause chronic depression: 1.) genetic predisposition – which I certainly have from both sides of the family; 2.) neglect in infancy and childhood – which I can exclude for myself; 3.) repeated experiences of helplessness over long periods of time, concerning “significant others” like parents or other very close family members – which is very much the case with me. I had never told her what caused my chronic depression, because that’s simply too damn difficult a task – I don’t want to hurt my parents, because I know they had to endure a lot worse from their parents and never had a chance to not become slightly messed up either, but I could name dozens of situations that led to me becoming depressed and developing patterns of avoidance. My mother probably noticed that I was looking for the right words a little too long, and when I finally answered, it was just the three points mentioned above without connecting them to any personal experiences.
This was the worst time possible for this conversational topic to come up; on a different day, I might actually have welcomed the chance for broadening this point with her, but NOT ON CHRISTMAS EVE…
Myself, I started feeling better in the afternoon and got through the evening ok. We had all agreed to not buy any presents for each other because money is tight, so the big emotional climax was missing, but at least nobody fussed about it and I wasn’t reminded to get a job either…

Sunday, December 25th

I slept like a stone, until noon almost. The day was quiet, but pleasant. In the afternoon we went to see my grandmother and aunt, and in the evening I met one of my school friends who is home for Christmas. I didn’t feel like crying.

Monday, December 26th

Boxing Day is a national holiday too in Germany and at least in my family entirely dedicated to laziness. This year was in so far unusual as the family had a bowling tournament with Wii Sports – my mother isn’t much of a computer user and doesn’t even have an email address, while the rare behaviour for my father was to actually come out of his office for a family activity. So it was rather strange to see them playing a console game, but I really enjoyed the whole enterprise!

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So that was my Christmas, in a nutshell. In a little while I’m leaving for meeting another friend; I’m trying to fill the days with pleasant and diverse activities, so that my depression index goes down again and I will be fit for the last month of uni and exams once Christmas break is over, because if I learned one ting in therapy, it is that you must “fake it until you make it”.

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.

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.

Sick Leave

Today and tomorrow I’m on sick leave, staying home with a sinus infection. The timing is inconvenient and at first I still meant to go because I have two mandatory classes today with only a limited number of “allowed absences” (2 – 3 times), which naturally I don’t want to use up that early in the semester already. But ultimately I felt like crap and I also am going on a palaeontology excursion on Saturday, about which I’ll have to write a report and thus earn my first grade in geosciences, so I figured it was even more important to be in a proper shape for that.

Perhaps my sad mood earlier this week already foreshadowed the sickness, maybe I got sick because I was stressed out – there’s no way of knowing. Fact is that even though my throat is sore and my nose stuffed, I feel a lot better right now, with two full days of free time at my disposal. I’ve been conversing with my therapist via email since Tuesday and he reminded me of strategies we had figured out for maintaining a healthy balance: admittedly, without even noticing I had neglected some important points, like making sure that I did enough recreational activities. If nothing else, this relapse was a warning that even though I’ve been free of depressive symptoms for a few months now, I’m still walking on thin ice and that only a relatively short period of stress can throw me right back.

Back in February, I had come down with influenza (the real one, not what people commonly call the flu). It lasted for five weeks and was quite possibly the sickest I have ever been. My boyfriend was my saviour during that time, getting up at night for fetching me something to drink or preparing a hot water bottle, because I was too weak to get up. Night after night high fever alternated with cold shivers, I could not breathe properly because my entire respiratory system was “blocked” and sleep was only possible when sitting up… my boyfriend would afterwards confess to lying awake, worrying I might stop breathing. To make a long story short, it was utterly horrible and made me get flu shots as soon as the vaccination was available this autumn.
The recovery took a long time; only by the end of May I had returned to the pre-flu physical state. During all this time, I had already been in therapy and my therapist had expressed worries more than once and strictly ordered me to not do any kind of physical exercise for at least six weeks after recovering (he became a therapist via the medical route) because it might possibly damage my heart.
The reason why I mention this is because my therapist had highlighted before that mentally, I am in a similar state as my body was when recovering from the influenza: doing better, but still weak. I have had chronic depression for 18 years, with the latest episode being especially severe and lasting almost a year and a half. I cannot expect to have the same capacities as a person who never experienced depression, not nearly, and it will be a long while until I get there.

And now I really need to go (back) to bed. 😉

Mathematics For The Clueless

Part of my university schedule for the next semester has been published. It’s going to boil down to about 25 hours per week – not yet sure how many exactly since it can still change. The whole structure of it is a lot more like school than my old degree was. I’ll start at 9 AM every day and have lectures until the early afternoon, afterwards there will be more practical classes on most days. Friday afternoon appears to be off, however, which is nice. If nothing else, it offers me a comfortable time window for therapy sessions.

Apart from geosciences – geology, palaeontology, micropalaeontology, crystallography – I’m going to have classes in mathematics, physics, chemistry and biology. Crystallography is the only subject I haven’t had anything to do with at all so far; mathematics the only subject I am afraid of. I’ve always struggled with maths in school, so that makes me a bit nervous, but I checked a book on the basics out of the library and will start repeating them so they are already fresh in my head when I get confronted with it in class. It’s aptly named Mathematics For The Clueless. I also checked out books on physics and chemistry, but since I never had any problems with either, this is intended as a little warm-up rather than serious repetition.

Right now, excitement clearly outweighs the anxiety and I hope it stays that way. Unlike a couple of weeks ago, when going back to university still appeared the lesser of two evils, I am actually looking forward to it now and am very motivated. I only hope it stays that way; intellectual challenges I can tackle, but it’s going to be difficult if I start feeling like me being there doesn’t make sense anymore.
As long as I am undergoing psychotherapy, there still is the option of my therapist giving me a sick note if things go wrong really badly. Of course, I do not want that to happen either. I want my degree, want to prove that I can do this. I’ve spent so many years with a sense of failure lingering in the background…

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.

Welcome To Your Life

I had a clinical interview with another psychologist this morning – the same who created my personality profile back in December before I started psychotherapy. It was more or less a follow-up, consisting of the same questions.

The depressive episode was officially pronounced over, even though some residual symptoms currently remain. The panic disorder is gone (I haven’t had a panic attack in a year), and so are the slight traces of agoraphobia she could detect six months ago.
Of course, my “avoidant personality structure” still remains, but it has softened up a bit and the extremes of the social anxiety are gone as well.

It’s a rather strange feeling – despite the fact that I knew I was doing much better, there still is a difference between merely suspecting and being officially told that the last depressive episode is over. I am happy, mostly, and a little bit nervous.

Fortunately, I have the chance to continue therapy, because I don’t feel stable enough for carrying on completely on my own just yet. The last relapse brought up too many doubts to make me trust myself (yet).
However, right now I’m not relapsing, and there’s still work to be done. I got rid of the depression, but not of what caused it and was caused by it. I picture it as a decrepit house being renovated: the roof got patched up, the debris cleared out… now I need to replace all the broken furniture.

The therapy session in the afternoon was intense, but in a good way. The headline actually is a sentence my therapist said to me today – to signify that for the first time ever, I can start living without being ruled by an illness.