realisation

I woke up at 5am this morning. It was one of those awakenings that just happens, suddenly and intrusively. I decided to read. I was reading a book about experiences with depression. Reading is stressful. I feel the need to read over most sentences more than once, and still I find they don't sink in. It's incredibly frustrating. But still, I read, for the distraction. After giving up on reading for the moment, I pondered my own experience with depression. I thought about times when I was doing well, and times when I was depressed but somehow managing it (i.e. for whatever reason, the depression was bearable). During these times I wasn't wandering around with nothing to do but feel the unbearable pain of being. I wasn't excruciatingly bored, wishing for a distraction to come along. I felt no deficit in my social life. I was quite content to watch tv. I was able to relax and be distracted.

Now, as my depression waxes and wanes, I experience persistent emptiness, boredom and loneliness. I am stuck in one hell of a rut, and it must be deep because I can't get out. I long for the time I had a vibrant social life. I have to ask: what happened there? Some friends moved away, some acquaintances I lost interest in. Plus, I no longer live in sharehouses, which involve near constant social interaction. What's left is four friends in Newcastle, none of whom initiate contact with me. One has a baby, two work full time, and the other has her own mental health problems and is a relatively new friend. Apart from the fact that I resent always having to be the one to organise get-togethers, it's hard to make the effort to do so when I'm depressed.

It's hard to admit to loneliness. It's even harder to tell someone about it. It seems so pathetic. I've asked myself if it's reasonable to feel lonely. After all, I have four friends, some new acquaintances, my boyfriend, and my boyfriend's family. My own family isn't that far away. But, maybe the problem is the lack of connection I feel with all these people. I just can't be that outgoing, talkative person I once was. For the first time in a long while, I feel shy and awkward. I'm at a loss for words most of the time. I feel blank, with nothing to say and unsure of how to actually have a conversation.

This strange inability to function socially reduces my motivation to even initiate social contact anymore. I just kind of gave up, gradually. And now I don't have much left in my life at all.

I've tried to think of what exactly has changed. I'm not trying to figure out why I'm depressed at this point, because according to my diagnosis it's biological. I'm trying to figure out why the quality of my depression has changed. Life was once bearable, and now it's a struggle to get through each day. I blame it on being in Newcastle, being unemployed, not knowing what I really want to do with my life, living in a crappy house, and having no social life. It's hard to see that a lot of the way I think and feel about these things is directly caused by the depression. It's my mind playing tricks on me. It makes everything seem uninteresting, meaningless and unenjoyable. It makes it feel impossible to change the things in my life which I attribute my depression to. Motivation is low, because I can't imagine getting any pleasure out of things.

I can blame depression on any of these things, but the fact is that I've been depressed in many different situations. Employed or unemployed, in Newcastle or Sydney, sure of what I want to study or not, nice house or crappy house, lots of social contact or none. Change might not make the depression go away, but it could make it more bearable.

splitting

Yes, okay, I have to admit to it. Now that I think about it, how could I possible deny it? It's been a strange problem in every relationship I've had. It's not just normal uncertainty about the relationship, I do seem to go between two extremes. This person is amazing, this person is terrible. I may not end up hating people, but I do end up feeling like they are against me. Sometimes I know how irrational this is. I also think that people must also love me or hate me. There's no in between.

Chaotic relationships... my first long term relationship involved dealing with his neuroticism, but then there was mine. The abandonment thing was a big problem. I couldn't deal with him going away. I interpreted everything so irrationally. I don't even want to go into it.

Don't get me started on my high school boyfriend. I was simply a psycho bitch. I went from thinking he was the best to thinking he was crap and wanting to break it off. All I really wanted was to have someone, but I drove him away. I would always start arguments, and I don't really know why. I accused him of so much crap. So he dumped me, and I was absolutely devastated. He wasn't my type, and there really wasn't really any attraction, I just wanted a boyfriend.

down

My mood dropped after seeing the psychiatrist today. Probably because there was nothing to feel apprehensive about.

I'm at home alone and it's night, but I'm doing okay. I don't know why I can't usually handle this situation. When I was younger if I was feeling alone I would have to have the tv or radio on to feel connected to the outside world. I used to fall asleep with the radio on.

These days, sometimes I'll find myself at home alone at night with no plans, so I'll get into a frenzy of trying to find someone to hang out with. It just comes from a fear of being alone. Sometimes I can handle it, though.

cigarettes

I've been smoking a lot. I feel elevated, and agitated. I've started tracking my moods on moodtracker.com and posting on the forum there. It's good to just talk to people I don't know. It's liberating. I finally feel like I have some support!

There is just a hint of anxiety as well. It's hard to separate it from the agitation. I feel like I can crap on and sometimes can't stop myself from saying something. I have the urge to just write, or do something. I'm waiting for my psychiatrist appointment. I'm sitting outside in the cold at uni, just waiting until I can catch that bus. I don't feel like I could focus on my assignment, but I do feel motivated to work on it.

This sort of writing is so disjointed, but it helps. Any writing helps. I usually can't write this much. I'm getting psychomotor agitation. It's different from the inner agitation, but it can go along with it. I'm feeling both. I don't know what to do with myself. I thought all this would end when I was off the medication. It hasn't. I guess I gelt this way before abilify, too. And I wasn't on much else then. I was almost weaned off effexor. I don't know what started all this. I thought it was the effexor making me agitated, and it stopped for a while when I managed to lower the dose. But then it started again, and it got worse on abilify. Maybe it was a bit better on risperidone, but I didn't take it for long enough to know. Now I'm just back to how I was before abilify. I can't read for extended periods. I used to be able to. I can read, but it's multiple things at a time. It's hard to focus on reading articles for my assignments.

I hope I don't get depressed again any time soon. I might like to be free from agitation, but depression is just so dull. Not normal dull, depressingly dull. It's like a heaviness in the air. It's like having sensory deprivation, or hearing the same tone constantly.

euphoria

I know the feeling of euphoria well. It can be a tingling and a buzzing that spreads throughout the body. It can be a feeling rising in my chest, like anxiety, only good. It's a dizzying high. I have felt euphoria without the aid of drugs. Falling in love, listening to music, exercising, socialising, dancing, drinking, seeing a band, seeing something pretty, or just catching the bus on a good day. All of these things have given me euphoria. I'm always chasing this high. None of these things really do it for me when I'm not in this happy state. But when they do, they do it good. Just fantasising about it is amazing, when I'm happy enough to be able to imagine it. It makes me want to run everywhere. It makes me want more of it. It makes me want to be around people, and it makes me feel charismatic.

I think this is how my obsessions with people came about. I would be attracted to someone, and just get such a high from being around or thinking about the person. It was the highest of highs, and so addictive.

ICD borderline criteria

If I were to go by the ICD, there's no way I could be borderline! For starters, I would need 3 of:

1. marked tendency to act unexpectedly and without consideration of the consequences;
2. marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;
3. liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions;
4. difficulty in maintaining any course of action that offers no immediate reward;
5. unstable and capricious mood.

AND 2 of:

1. disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);
2. liability to become involved in intense and unstable relationships, often leading to emotional crisis;
3. excessive efforts to avoid abandonment;
4. recurrent threats or acts of self-harm;
5. chronic feelings of emptiness.

AND these would have to be chronic, pervasive and present across all situations.

The only of the first section that I could possibly have are unstable mood and tendency to act without consideration of the consequences. Definitely not the others. And I do consider consequences, I just decide that I don't care at the time. I'm obviously capable of maintaining a course of action that has no immediate reward. I just also tend to really enjoy things that give an immediate reward.

DSM stuff

So according to the DSM, having a personality disorder means that you do not feel or behave the way you're supposed to ("as expected") in your culture. I guess it's just another way of saying that you deviate from "normal" in some ways, which is necessary for any psychiatric diagnosis. I don't know why it's emphasised for personality disorders. It's as if they're still thinking of these disorders as being a manifestation of moral weakness. But, they're only called "personality" disorders, I assume, because they are "pervasive and inflexible", have an "onset in adolescence or early adulthood", and are "stable over time". This means that the symptoms are always there, and they have been since a young age, and they are there in many different situations. Personality is supposedly like this, although you would call them traits, not symptoms. Also, a personality disorder must involve "distress or impairment", which is what makes it a disorder.

