Checking Off All the Little Boxes

As with any job there are trends that I have observed in the psych field that seem to occur every year. The transition from spring to fall is when we start to see those who are depressed come out of the wood work. Winter is when we see the more at risk population, low income, frequently homeless and those with a history of incarceration. Spring is when we start to see higher incidence of mania and/or psychosis. Summer is a bit of a hodge-podge, but I think there tends to be more family related stress and strife that plays into that. Kids are at home, there are higher expectations for temp workers to find employment and it’s hot. People get grumpy and pissy and irritated when they’re hot.

Let’s focus on that bipolar population, sorry, I really should say it as the population who has a history of bipolar disorder/suffers from bipolar (let’s call it BPD I/II from now on). Like I said above, most tend to go into a more manic phase at this time of year. Not everyone though. Some get the pleasant experience of a mixed episode meaning that they experience some depression symptoms and some manic symptoms. This group tends to be at the absolute highest risk of suicide: feeling suicidal, coming up with a plan and they have the fucking energy to be able to actually carry through with those plans. The sad part is that they have the highest rate of success. I’ll go look up the research again should anyone want to see that. My knowledge is coming from stuff I had discovered in 2007 when I was desperately trying to figure out the world of psych for my first job and then from observations throughout the years. Incidentally it’s also one of the major reason why people who start on anti-depressants are at higher risk for suicidal thoughts and carrying out plans; the antidepressants don’t affect their thinking and emotional state as quickly as they affect the physical symptoms of depression. They get the energy and even some motivation before they actually start to feel better. It sort of mimics what a mixed bipolar episode does for people.

Anyway, the point of this post is that I fall into the smaller group of people with BPD that are more likely to feel depression than mania at any change in seasons. That is partially because I have the type II version which nearly always tend toward depression rather than the hypo mania side. I think I’ve experienced hypo-mania only a handful of times in my life and those episodes are nearly always followed by a pretty strong crash into depression. I normally can observe the symptoms and act on them before they get to the absolute bottom. I start eating healthier, exercise more, attempt to read more, make a good go at trying to get better sleep, and all that good jazz. It’s actually the primary reason why I do any of these, not to lose weight, not to look better in my favorite jeans, though those are all really awesome bonuses.

This year hasn’t been so kind about it. Over the last 6 months I have continued to experience various symptoms of depression despite taking all the above actions and asking my doc for some med changes. What really has sucked is that the last three months I finally got hit hard by the complete lack of motivation to do what I need to in order to keep myself from tanking further. Exercise? Yeah, non-existent. Eating better? Forget it. Wanting to do much of anything? Ha! That’s funny. Feeling good about my job and what I’m doing there? Eh, still some of that, but it’s really damn hard to get myself to not be cynical and wanting to interact with patients much. By Saturdays I’m kind of useless. I try to get as much done in the morning since I developed that routine and if I don’t complete it, I’m fucked.

I wasn’t fully aware of just how bad things had gotten until my husband started to ask me about it. The fact that he was aware and able to ask about it is saying something because he really doesn’t have the awareness of such things that some/many people do. I had given him some reference material when we first started dating and even gave him a pretty clear (I thought) list of symptoms that I tend to experience, subjective and objective. A few months ago when I asked him about it again he told me point blank that he really couldn’t notice the subtle changes over time much at all. He’s never been very good at reading many of those things and whatnot so it’s honestly not much of a surprise. He’s a tech dude, he gets tech things really well and is great at problem solving but when it comes to things that he can’t do much about he is pretty apathetic about them. When it does get to the point that he is completely aware it really is hard for him to deal with. He wants to fix it. He wants to make it go away. But it’s not that easy, probably partially because I really am not good at listening to anything or anyone once I get to this point.

I think it’s probably a bad thing when all the things that I’m upset about in relation to myself are basically check boxes for the DSM-IV diagnosis for depression. Let’s look at this list from NIMH:
Major Depressive Disorder requires two or more major depressive episodes.

Diagnostic criteria:

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day

1. Depressed mood most of the day. Worse the last three or so weeks, but been experiencing some since November.

2.Diminished interest or pleasure in all or most activities. Reading? Meh. Exercising? None. Wanting to go out? Eh. I’ve really only gotten excited by a few select things, many of which I’m really not as excited about as I would have been a year ago. Even then it’s a very short-term thing. *sigh*

3.Significant unintentional weight loss or gain. Actually this one I’m not experiencing as much. Some weight gain, but that’s what happens when you go from a 1350 calorie a day diet and exercise to around 2500 and not exercising.

4.Insomnia or sleeping too much. Ugh, yes. If I don’t take something to help me sleep I toss and turn the whole damn night. I don’t actually seem to fall asleep and stay asleep until sometime after 6 or 7 am. Given that I only got to sleep past 8-9am two days a week until this last week that was pretty significant. Now I get four days a week, but holy crap is it hard to get up. Work or school were pretty much the only things that could pull me from bed from 11am. Now that I am not in school, well let’s just say I haven’t gotten much of anything accomplished this last week.

5.Agitation or psychomotor retardation noticed by others. Anytime I am not at home. Especially if I am with or around people. It’s not as pronounced at work, but it’s been commented on several times the last few weeks. Yay for nearly autistic like repetitive movements to decrease anxiety…

6.Fatigue or loss of energy. Why don’t they have this as number 5 rather than 6? It goes so much better with the insomnia question. Anyway, yeah. This is probably my biggest complaint. I am freaking tired all the time. Doesn’t matter how much or how little sleep I’ve gotten, whether I have plans or things to do or absolutely nothing at all to do, I am exhausted. It sucks.