I went to borders to check out some books, and I found one called borderline personality disorder: a therapist's guide to taking control, by freeman and fusco. For every DSM criterion there were vignettes to demonstrate it and a series of questions to ask to see how much the patient has problems with that criterion. I found that the only ones I scored high on were impulsivity, suicidal thoughts and emptiness (the first mainly applies when I feel stimulated, the last two only apply when I'm depressed). I didn't even score that high on self harm or emotional instability. I have a little bit of all of the criteria, but not enough, I don't think. I have at times frantically tried to avoid abandonment, but this doesn't happen in every relationship and I think that I exhibit a pretty mild form of "frantic" compared to the vignettes. In my first ever relationship in high school I probably acted exactly like someone with BPD. I may still be a little bit like this. It doesn't mean I have BPD.

I don't idealise people as much as just become obsessed/fall in love easily. I certainly don't devalue anyone afterwards.

I don't have the identity disturbance that was described in the book. I definitely have a normal amount of identity disturbance for a young person.

I could relate to some of the questions about anger, but they only applied to when I'm feeling agitated.

I'm not that emotionally unstable since I can go through long periods of stability, and I usually have a general mood which lasts more than a few days.

I've experienced dissociation and I'm sometimes paranoid. I'm not paranoid about being abandoned as much as being judged, though. And mostly I've experienced dissociation randomly, not during stress. I think it's pretty normal to have experienced some sort of dissociation. It's not a problem for me, I don't lose time or space out. I think the paranoia is related to social anxiety, or maybe the agitation.

So the criteria I actually fulfill are impulsivity and irritability when agitated or stimulated, and emptiness and suicidal thoughts when depressed. I may experience some dissociation and some paranoia when I'm agitated. I do fear abandonment, but this only comes out when I'm depressed. My relationships improve as I get older. None of the criteria that I fulfill are constant for me. They are not stable over time. They're not pervasive and inflexible. The identity disturbance and abandonment fears have improved over time, like you would expect. I don't see any way that a personality disorder could explain my symptoms.

On the other hand, I looked at a book about understanding the DSM. The section on bipolar was interesting. Mania was described more clearly: elevated mood interrupted by irritable outbursts, increase in goal-directed activity which can appear like unrelievable restlessness (exactly what I experience), thoughts & mental activity speed up (for me, reading and writing fast), high level of verbal output (in speech OR writing), loosening of inhibitions, foolish ventures e.g. business decisions, spending, sex.

Instructions were given to confirm presence of mania or hypomania by looking for changes in: sleeping and eating patterns, energy levels, restlessness, increased activities especially risky or destructive ones, problems concentrating, easily distracted, instances of extreme feelings of happiness, laughing inappropriately (usually accompanied by agitation), increased talking, pressured talking, racing thoughts - unable to keep up with the influx, impaired judgment, grandiose ideas, inflated self esteem, increased irritability or impatience, easily excitable, lack of interest in personal relationships, hallucinations, incoherent speech, violence, disorientation. Also important is a history of alcohol and drug use, medical conditions and medications.

Hypomania was described as increase in energy or irritability, decreased need for sleep, increase in activities (including spending), increase in pressured verbalisation, and the tendency to become quite creative.

Cyclothymia was described as having milder mood episodes but being chronic, lasting at least 2 years with no symptom-free periods lasting more than 2 months.

BP-II patients have a strong family history of bipolar OR depression.

The book also had an interesting case study of a bipolar woman. She had a complicated history of social and behavioural problems. Her mania manifested as delusions, compulsions, being argumentative, paranoia, dissociation, anxiety and obsessions. Her symptoms started at age 16 but she wasn't diagnosed properly until she was 34 (she was diagnosed with depression at age 30). She has tried over 15 meds, none of which stabilised her. She apparently had depression, low self esteem and attachment issues since childhood. She has a history of childhood abuse and parental abandonment. She has been married 3 times and had multiple abortions. She has violent mood swings and deep depressions, which she always thought was caused by PMS. She self medicated with marijuana every day from age 16 tp 36. She has always felt inferior and continues to. She has casual sex and has had numerous troublesome relationships. She idealises men and feels rejected when relationships end. She has no social or recreational interests. She excelled in school when she applied herself but always had trouble with concentration, attentiveness and social skills. She is generally suspiscious of people. She dropped out of school, and later attempted further study, but couldn't complete the degree. She has had many types of jobs, and self doubt and social fears stop her from following through on career decisions. Compulsive shopping binges lead to financial trouble. She has had chronic insomnia problems, increased appetite and weight gain. At the time of the assessment she reported depressed mood but she seemed talkative and her speech was pressured and non-goal-directed. She has had inappropriate judgement in the past and reports poor concentration, although she was alert during the interview.

It's interesting that no one ever tried to give her a borderline diagnosis! According to this book for a proper diagnosis of bipolar you need to identify mood episodes and then see if they meet the criteria AND see if they affect many areas of functioning. Current and past behaviours must be considered.

more information

I will write down anything I can think of about my symptoms. This is the only way to ever get the right diagnosis. I need to compile as much information as possible.

When I am agitated, I am also very irritable, my thoughts race, and I do spend quite a lot. I am also more likely to drink a lot, self harm or take OTC drugs. These last ones seem like engaging excessively in risky behaviour. I noticed how much my thoughts were racing last night when I was agitated and I did some mindfulness exercises. I sat back and watched my thoughts flicker past, and that's what they did, they flickered. Normally my mind is pretty blank and then thoughts come into my head every few seconds or so, but this was like watching a movie in fast forward. I didn't even know what these thoughts were. I was still able to have other thoughts on top of this flickering, but it was there, and it usually isn't. It's hard to concentrate on anything in this state.

I also can feel a strong urge to speak, even if I don't know what I will say.

I can be so agitated that I move from one activity to another, getting too bored with each and not being able to focus on any of them.

Also, I feel hypersensitive to stimulation, especially sound. Noises just piss me off, and I'm too easily distracted by them.

stuff

http://imbound.blogspot.com/2004/12/help.html

A very illuminating blog post. I can see myself being diagnosed as borderline, being put on more antipsychotics, and never really understanding what goes on in my head. This might not be what would happen. If I was diagnosed with BPD, I'd get to go to the centre for psychotherapy and be in a really good program. But, I have to be currently self harming to get into the program. I'm not going to self harm just so I can get in! That's the thing, I don't self harm much at all. So really, I'd be left with seeing some psychologist once every 3 weeks and trying to convince the psychiatrist to put me on something other than antipsychotics.

Right now I'm thinking, how could I possibly be borderline when on a day like today I am completely fine? Not elated, irritable, depressed, sad, lonely, empty, or even agitated. There are plenty of things I could feel crap about. I go through quite long periods of doing really well, and being completely stable.

I will definitely not accept a diagnsosis that I don't agree with. There are a few options for if it comes to it and I need a second opinion, most of which are in sydney and cost more money: the good mood clinic, the black dog insitute, insight psychology, the hills clinic, the lawson clinic, wesley hospital.

All of these would need a GP referral for the medicare rebate, but I could call and ask them all how long the waiting list is and then decide which one to go with.

There are also more psychologists in newcastle. There are 3 places I can call that use medicare. I'm just going to have to be persistent in finding the right treatment.

I think that for some periods of time I fit the diagnosis of generalised anxiety disorder, but it's not a constant in my life. I can sometimes relax and forget my troubles.

I'm worried about uni and whether I should drop the cognitive psych course. I just really haven't done enough, and it's the end of semester. I don't think I really have the time now to do everything I need to pass this course. It's difficult, because it's the last course I need to finish my first degree. I just need to be realistic about it, though. Could I complete an assignment and study for the exam in 3 weeks, as well as do the assignment and study for abnormal psych? Maybe. I just don't know! And I'm worried about what will happen if I don't complete the course. It will be another time I'm failing, and another opportunity missed to finish this degree. I have had such a hard time, though, and it's been such a struggle. I've been going through depression, anxiety, agitation and med changes. I haven't had any consistent treatment at all. If I don't have this degree I don't mind so much, I guess it's more about what other people will think. People will think I have failed yet again. Or maybe not, maybe they will understand that I've been having a hard time. Maybe it doesn't matter as much as I think it does, since it is my life and everything. I'm living completely independently, so I don't exactly need to rely on other people, so what they think shouldn't really matter.

I guess I always worry that everything will fall apart if things don't go to plan. Maybe it was unrealistic to try to do more than one subject in the first place. I knew I was in a bad place. Going back to uni was a good way to get me out of depression, but too much is too much. Maybe not much for someone else is too much for me right now.

So, what if I drop the course? What if I won't be graduating soon? Maybe I shouldn't focus so much on the what ifs. Or the shoulds, for that matter. I could just take it as it comes. I could focus on completing the abnormal psych course, and doing well. I've already got an HD for the first assignment, imagine if I did really well overall in the course? I suspect I will since I already know so much from my own research. If I can just focus on the one course I could do so much better. I have plenty of time to complete other courses.

So, looking at this non-judgementally, I started off doing 3 courses, stuff got in the way, and I ended up completing one course. That's not really so bad.

Things happen. Most of the time they are neither all good nor all bad. This is a good thing for me to learn, I think.

more symptoms of the past and present

Traumatised by graphic or disturbing parts in movies, then can't get the images out of my head, since childhood. The images linger for years and cause so much distress.
Paranoia.
Can't handle being alone at night - extreme fear of house being broken into or extreme loneliness.
Obsessing over possible medical conditions.
Memories over social failures stick with me.
I can feel completely stuck in my thoughts, can't get thoughts out of my head.
The images of catastrophes that could happen get stuck in my head.
Pervading sense of doom.
Panic, doom, visions of the world ending, obsessions.

writing and hypomania

Back to thinking about my week of frenetic writing. I think I definitely had enough of the criteria for a hypomanic episode. Elated mood, decreased need for sleep, increased involvement in goal directed activity (writing to get read and published online and to make money), irritable (especially when my boyfriend tried to get me away from my computer), subjective experience of thoughts racing (flight of ideas), pressured writing (pressured speech), overconfidence (inflated self esteem).

I was staying up most of the night writing, and writing most of the day. I normally don't write much and it takes a lot of effort. This didn't. I had so many ideas, and I had to write them all down. And other people had to read them! I thought that my ideas were very important. I thought I was great for writing this stuff. I thought I could make lots of money. I just had to keep writing. I didn't miss sleeping, I felt energised. I didn't think it was weird or unusual at the time, but it is looking back on it.

It could have just been me getting an idea in my head and getting excited about it. But it's the lack of a need for sleep, and the fact that it was so unlike me, that makes it stand out.

After I stopped writing my thoughts were still racing a bit, then I went on abilify. I thought it was great at first, my mood was great and I had so much energy. Then it just made me so anxious and agitated.

Risperidone calmed me down a bit. I didn't take it yesterday, and last night I was so agitated. Today I feel like I really could just lie in bed. The agitation might come later, though.

It was weird not waking up at 3am. I woke up at 7. I think 6 or 7 is a good time for me. The early waking was obviously just caused by abilify and has stopped now.

My normal pattern is staying up late. If, like in the week I was describing, I don't feel like I need much sleep, I can still get up in the morning and have energy. Otherwise, I just want to sleep all day.

I had such a good time just having coffee with friends last night. It's good to know that I have such good friends who will really support me.

again

Feeling agitated again. I'm having trouble finding words, articulating. I have the urge to speak but I don't know what to say. I had coffee with friends but felt on edge the whole time. My mind kept going blank. I wanted to talk or do something, anything. I'm calming down now.

Sometimes I find it hard to stop myself from speaking, like it flows out without my control. I speak before I know what I'm going to say. I feel embarassed after, for saying too much.

I may be slightly depressed. I feel pretty hopeless about things, about uni, getting a job, and getting treatment, also just life in general. I want my depression to be lethargic like it normally is. I want to just be able to hide. But no, I have the need to keep doing things.

I feel down a lot. But up at the same time. I just feel low, but keyed up. It's like my brain is on fire.

I think I can sleep now.

a proper post

I feel better, calmer, less emotionally violatile since taking risperidone. Such a tiny dose and it still affected my appetite. It would be dangerous for me to put on any more weight, so I'm going to stop taking it and see what happens. Hopefully the two small doses were enough to calm me down after the horrible abilify experience.

more on rejection sensitivity

http://www.psychiatryonline.com/content.aspx?aID=2936&searchStr=bipolar+ii+disorder

"Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods. The problems that result from rejection sensitivity must be significant enough to result in functional impairment. There may be stormy relationships with frequent disruptions and an inability to sustain a longer-lasting relationship. The individual's reaction to rebuff or criticism may be manifested by leaving work early, using substances excessively, or displaying other clinically significant maladaptive behavioral responses. There may also be avoidance of relationships due to the fear of interpersonal rejection. Being occasionally touchy or overemotional does not qualify as a manifestation of interpersonal rejection sensitivity. Personality Disorders (e.g., Avoidant Personality Disorder) and Anxiety Disorders (e.g., Separation Anxiety Disorder, Specific Phobia, or Social Phobia) may be more common in those with atypical features."

ICD-10 criteria

http://www.fortunecity.com/campus/psychology/781/icd.htm
"F30.0 Hypomania

Hypomania is a lesser degree of mania, in which abnormalities of mood and behaviour are too persistent and marked to be included under cyclothymia but are not accompanied by hallucinations or delusions. There is a persistent mild elevation of mood (for at least several days on end), increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. Irritability, conceit, and boorish behaviour may take the place of the more usual euphoric sociability.

Concentration and attention may be impaired, thus diminishing the ability to settle down to work or to relaxation and leisure, but this may not prevent the appearance of interests in quite new ventures and activities, or mild over-spending.

Diagnostic Guidelines

Several of the features mentioned above, consistent with elevated or changed mood and increased activity, should be present for at least several days on end, to a degree and with a persistence greater than described for cyclothymia. Considerable interference with work or social activity is consistent with a diagnosis of hypomania, but if disruption of these is severe or complete, mania should be diagnosed."

http://www.fortunecity.com/campus/psychology/781/cycloicd.htm

"F34.0 Cyclothymia

A persistent instability of mood, involving numerous periods of mild depression and mild elation. This instability usually develops early in adult life and pursues a chronic course, although at times the mood may be normal and stable for months at a time. The mood swings are usually perceived by the individual as being unrelated to life events. The diagnosis is difficult to establish without a prolonged period of observation or an unusually good account of the individual's past behaviour. Because the mood swings are relatively mild and the periods of mood elevation may be enjoyable, cyclothymia frequently fails to come to medical attention. In some cases this may be because the mood change, although present, is less prominent than cyclical changes in activity, self-confidence, sociability, or appetitive behaviour. If required, age of onset may be specified as early (in late teenage or the twenties) or late.

Diagnostic Guidelines

The essential feature is a persistent instability of mood, involving numerous periods of mild depression and mild elation, none of which has been sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder or recurrent depressive disorder. This implies that individual episodes of mood swings do not fulfil the criteria for any of the categories described under manic episode or depressive episode."

agitated depression

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VM1-4BT7JCG-4&_user=915767&_coverDate=04%2F30%2F2004&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1331482145&_rerunOrigin=scholar.google&_acct=C000047922&_version=1&_urlVersion=0&_userid=915767&md5=02921e7b319ac5ff68395f33c25dc103

"Mixed depression was operationally defined by the coexistence of a MDE and at least two of the following excitatory signs and symptoms: inner psychic tension (irritability), psychomotor agitation, and racing/crowded thoughts.

MDE plus psychic tension (irritability) and agitation accounted for 15.4%, and MDE plus agitation and crowded thoughts for 15.1%. The highest rate of mixed depression (38.6%) was achieved with a definition combining MDE with psychic tension (irritability) and crowded thoughts: 23.0% of these belonged to MDD and 76.9% to BP-II. Moreover, any of these permutations of signs and symptoms defining mixed depression was significantly and strongly associated with external validators for bipolarity. The mixed irritable-agitated syndrome depression with racing-crowded thoughts was further characterized by distractibility (74–82%) and increased talkativeness (25–42%); of expansive behaviors from the criteria B list for hypomania, only risk taking occurred with some frequency (15–17%).

These findings support the inclusion of outpatient-agitated depressions within the bipolar spectrum. Agitated depression is validated herein as a dysphorically excited form of melancholia, which should tip clinicians to think of such a patient belonging to or arising from a bipolar substrate. Our data support the Kraepelinian position on this matter, but regrettably this is contrary to current ICD-10 and DSM-IV conventions. Cross-sectional symptomatologic hints to bipolarity in this mixed/agitated depressive syndrome are virtually absent in that such patients do not appear to display the typical euphoric/expansive characteristics of hypomania—even though history of such behavior may be elicited by skillful interviewing for BP-II. We submit that the application of this diagnostic entity in outpatient practice would be of considerable clinical value, given the frequency with which these patients are encountered in such practice and the extent to which their misdiagnosis as unipolar MDD could lead to antidepressant monotherapy, thereby aggravating it in the absence of more appropriate treatment with mood stabilizers and/or atypical antipsychotics."

back to the borderline/bipolar distinction

I think that borderline personality disorder and bipolar disorder are two different things, they can just really look like each other, especially when comparing BPD and BP-II. I'm worried about getting the wrong diagnosis. I have a long-standing pattern of extreme sensitivity to rejection, and mood/emotional reactivity/lability/instability, whatever you want to call it. I also sleep more and overeat when depressed, and I get that leaden feeling in my body. All if this is what defines atypical depression, but the first two could also point to BPD. In a previous post I went through the BPD criteria, but now I'm starting to wonder about it again...