7.Feelings of worthlessness or excessive guilt. Not too bad, not yet. I’m starting to feel some of this, especially since I haven’t been much interested in doing things I need to like helping around the house. Blargh.

8.Diminished ability to think or concentrate, or indecisiveness. Worse so than usual, yes. Indecisiveness is something I always experience, but not to this extent. Lack of ability to think or concentrate? Oh yeah. I am slow to respond or pick up on what others are saying and am definitely more flighty than usual. The only thing I really seem to be able to concentrate on is a book when I’m reading, but even that is iffy.

9.Recurrent thoughts of death (APA, 2000, p. 356). I don’t think so, though it’s hard to tell since there is a lot of conversation at work about our suicidal patients. What I really want is just to be able to sleep until I actually have gotten enough *good* sleep to be functional again. I don’t know if that counts or not, but I’m leaning towards no. Maybe some of the therapists/counselors I know would disagree, but really I don’t care all that much whether they disagree with me or not. I don’t feel like I’m suicidal. I haven’t actually thought about what it would be like for me to die or even thought about plans. I have discussed what people do that just seem silly or don’t actually work, but that’s about it.

Just for shits and giggles, let’s take a look at the manic side of things too.
Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).

Manic episodes are characterized by:

A.A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) Ugh, irritated mood is one of the major things that my husband noticed. I’m irritable, easily agitated and more and more frequently difficult to get along with. I know that some people actually have irritable or angry depression so I don’t know if this is depression related or not.

B.During the period of mood disturbance, three (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

(1)increased self-esteem or grandiosity Not so much, no.

(2)decreased need for sleep (e.g., feels rested after only 3 hours of sleep) Definitely not.

(3)more talkative than usual or pressure to keep talking Maybe pressure to keep talking, but I don’t believe so.

(4)flight of ideas or subjective experience that thoughts are racing Is the inability to really control where my thoughts go or what they do part of flight of ideas or racing thoughts? I don’t know that they are racing except when I’m feeling massively anxious, but maybe? Probably not.

(5)distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) Ugh, yes. Too much of anything overwhelms me and makes it difficult to focus or concentrate on anything, but again, this is also a symptom for depression or at least one of the things that tends to come up with depression.

(6)increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Psychomotor agitation, yes, but that’s also a symptom for depression and anxiety as well.

(7)excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)” (APA, 2000, p. 362). Luckily for me, no. The closest would be buying sprees, but I usually force myself to think about things for a while before purchasing. It also helps that I don’t have that much in the way of expendable cash.

So there may be some hypo-mania mixed in there too, but if so it’s nothing compared to this fucking depression. It’s interesting how easy it is to check those things off right now. Well, it’ll probably be more interesting when I come back and look at this in a few months, but I can look forward to that.

This post has gotten waaaay too long so I’ll just leave it off here. If you got all the way down here, wow, kudos to you. You are now free to return to your regularly scheduled day and activities, whatever those are.

New experiences at work

Hello there. I have left this blog inactive for too long. This is probably not the greatest topic to start up again with, but I have to vent somewhere.

I started working at a locked psychiatric acute treatment unit a few months ago. I’ve been working in psych for years. Five years I think. I’ve been in some pretty funky situations with people threatening all sorts of things, people out of control, and people acting out against others. However, I’ve never really been in a situation with someone who is not just actively planning suicide, but acting out on it.

Well, tonight that changed. I was just getting ready to leave work. Grabbing my purse and going out to grab my jacket and all that good jazz when one of the room call lights goes off. Since there were only two other staff in the facility and one wasn’t in the office I went out to see if they needed some help. Turns out the counselor found one of our patients in her room trying to hang herself with a part of her blanket that she tore apart and was trying to loop around the door handle. She had tried to block the door from opening with her body (why the doors open into the rooms and not both ways is still beyond me) but luckily it’s hard to block a door with your body if you’re not propped against something.

I think the thing that stands out to me the most is that she had written a suicide note and had it right there on the desk. This wasn’t a call for help, this was an outright attempt. A pretty good one too. I’ve had patients threaten to hurt themselves and declare they were actively looking for ways to do it, but they never actually managed to do so. This gal, she planned it well. She waited until right after a check (every 15 minutes due to risk) and tore the blanket, tied it, and arranged everything. Lucky for us, the counselor went to talk to her earlier than the patient had expected.

The good thing is that we worked well as a team. The RN took lead and the counselor and I were able to act on directions calmly and without tripping over each other. The other patients remained safe and most didn’t seem to even realize something funky was going on. I don’t know if that speaks to our handling of the situation or to how low functioning this particular group is.

I hung around until our program manager could come in since I have to be back in at 6 am and didn’t really get much of a debrief. I guess this is probably it for now. I don’t feel that I need it as much as the counselor does (did?) as she was the one who found this patient and interrupted her. I can only imagine the emotions associated with that, the number of questions, “what if…” that would come to mind. I’m sure she’ll get the debriefing she needs – our program manager made sure to ask how she was doing during their first phone conversation.

Regardless, I’m bringing some chocolate in for both of them and my manager. They deserve it for how well everything was handled and for remaining calm and collected while still at work. I already have my chocolate so it’s only fair that I make sure they get theirs too.