1. Do I frantically avoid real or imagined abandonment? Not at the moment. I'm in a very stable relationship. I have in the past, but really I think it was more about rejection than abandonment. I also don't worry about being abandoned by most people. All of my stalking behaviours were related to becoming obsessed easily... this could be related to many things. Anyway, for me, it's more about fear/avoidance of rejection than anything else.

2. Splitting. Okay, I do tend to idealise people. But when do I devalue them? It's common to idealise people when one has low self esteem, but I definitely do not devalue people, especially not openly. Like I said before, I feel hurt very easily by people, but that's due to my sensitivity to criticism and rejection.

3. I may not be as impuslive as I think. I still manage to plan some things. I'm only really impulsive when I'm in a more manic-like state.

4. Unstable self image and sense of self. These have really improved with age, and I feel much more like my own person the older I get. I don't change my identity in any extreme way.

5. I really don't self harm that often.

6. Mood instability. Mostly my mood goes between depressed, normal and elated. I'm only irritable when I'm agitated.

7. Chronic emptiness. I don't always feel this way. It's only when I'm depressed, so I wouldn't say it's chronic.

8. I'm not really an angry person at all.

9. Paranoid ideation, delusions or dissociation. I've never been delusional. Any paranoia I've had was related to social anxiety or caused by drugs. I've only ever experienced the sort of depersonalisation that most people have experienced before.

I just think that even if I do have some of the symptoms, I don't have them often enough or across enough different situations. I also don't really have the most characteristic features. Maybe the psychiatrist is biased towards BPD, just like he's biased towards prescribing atypical antipsychotics.

emotional instability

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TBV-4S02JS6-1&_user=915767&_coverDate=05%2F30%2F2008&_alid=1334326523&_rdoc=1&_fmt=high&_orig=search&_cdi=5152&_docanchor=&view=c&_ct=186&_acct=C000047922&_version=1&_urlVersion=0&_userid=915767&md5=591622c8b8e9e1601f466c40857f2d0b

Apparently bipolar involves reactive/unstable moods even in the non-depressed/non-manic phase.

career goals

I had such a good lecture today, for abnormal psych. A woman from the centre for psychotherapy came along to give the lecture on eating disorders. First she told us about how when she was studying for her psychology degree she was told her marks weren't good enough to get into honours. She said that she always knew she wanted to work with people, she just didn't know how. She did her masters and then has been working with people with eating disorders ever since. She said that you don't need to do psychology to become a counsellor, but it helps to get jobs, and that it's a good idea to do some volunteering. She now has her dream job. She really inspired me, and I realised that my dream job is to be helping people with mental health problems. I feel a lot better about my career goals now. She recommended becoming a lifeline counsellor, so I'm going to do the training course and see how it goes.

I got 85 for my essay, the one I was having panic attacks over. I feel ambivalent. I was excited and happy, but also confused and somehow dissappointed. I still got some very critical comments, which of course they do because psychology students have to write a lot of essays, and feedback is good. I still keep thinking that they must have made a mistake with the mark. It also said that I had 0% plagiarism (or "similarity" as they call it now). I didn't even think this was possible, but maybe they take out all the references before they calculate it. I should be so proud! But I doubt myself even more. Or, should I say, I doubt the marks they gave me. Both the mark and the similarity score are not what I expected. I was expecting a credit, and an okay similarity score. Seriously, how did I get an HD? Is it for real? I couldn't believe it when I saw the mark, I had to keep checking to make sure it wasn't just a random number.

Maybe I feel bad because I'm worried that it actually was a mistake and they will take it back. I just checked again, and the mark was still 85. The good parts of the essay must have balanced out the less good parts, I suppose. I only did really well in one section of the essay, but I guess that I had to have lost 15% of the marks somewhere.

I hate how impersonal it is, getting your essay back through turnitin. They even have "G" and "Exc" next to bits of the essay, instead of comments that were more obviously written by a real person. Arrgh, I'm just going to send myself crazy over this. Think about it, only 16% of people got an HD, and I was one of them, even though I was going through extreme anxiety because of abilify. My high school physics teacher always told me that I could do so well if I just applied myself. Teachers always say that, but maybe he was right. Maybe I will go and apply myself to the next assignment.

Oh, the other good thing from the lecture today. I learnt that you should eat every couple of hours to reduce bingeing. If you don't eat regularly enough, if you let yourself get really hungry, you actually get more emotional, and those emotions can lead to a binge. I sort of knew that already, but I thought that 3 meals a day was enough. It does make sense, though. Something I read about treatment for bulimia involved getting the patient to gradually increase to eating 5 times a day! I think that doing this would really help me overcome my guilt towards eating, as well.

more on diagnosis

http://www.springerlink.com/content/4af1prhmcw75n6df/

Apparently atypical depression can be an indicator of bipolar. Atypical depression involves a long-standing pattern of extreme sensitivity to rejection. This, I think, could be the equivalent of frantic attempts to avoid abandonment in borderline personality disorder.
Note: there is another way to interpret this. Atypical depression involves mood reactivity as well, and both mood reactivity and hypersensitivty to rejection could be equivalent to the mood reactivity in BPD.
So there is another way in which BP and BPD can overlap. That just leaves dissociation and splitting to differentiate BPD from BP. Although, a science direct search yields a lot of articles for "dissociation in bipolar disorder", and it makes sense that it could occur since bipolar disorder can involve psychotic symptoms, and dissociation is a sort of sub-threshhold psychotic symptom. As for splitting, it may be the one thing that really characterises BPD. I read some of a clinical guide on treating BPD and a lot of it seemed to be about dealing with splitting. Mostly it was about dealing with the difficulties that the patients bring, such as being insulted.

Plus there is the diagnostic category of bipolar not otherwise specified, which includes full hypomanic symptoms without depression, or a history of depression with hypomania that doesn't last for four days. Cycling between depression and hypomania throughout the day can be classified as BP-NOS. Wouldn't this look exactly like BPD, especially if the person had a long-standing pattern of hypersensitivity to rejection?

Of course there are still many other things that could differentiate BP: agitation, racing thoughts, increased activity in general and especially goal-directed activity, decreased need for sleep, flight of ideas, pressured speech, distractibility. None of these should really happen in BPD, at least not in a cluster. If they do happen in a cluster that also involves elated or irritable mood, even if the symptoms don't last that long, I guess that would indicate BP or BP-NOS. This is one way to differentiate BP from BPD, but it still leaves the problem of differentiating BPD from BP. BP can still "look like" BPD.

Apparently it's common for people with BPD to also have Axis I disorders like major depression. You can even have both BP and BPD. It's all very confusing. Obviously mental health diagnosis is not an exact science.

My current state

I'm back to feeling as agitated as I was before abilify. I feel kind of elated, though. I wish I could work on my assignment, but I can't focus. My mind is too crowded. I feel like doing things, not sitting here in the library. I have what they call psychomotor agitation, I think. Leg jiggling. Writing calms me down. I feel disjointed. I don't quite feel safe with so many people around me.

I experienced such a rush of euphoria while I was exercising this morning. I embraced it. I woke up at 3am but I feel energised. Part of it must be a lack of sleep, and because I went to the gym this morning. I think sleep deprivation and exercise can make me more energised or agitated.

I guess I also feel anxious in this agitated state. Maybe it's still the after-effects of abilify, but it's different somehow. I feel clear. My mind is clear yet it is crowded. It doesn't really make much sense. I feel like I'm slipping into insanity.

For hypomania, "the change in functioning for some individuals may take the form of a marked increase in efficiency, accomplishments, or creativity. However, for others, hypomania can cause some social or occupational impairment."

Occupational impairment... does that include not being able to study?

I'm a lot more efficient at some things in this state, like exercising and writing. I can't write anything to do with my assignment, though. I don't feel that worried about uni at the moment. I feel that all will be well, unless of course I can't calm down.

Sometimes I feel this rush that reminds me of the effects of ecstasy.

Anyway, I feel like I can't calm down or slow down at the moment. I feel sort of like I've taken stimulants.

I have intrusive and vivid thoughts. I've always had those. I sometimes feel paranoid in public. My extreme fears/phobias seem to come from intrusive, vivid thoughts. They're not so much phobias, because they are fears about situations I don't actually find myself in. Situations that will probably never happen to me. They are more like obsessions. I can imagine such horrible things happening. The first thing was just death in general, when I was very young. I felt I could imagine what death would be like. I guess this what at an age when I didn't really understand death. I thought of it as unconsciousness, and then I associated sleep with death and sleep seemed scary sometimes. I also pictured the end of the world. That was an obsession for me, for a long time I think. It started when I was around ten. It may have been related to the religious ideas I'd been exposed to. I thought about it all the time, and it scared the crap out of me. Then, in 2008 I became obsessed with my fears of flying and surgery. I knew I didn't have any plane trips or surgery coming up (I've never even had surgery), but I thought about it a lot. I pictured these bad things happening.

borderline or bipolar?

Borderline symptoms

1. irritability
   
2. emptiness
   
3. mood instability
   
4. avoiding abandonment
5. impulsivity
   
6. self harm & suicidal thoughts
   
7. splitting
8. unstable identity & sense of self
   
9. dissociation

Hypomania symptoms:

1. abnormally and persistently elevated, expansive, or irritable mood that lasts at least 4 days

This period of abnormal mood must be accompanied by at least three additional symptoms from a list that includes:

2. inflated self-esteem or grandiosity
3. decreased need for sleep
4. pressure of speech
5. flight of ideas
6. distractibility
7. increased involvement in goal-directed activities or psychomotor agitation
8. excessive involvement in pleasurable activities that have a high potential for painful consequences (this is what I consider to be a manifestation of impulsivity).

If the mood is irritable rather than elevated or expansive, at least four of the above symptoms must be present.

There are six symptoms that BP and BPD can share: irritability, impulsivity, changes in self image, suicidal thoughts, mood fluctuations and emptiness (related to depression in BP). Only five symptoms are needed for a borderline diagnosis. Four or five symptoms are needed for hypomania, and for Bipolar II mood fluctuations (depression/hypomania) are also required. So, there can be a lot of overlap. The difference is the duration of symptoms and if other symptoms are present. BPD symptoms are meant to be consistent over different situations and many years, but moods last no more than a few days and usually for less than a day (with many moods in a day). Hypomania symptoms occur in a cluster and last for four days or more. Depression in bipolar II lasts 2 weeks or more and is also a cluster of symptoms.

The symptoms that differentiate borderline from bipolar are avoiding abandonment, splitting and dissociation. The ones that differentiate bipolar from borderline are agitation, decreased need for sleep, distractibility and pressured speech.

I have experienced all the symptoms that go with BPD and BP at some point in time, as well as anxiety, so the important thing is how the symptoms cluster together and how long they last for.

I can identify some definite clusters that have lasted more than a few days:

Cluster 1: elevated mood, decreased need for sleep, increased involvement in goal-directed activity, flight of ideas, inflated self esteem (maybe).

This period lasted about a week. I was staying up late writing, and writing almost continuously throughout the day. When I wasn't writing I was researching how to make money online. I felt great. I got it into my head that I could make money on the internet with my writing. I wrote fast, ideas spilling out. I thought that what I was writing was really important and I had to get it out there. It was definitely goal-directed - I wanted to write things that people would read and make money from it. I felt energised without much sleep. I wrote about 6000 words, but a lot of it had been deleted and rewritten. It was coherent and everything, but I wasn't thinking all that clearly. At the time I was sure that everything I was writing was correct and well-informed, and to most people it might have seemed that way, but I was writing about science and philosophy, and it wasn't all that well-informed or correct. This was a very distinct period which started and ended abruptly. It was a persistent state over the week, though. As for the inflated self esteem, I didn't think I was the messiah. But I did think I had some important things to say. The whole thing was just very unlike me. I don't write much, unless I really make the effort. I also usually need to sleep a lot and still feel tired (although that is related to depression). I also usually wouldn't have the confidence to write and publish my writing. I don't usually come up with ideas that easily, unless I've been in a similar state. Even then, it's usually hard to get my ideas out. I am usually not that motivated to achieve goals, and even when I'm not depressed my mood is not so elevated.

Cluster 2: elevated mood, increase in goal-directed activity, excessive involvement in pleasurable activities that have a high potential for painful consequences, inflated self esteem.

I'm not sure how long this period lasted for, but it seemed to be most of 2007. I was addicted to exercise, the goal being weight loss. Pleasurable activities included drinking, drugs and casual sex. I thought that everyone must love me and I just felt great. I had periods of euphoria without drugs.

I had a similar experience at the beginning of 2004. I had just moved to a new city by myself, away from home for the first time, starting uni, meeting all new people. It was an exciting time for me. I felt high a lot of the time. I wanted to be social all the time. I felt great about myself for the first time. I started drinking dangerous amounts and generally just being wild and impulsive, wanting to party all the time. My goals were to meet people and make friends, and that I did.

It may have been a few different periods in 2007 (all more than a few days) which were broken up by normal moods and other periods of dealing with negative consequences: heart break, failing uni etc. My worst depressive episode came on gradually, starting at the end of 2007. My depression got worse and worse, but I still had some periods of relief. I was depressed for most of 2008 and 2009.

In the second half of 2008 I first experienced agitation while depressed. I didn't know what it was at the time, but I couldn't just lie in bed and stare at the ceiling as I wanted. I had some sort of energy or drive, but it didn't feel good. Nothing could satisfy the drive because I couldn't focus on anything. I couldn't just read or watch tv. So I started drinking more, and taking phenergan to help me sleep.

I got some relief from depression in early 2009, while living with my mum and taking a break from everything. I might have had another cluster of hypomanic symptoms: goal-directed activity (learning spanish and keyboard and planning to go overseas to teach english), decreased need for sleep, slightly elevated mood... not enough to fulfill the criteria, though.

I haven't included distractibility because I'm not sure about it. I think I'm always pretty distractible. Of course, I have had times when I've been functioning normally and have been able to study without getting distracted, so I think it's related to both depression and agitation.

After I started working again in 2009 I became severely depressed again. Sometimes I had agitation too. My job ended and I was still depressed. The agitation got worse in early 2010. I called lifeline and considered going to hospital, but I figured they would send me away.

Even in the two years I spent mostly depressed, I had some periods of partying and excitement and doing some really stupid things. I met some random people on the street one night and brought them to a party when it was about 2am and the party was almost over. There were probably six of them, from two different groups of people I met. I got in a lot of trouble with the party host. All I wanted to do was have a good time, and I didn't want it to end. I would talk to anyone and everyone in these periods. Sometimes I just had boundless energy. When I was out with friends, walking to the next pub, I wanted to run, not walk! This was more apparent in 2007, I think, before I got so depressed.

That agitation has continued to be a problem. It's activation, pressure to do things, unwelcome energy. When I'm in a good mood and I get agitated it doesn't really feel like a bad thing. But if I feel at all any sort of negative mood or emotion, agitation is horrible.

agitation

Agitation and depression. The two most horrible things. When they occur together, it's most horrible. Agitation is like having a lot of energy, but in a bad way. It's the reason I'm writing and not reading or watching tv or doing something else relaxing. Maybe having energy is good when it's energy that can be put to good use (because you can still focus on things) and when it's energy that can be exhausted. It's also not just having the energy to do things, it's a constant pressure to do things. It comes from inside. I don't necessarily want to do anything but I have to. I have energy in my head but I can't so much with it because I can't focus. I can't sit down and focus on one thing for too long. It makes it hard to read a book or work on assignments.

In this state I think that I would rather be depressed, but of course I would think that now.

I thought the agitation was caused by medication, but obviously not.

In the past I've had a lot of energy, but it felt good. I felt driven to do things, but I also wanted to do things. I think "yeah, I was doing so well in 2007". It was the year before I became severely depressed. I was so HAPPY. I had so many friends, and oh how I loved my friends. I worked, I partied all the time, I exercised so much at the gym. I was just so freakin happy. I thought everyone loved me. I didn't bother with things like studying. I didn't get depressed after a night of heavy drinking. Having a hangover was just a relaxing day. Drinking was an ecstatic experience. So was dancing. When I went out dancing I could picture myself doing it forever. It seemed like the most important thing in the world. I felt attractive, alive, charismatic. All this is actually very unlike me. I change a lot, I guess. I miss that person, though. I miss being like that. I thought things would be that way again. I just miss feeling that way. I was on top of the world.

Was this some sort of pathology? Was I actually hypomanic, instead of being a normal, outgoing woman in her early 20s? Normal... no. Not normal for me. Maybe normal in that I've experienced these shifts in my social functioning before. Am I shy or am I that outgoing, confident, social, talkative person?

I remember feeling high sometimes, as if I had taken ecstasy. I didn't need drugs to get high. I just needed some music, some people and some booze. I've been chasing that high. I still go out dancing sometimes, and I wonder what happened to my high. It's not that I'm depressed, I just can't believe the huge shift in my experience. Of course, I'm older now. These things get less fun.

So maybe agitation is just energy without the high. Anyway, it sucks. But everything shifts, nothing stays the same. Maybe tomorrow I'll feel normal and subdued. Or maybe I'll have positive energy and try to write a book. I'm just so glad I'm off the abilify and I don't have to put up with that level of agitation and anxiety. I feel so much better now. No drugs. I'm supposed to take risperidone tonight.

Why am I being prescribed these drugs? I really don't understand. Maybe the doctor has some theories he's not telling me about, or maybe he just likes these drugs a lot. I certainly don't think that people are usually prescribed antipsychotics because they have anxiety. At least he didn't put me on another antidepressant. Well, which is worse? I don't know. I don't want to take anything, I don't want side effects on top of symptoms. It's too hard to know what the drug is doing to me. I feel so much clearer without any drugs.

Hmmm... risperidone. Should I try it? Just so I can say I did? It will just knock me out and make me feel weird. How can I possibly believe that it could be any different?

apprehension

I'm about to go to the psychiatrist. I hope I get something good out of it, like a referral, and some better medication options (even no medication would be good). I know I have to be realistic about medications, but I struggle with being on them when I don't even know what's wrong with me. Abilify gives me energy and that's about the only good thing. I could get more energy by sticking to a schedule, which I think I should do anyway. I'm already in the habit of waking up early, now. Abilify may have corrected my sleep problems, but then it created more. I woke up at 1am yesterday. I was agitated so I stayed up. It makes me feel so awake, so aware. Aware of every emotion, aware of sounds that might be someone breaking into my house (this has happened to me before, without the help of drugs, but I hadn't experienced it in a while).

Having energy is so good, being agitated is so crap. I think that you can't have one without the other when medication is involved. You can have energy and still be calm, which is ideal. I just want to feel like myself, which I do more so today after not taking abilify.

What if it's also really improving my mood? I almost forgot about how depressed I was before. Well, right before I started abilify I wasn't exactly depressed. I was already a bit agitated. My thoughts were racing and I had more energy. That was one of the things abilify was supposed to help with, but it's made it worse. Sure, I'm not depressed, but I go through so many intense and overwhelming emotions in a day. I've started to use the DBT technique of recognising my emotions without being judgemental. As soon as I feel sad or empty I usually automatically think that I'm slipping into depression. I've realised that's not always the case. It's just an emotion, and I have them a lot. They may be very intense, but that doesn't mean they will last forever. It's a big deal for me to realise this.

Anyway, I think that abilify will be exceptional when it comes to preventing depressive episodes. I would like to go on a lower dose, though. Hopefully then my anxiety and agitation won't be any worse than usual. I feel quite good this morning, and I didn't have abilify yesterday, so maybe the lower levels still do something good.

I'm trying not to think about this medication and black-and-white terms. Abilify is grey, just like everything else. It has good and bad effects on me. I'm supposed to weigh these up, with the help of the doctor.

If the abilify helps me to improve, then that is the most important thing. I'll improve with more energy and less depression, but I'll also be hindered by increased agitation and anxiety, plus the lack of sleep does not help. I don't want to be given seroquel to help me sleep. I have no trouble falling asleep, anyway. I don't want someting that will help me stay asleep, because then I will be sleepy all day, and that will cancel out the good things about abilify as well as the bad things. Or, I could always try. I guess I can't judge a medication until I try it.

I still want to try lamotrigine. It might actually help reduce the agitation. I think it's been months now that I've been feeling agitated. It's not just a transient thing. I haven't sat down and read or watched tv for a long time (or if I try, I feel too restless or get distracted). It's horrible not being able to switch off. It's great that I'm motivated to go to the gym, but I can't be at the gym all the time. I can't be doing things all the time, I need to be able to relax.

I hope this blog will give me some insight and help me along the way. I come up with things that I wouldn't if I were just ruminating. Rumination just leads to repetitive thoughts, anyway. Once I've written something down I'm less likely to write it again, so at least I come up with stuff that's different. I've been doing a stream of consciousness sort of thing, just writing what comes into my head. Hence the writing seems disjointed and abrupt. That's okay, though, I'm not writing a book.

Okay, it's time to go get on the bus.

How can I be so sure....

...that I want to be a psychologist? There are many other things I could do, and when I think of that it scares me.

I don't really know who I am or what I'm into. Maybe I would like to do photography, learn a language, be a philosopher, be a perpetual student, get a job (any job), conduct research, help people, write, become an accountant or a cook. Or maybe I could own a cattery.

I guess it boils down to black-and-white thinking. I'm neither black nor white in any dimension. I could do many things, but eventually I will be doing something as a job.

There are a few reasons I really want to be a psychologist:
1. There seems to be a lot of work out there for psychologists.
2. I want to help people.
3. Other jobs would be boring and unfulfilling e.g. being an accountant, working for a bank.
4. I want a job that suits my personality.
5. Career tests say that I should have a job helping people.
6. Psychology is what I'm most interested in.
7. I particularly want to help people who have the same problems that I've been through.
8. I think I might be good at it.
9. It's well paying.
10. I'm probably not suited to a lot of other jobs that might interest me.
11. I want the option to work for myself or to work part time.
12. I really enjoy talking to people and helping them with their problems.

Now that I'm at the point in my life when I can finally see something ahead of me, I think commitment is the key. I would love to continue studying different things and fantasising about all the things I could do, but at some point I need a stable job. Being a psychologist would be an awesome job, and I know that there will always be work.

To make sure I really can handle helping people who have a lot of problems, I think volunteering is a good idea. Also, I want to try working as a carer for disabled people. If I hate it, then at least I'll find that out.

Another D Word

I forgot one: disarray. Although, I don't know if it describes depression or my life in general. Yes, I think I must have BPD. It will be hard to find out if do. I can't wait for my assessment. I want to know what's wrong with me, and I want to know now. Every doctor has a different theory about what my problem is. "Depression is a vicious cycle, you just have to break the cycle", "people who have had these problems for a long time often don't respond to antidepressants, but a tiny dose of effexor might make you feel better", "effexor is one of the best medications for depression", "people who have similar problems to you often don't respond to antidepressants or mood stabilisers; you are more unstable than someone with bipolar; diagnosis isn't important; here, have some abilify."

I'm quite sick of these wishy-washy theories. There are good reasons for diagnoses, and doctors know this. They could just admit that they don't know exactly what my problem is. Why are they all so sure of themselves, yet they all think different things?

So, the last doctor I saw suggested (indirectly) borderline personality disorder. Subsequently I've done my research. I knew what he meant when he became interested in my childhood and self harm, asked me if people take advantage of me, and suggested that my moods are more unstable than someone with bipolar. I confronted the idea and he said that it's a possibility, but of course diagnosis isn't important. After all this research I've decided that, either way, DBT seems like a really good option for me. If I don't have BPD, I definitely have borderline tendencies:

1. Frantically avoiding abandonment. Definitely. I could even be considered a stalker. I sometimes can't handle being alone, I can be needy and clingy, and desperately try to get people to stay with me.

2. My problem is idealisation. Devaluation happens, but it's not as intense. I don't suddenly hate someone, I might just become indifferent of feel extremely hurt. I've had some pretty bad relationships with friends and boyfriends and flings. By bad I mean up and down, crazy relationships. Maybe a couple of them were borderline themselves. I do tend to think of things as all good or all bad (including people), but generally my relationships are pretty stable. I just feel hurt very easily.

I guess there have been 3 crazy relationships. The first was my high school boyfriend. I kept going from liking him to hating him, I started fights for no reason to test him, I was jealous for no reason. I wanted out so I started a fight and he dumped me, but then I was devastated and begged him to take me back. He was not my type at all. I didn't want him when I was with him, and then when he dumped me I wanted him back for months. Sigh.

The next one was my best friend in year 11 and 12. Maybe she was the crazy one, I don't know. It was intense, more like a romantic relationship than a friendship. I won't even bother going into it now, but it was a roller coaster friendship, which I ended abruptly when she pissed me off one time too many.

The last one was a short, intense fling. In the few days we were together I went through extremes of obsession and indifference. He apparently went through the same thing and dumped me. Similar situation to my high school boyfriend. I stalked him over the internet and begged him not to leave me. Wow, talk about a lesson in how pathetic I am.

- Unstable self-image and sense of self. Most definitely. I have tried to base my personality on other people's for most of my life. I have basically tried to be someone else - using different friends as the mould, whoever I was idealising at the time. I act differently around different people. I don't know who I am at all, and sometimes I don't even recognise my face in the mirror. My life plans are chaotic and always changing.

- Implsivity in all areas except reckless driving, because I have never driven a car. Drinking, drugs, casual sex, food (bingeing/purging), spending. I always act on impulse. In fact, planning doesn't come into my life much at all. I don't like committing to things and I find it hard to carry out plans. I basically rely on impulse. It makes it difficult to get anything done in life.

- Self harm, suicidal thoughts.

- Mood instability. Intense emotions lasting a few hours. I get intense sadness, anxiety, and sometimes joy and excitement. Other emotions are jealousy and guilt. The moods are not supposed to last more than a few days, but I guess the depression could be a separate thing.

- Feeling chronically empty. I always feel like something is missing, but I don't know what. I often see life as being essentially meaningless. Intractalbe boredom can be a big problem. I see other people as being empty too, sometimes, because their lives don't have any meaning either. I sometimes feel such a void inside of me that I try to fill it by doing the impulsive things outlined above.

- Angry outbursts. Most of my anger is internal. I can be very irritable, though. I'm never aggressive, and I avoid conflict at all costs. I bottle up anger, or I take it out on myself, or I rage in private. I also get frustrated extremely easily, which can cause a mini rage.

- Stress-related paranoid ideation, delusions or dissociation. I do get paranoid quite a bit. No one has ever told me that I'm delusional, but I do think some pretty warped things sometimes. I have experienced dissociation before, usually when I'm listening to a fight. It's hard to tell because dissociation can involve memory loss, and I do have some strange memory gaps. I've also experienced derealisation and depersonalisation. When I was younger, sometimes I would wake up in the morning and have to remind myself of who I was and what my current situation was. It wasn't that I'd forgotten, I just felt very strange.

DBT

I really like the idea of radical acceptance, and it's a technique I found myself using before I'd heard of it. For example, it's 1am and I'm awake after a few hours of sleep. After years of having problems with insomnia, I gradually stopped fighting it. If I can't sleep, I can't sleep. It usually doesn't kill me. Getting angry and frustrated over not being able to sleep definitely doesn't help. Focussing on something else for a while and seeing that if I don't sleep now, I will most likely sleep later, does help.

I guess not having a job makes it easier, as does being on abilify and having extra energy. When I knew I had to get up early for work, I used to get really anxious if I couldn't sleep. That's got to be the least helpful possible reaction.

Tonight I kept waking up, thinking of someone breaking into my house. I feel in a constant state of hypervigilance. I've been through this before. I wonder "why now?", though. Why, when I've found a medcation that seems to reduce my depression symptoms am I more anxious? I think that any medication that gives you so much energy is probably not going to do much for your anxiety. But, it's not a good reason to stop the medication. I would still have a problem with anxiety if I weren't taking it.

One of the reasons I'm so interested in DBT is because it was created for people who don't respond to other therapies like CBT. I think I'm a good client, one that is not difficult to deal with. I listen, I learn, I do my homework. I would never say anything mean to a therapist. I don't know them well enough, and I tend to idealise them anyway. Not to the extent that I would become attached, but I do tend to expect certain things of the therapist. If these expectations are broken I usually blame myself. Otherwise, I might decide that I'm just not comfortable with the therapist. I would never ever ever disrupt the therapeutic relationship. I might be too nice, trying to avoid not-so-nice topics like self harm and suicidal thoughts.

The only time I can be mean is in a relationship where I am sure that I'm completely accepted by the person. I don't ever have the urge to do or say anything mean to anyone, unless I'm taking some emotion out on my boyfriend. That's usually how it is. I wouldn't be able to do that to anyone else. It's not just that I'm completely accepted by him, I also know that he can take it. I don't think I've been so mean since I was much younger and I had my little outbursts. Most of my adult life, if someone made me angry I suppressed the hell out of that anger. When I was in high school I was more a fan of the cold shoulder method. I used that a lot as well in my first long-term relationship. I didn't know what else to do. At least now I talk about my feelings. I just express them in the wrong way sometimes.

Exercise and alcohol saved me from anger and a multitude of other negative emotions in 2006/2007. I thought I was doing well in those years, but maybe I was just doing well enough for my coping strategies to work. I drank socially, I did everything socially. Except for exercise, that was something that was for me. It's such an important part of mental health, I think. Exercise sure does make you feel good, unless you're depressed. That's how it seems to be for me anyway. If exercise works as a treatment for depression then it must take a while for the effects to kick in. I sometimes felt worse after attempting to exercise. Going for a walk made me see how desolate the world was. Depression is full of D words: desolate, dull, deformed, destitute, dreary, dismal, deserted, devoid, dismay, drab, devastating, deprived, depraved... I could probably come up with more.

DBT prioritises self harm as a behaviour to reduce, but the one I most want to reduce is binge eating. I don't do it to extremes, but it would help me so much if I had some control over my eating. Not full control, but not a loss of control either. I want to be able to eat just as much as I actually want to eat. I want to be able to stop eating when I don't feel hungry anymore. I want to eat sweets and savour them, not satisfy some intense urge that makes me feel out of control. I want to eat without that feeling of guilt. I want to see food for what it really is: a source of energy for my body. I want to be able to stop eating earlier without it feeling uncomfortable. Maybe that last one is asking a bit too much, but I'm hoping that with practice, eating normally will be normal to me.

I guess I could start by trying to stick to a meal plan and then writing down how I feel, and coming up with some self soothing activities. Right now I actually feel hungry but I still don't know if I "should" eat. Maybe I should make it a goal to eat when I'm hungry, and to not eat when I'm not hungry. Maybe the feelings of guilt will go away.

I spend a great deal of time and energy thinking about whether or not I should eat, whether or not I should stop eating, whether or not what I'm eating is "healthy", how many calories I might be eating etc. The difficult thing is that I want to change my eating habits while at the same time thinking about food less. How can I remember to work towards my goal without thinking about food? The more I try to change my eating behaviours, the more obsessed I become with food, and the more I just want to eat but try to stop myself.

I usually have those two things working against each other: I want to eat and I also want to stop myself.

The observant mind...

Here I'm going to practise being oberservant, not evaluative...

I'm lying on my stomach, diagonally across my bed. It's a double bed, and the covers have slipped off the corner. I have three pillows around me, one with a sea theme, a green one and one that I can't see. The walls are white, and in the corner where they meet there is a quarter cylinder. One wall is painted brick. The other is smooth, but has some dents and smudges. The fan heater is behind me, switched off. The blanket is squashed up at the bottom of the bed. I'm wearing socks, pyjama pants and a jumper. The jumper is black and has a hood. The pyjama pants are blue with pictures of red hummers.

ok, I think that's enough for now. I have to say there's something relaxing about observing without judgement. I tried some "autogenic" relaxation earlier as well. I haven't used relaxation techniques in a while. They used to help; I especially liked taking a hot bath and gazing at a candle. It's hard to remember to try these things when under emotional distress. I might make a list of things I can try:

guided relaxation
hot or cold shower
gazing at a candle
write - describe my surroundings
practise doing something mindfully e.g. brushing teeth
pay attention to my breathing
write - describe a more complex situation without evaluating it

I might try the last one now...

Today I had breakfast at APK. We sat down, read the menus, ordered and an hour later we got our food. The breakfast pizza had tomato sauce, cubes of bacon and cheese. In the centre were mushrooms and on top were two fried eggs. The yolk was bright yellow. I ate about 2/3 of the meal. My coffee was in a mug, and had chocolate powder on top. There was a small, light brown hair on top of the pizza. There were about 5 full tables when we got there, and about 10 when we left. There was one waitress. She had pimples on her cheeks, covered with makeup. She walked past us about once every 30 seconds. There was a salt shaker on our table, with a few grains of rice in it. There was no sugar or pepper. There was a breakfast menu on our table with a drinks menu on the back. I took a menu from another table which had more drinks on it. Milkshakes were $5.50 and thickshakes were $6.50. I ordered a thickshake. I got a tall metal milkshake cup with a frothy brown liquid in it. It was a mixture of milk, ice cream and chocolate syrup. I asked the waitress to put more ice cream in it for me. I got another tall metal milkshake cup with frothy brown liquid in it. It was a combination of milk, ice cream and chocolate syrup. The total cost of two breakfasts, two thickshakes and a coffee was $48.

ok, enough of that. I think I managed to write observantly, which made it hard to express my disgust at the service. It's good in that it doesn't evoke any emotional response, which makes me feel quite calm. I was horrendously depressed after breakfast because I'd had to part with almost $50 for a pretty crap experience. I even decided to never go to a cafe again.

So, it's been quite a progression of emotions today. Started out happy, relaxed. Shifted to very depressed after breakfast. Then very anxious after seeing a friend. Then depressed and anxious. Then back to just plain depressed. Now, I'm more relaxed and content. This may be why I've always had trouble trying to use a mood tracker. How can I possibly rate my mood on a number scale when there are so many more dimensions to my mood?

coping strategies

My favourite coping techniques are eating, drinking booze, cutting and occasionally taking lots of OTC drugs. I should probably be more careful with multiple drug combinations. Take 5 that can't kill you at any dose and you're actually at high risk. When I had to get my implanon taken out and had extreme anxiety I took about 1000mg of valproate (which I hadn't taken at all in a while), 6 nurofen plus (probably about 75mg codeine), my usual 5mg of abilify and about 6 kwells. This was over the day, so at least I didn't take it all at once, but it was dangerous nonetheless. I didn't think of that at the time, all I cared about was getting through the implanon removal procedure.

I have had such terrible anxiety, which I was quick to blame on the abilify, but looking back at previous posts on this blog I can see that anxiety was already a problem. Agitation is usually dealt with using booze and food. Intense sadness is best dealt with by cutting. Anxiety is what brings on the drug use.

My friend just came around to say hi for my birthday and even just talking to her made me feel so anxious. There was a time when I was confident and outgoing. I was even pretty stable. I don't know what happened there, it's quite unlike me to be confident and stable.

I get all the physical symptoms of anxiety, which is the only way to know it's there. It's easy to not realise that what I'm experiencing is anxiety. I usually just focus on the problem I'm dealing with, not realising that the problem is actually anxiety.

Some things that make me anxious: making and receiving phone calls, reading text messages, checking email or facebook, opening mail, pretty much any sort of social interaction, checking my bank balance, attempting to do anything... and then there's the free-floating sort of anxiety that isn't connected to anything in particular.

I know that problem solving skills might help with the general anxiety but what is there to do about social anxiety? I don't always avoid these things so I'm getting plenty of exposure. I think some hardcore psychotherapy is what is needed. I'm just waiting patiently for a referral to a good psychologist.

anxiety

Today my mood is not so bad... but I feel very anxious and I'm not sure why. This happens sometimes, I feel anxious, act anxiously, but I don't exactly know what it is I am worried about.

Possible worries? Money. Family - I feel guilty for not talking to them enough, and also worried about certain interactions with them. Friends - who are really my friends? What do they really think of me? Fear of isolation. Work - will I be able to find another job? Can I manage on little money? Will my job cause more anxiety? Study - will I do well this time? will anything good come of it? centrelink, bills, house inspections, the cleaning that needs to be done, the things I need to find money to buy for my place, will I be able to keep taking care of my cats, will I lost the things that matter to me, do people approve of me? will I be able to keep it all together? what will I do if things fall apart?

the spectrum of polar bears

:) :) :) this is not how happy I feel, but maybe looking at the smiley icons can calm me down a little. Like the theory that smiling can actually make you feel happier.

I should probably start tracking my moods. Maybe I can use white polar bears and black polar bears. Today I'd give myself one black polar bear. Maybe two. I don't want to kill myself today. I'm thinking about the future, even if apprehensively so. It's more the anxiety getting me down today, so maybe I should use separate scales for depression, elation and anxiety. I could throw in another one for suicidality. Agitation vs retardation. Sleep time and quality. Alcohol, caffeine cigarettes. I could record my entire life. I'm an all-or-nothing person, and the all seems too extreme, too much to go through every single day. I need to find an easy way to record the important things. I don't do well with number scales. How do you choose a number? Choosing is even harder when depressed! I can spend hours trying to decide whether or not I'm going to buy a newspaper that costs a dollar, so how can I choose between 3, 5, or even 10 numbers? A graphic or verbal representation might work better. A verbal scale could be something like: crappy, double crappy, death wish. The polar bears thing could be the graphic representation of my mood. Either way, I'm using a 3-point scale which can be conveniently converted to a number.

So, today I feel crappy. But this morning I felt fine. Ish. Fine-ish. Verbal scale for elation: fine-ish, fine, happy. I don't know if I ever get past "happy", but I do get overexcited, sometimes restless. Let's call fine-ish the midline of my mood range, neither depressed nor elated. The elation scale can then be fine, happy, awesome.

So, when I woke up at 11am I was fine-ish, now, at 3pm I feel crappy.

Anxious, double anxious, or freaking out? I'd say anxious. Just a feeling floating around my mind that I have things to worry about.

Agitation? yes (in the form of jiggling feet and legs, nail biting). Tired? yes. Mentally or physically slowed? no.

Sleep? 10 hours or so. I didn't have too much trouble falling or staying asleep.

There! I did it. I recorded the important information about my mood state today.

on a more serious note...

As the name suggests, this blog is about the experiences of a mental health consumer. I find the term interesting. We are no longer called patients. I suppose this is supposed to reduce stigma, and it does make sense. After all, I would love to consume all the mental health that I possibly can. After struggling with my mind for so long, I've come to accept that there is no quick fix or magic cure for the problems I have. I've been told this many times, but I never really accepted it. I always thought that with the "right" treatment, I would get better. I thought that I shouldn't have to deal with these problems. It's not surprising that I thought these things. We're told that antidepressants "work". We're told that people with depression get better with treatment. Maybe that is true for some people. However, antidepressants don't work in the way we're told they do. It is still unclear how they "work", and whether they have any antidepressant effect other than the placebo effect. For me, they have made no noticeable difference to my life.

So, I continue to cycle in and out of depression. I fell back in hard a few days ago. It's amazing how it takes over my mind. One day I have friends, goals, hobbies, whatever else a normal person has to live for. The next day I'm alone with nowhere to go and nothing to do. Plus, no future in which I might have such things. It's very real. There is no point to anything. I desperately need a friend but I can't connect with anyone. I desperately want help but I can't find a way to communicate what I need, whatever that is. I wonder how I ever enjoyed simple things like reading or watching a movie. I can't get involved or engaged in things. What am I doing with my life? Oh, that's right, I want to study psychology. But why? What is the point? There's no point, I won't get any enjoyment from that at all. Where will it lead? More study, eventually getting a job, so I can afford to live. Ah, but why live? Most people want a job that is fulfilling. So do I, but how do you get this fulfillment when you're depressed?

Ok, so all this seems very real when I'm depressed. But do I truly believe all these things? I do, in the sense that I can't imagine any alternative, and it seems to me that these things will be true if I continue to be depressed. Certainly, a depressed person can't imagine not being depressed. What a pickle. If I could imagine my future undepressed self, I could still have goals and look forward to future enjoyment. I might even believe that yes, I do have friends, they are just not here right now.

So what do you do when you're so depressed that you can't do anything? I decided it was time to accept the fact that depression isn't going to go away like the common cold does (who was it that first came up with the ridiculous idea that depression is the "common cold" of mental illness??). I have to treat depression like a disability. It sounds depressing doesn't it? Yes. But apparently depression is the leading cause of disability in Australia. Which I've decided means that I can use disabled toilets. Probably not disabled parking spots though, since walking is good for depression, and I don't have a car anyway.

What do I do now that I've realised I'm disabled? I suppose I have to figure out what my limitations are. It also might be good to follow a proper treatment plan for my illness. Here's a list of things I've heard are good for depressed people, plus some that I thought of myself (go me!) :

- uhh... exercise... (yeah they keep going on about this one, I'll have to find something that doesn't make me want to kill myself even more)
- alcohol (oops, I mean no alcohol. damn.)
- setting daily schedules (I never thought I would actually do this... but I really might have to)
- cleaning
- cooking healthy food
- writing/blogging
- listening to music
- keeping in touch with friends
- keeping a mood diary
- sticking to my medication schedule
- keeping appointments with doctors and therapists
- organising my finances
- volunteering
- having my own space, and time to myself
- showering (yes, showering)
- sticking to a sleep schedule
- getting out of bed/dressed/out of the house before a certain time
- making plans to do.... things... that are fun
- remind myself of things I enjoy doing when not depressed, and keep doing them
- get as much support as possible from other people
- setting and achieving small goals
- telling people what I need/asking for help
- self-soothing activities (music definitely works, but I suppose candles and bubble baths are good too. I'm not willing to touch my bath, so long hot showers will have to do)
- meditation/breathing exercises

So there. Good night.