A Moment of Optimism

Tags

academia, anxiety, career, disappointment, hope, job, meds, optimism, recovery, symptoms, treatment, work, worry

Sometimes the sun comes out and I think rationally for a few minutes.

When I’m optimistic that my optimism could persist for more than a week or two, it’s a pretty good day.

But I have to be careful about getting my hopes up. Suppressing hope entirely is maladaptive, but when you overreact to disappointment as badly as I do, the reason for smothering optimism is obvious: it’s self-protective. These days I try to find some balance and develop a touch more tolerance to having my hopes crushed – allowing myself to be hopeful and anticipatory about some things where I feel I can handle it, but choosing not to expect the desired outcome in other situations where it would still hurt too much.

I’m feeling hopeful about my treatment coming to a point where I have symptoms more or less in hand most of the time. With the various elements I’ve been trying out lately, I think it could look something like this:

• ADHD meds and Yaz, with Ativan as needed.
• A few supplements and vitamins – Fish oil, Calcium, Vitamin D, and B complex.
• Regular talk therapy, focused on acceptance and keeping life in balance.
• Meditation, yoga, and a brisk walk outside every day.
• Light therapy.
• Regular blogging and entries in my gratitude journal.
• Regular extended time off.

Sounds peachy! Easier and cheaper than the current regimen, with fewer side effects! But how do I get there? The answer isn’t obvious because a big piece of the puzzle is my work. Most of that self-care takes time, and the goal of keeping stress manageable means that I just can’t work as many hours as I could if I ignored my body screaming out for yoga and meditation practice (which doesn’t work very well, by the way.)

So I have to come up with a job that lets me live sustainably. I currently have 15 months left on my contract, and I expect to start looking for work in a few months. I plan to look more broadly than just academia, because I think that achieving that sort of “dream” treatment plan would depend on my job conditions.

My job would have to be like this:

• 40-50 hour work weeks, tops
• Leave work at work
• No weekends or evenings
• Analytical/problem-solving work
• Writing and editing work
• Teaching and mentoring work
• Limited number of concurrent projects
• Largely independent but routine work
• First class benefits
• Flexible hours, flexible time off
• Work from home part time
• Good pay
• Some travel
• Located somewhere Mr. Chickadee and I find acceptable

Well, when you put it that way, I might as well just sit here waiting for flying monkeys to bring me bags of cash…

The part where I’m only willing to work so much and I want to be treated really well, that’s where the tradeoff usually happens. And I just don’t know where to look for professional work outside of academia that would take advantage of my skills without raping my conscience and lobotomizing my overeducated brain. It’s a big, scary world out there, kids.

Deadlined

Tags

acceptance, ambition, anxiety, deadlines, hypomania, symptoms, travel, work

Blogging has been sidelined by deadlines lately. I’ve been working on wrapping up a year-long project (that shouldn’t have taken that long by any means) and writing up the initial results of a survey from last month. Once I get out from under those swords hanging over my head, I have to write two talks to give next week, and another one for the following week. Plus a 5-minute lightning update report for the day after that. And I’ll have to run a 3-day working session.

It’s a lot of pressure, heading into two solid weeks of travel. Writing talks too close to the presentation date is a regretfully common practice, and one that I occasionally fall victim to. At least I’ve outlined the first two talks…

Toward the end of last month, I started seeing some manic symptoms. As soon as I noticed the first few of them, I started paying a lot more attention to what was going on. It’s the same pattern I’ve seen before – can’t sleep for a few nights, which triggers inexplicable high energy, throws ambition into overdrive, and propagates the fervent belief that I can do ALL THE THINGS. RIGHT NOW. And for awhile, I can and do.

As I started noticing a few of those typical behaviors, this time I tried to harness that energy and drive to get the important stuff done. The work that was dragging behind for ages is nearly caught up, and all that writing that I just couldn’t even face comes so easily that I berate myself for procrastinating on it for so long. The reality is, however, that I probably couldn’t have made the words flow that readily at other times. I’m trying to accept that I will probably always have this “bursty” mood-dependent productivity cycle, but as long as I can keep things within a reasonable range, that’s OK.

So I’ve been plowing through the work day productively for most of the last couple of weeks. And then paying for it with that weird wakeful exhaustion where you know your body is tired but your brain is wired, wired, wired. Mr. Chickadee falls asleep on the couch, while I watch another episode. When my general mood and energy levels are a little high (but not Lucy In The Sky With Diamonds high) it just takes so much longer to get my mind to shut down enough for sleep that bedtime keeps getting pushed later and later despite an unchanging 6 AM alarm. It’s a catch-22.

Heading into 2 weeks of travel followed by another trip, I probably won’t be blogging a whole lot for the rest of this month. I’ll try to keep up a bit, and will probably stay hypomanic with the time zone shifts and overstimulation, but that’s pretty much the way it goes for me when I’m on the road. At least I’m avoiding the bar these days and heading outside instead. The mountains and deserts will be calling my name, and who am I to ignore their majesty?

Equal Opportunity Inattentiveness

Tags

ADD, ADHD, diagnosis, gender, space cadet, symptoms, women

Reblogged from Black Box Warnings:

• 

By now, I think most people realize that girls can have ADHD too. It's not a gender-linked condition; diagnosis rates should actually be closer to 50-50, though some say 3:1 (but that makes no sense to me and I haven't seen those authors cite research articles - which I'm also not bothering to do because I'd inevitably get distracted and never finish writing this.

Read more… 719 more words

Finally, my moment in the sun on Black Box Warnings!

Hypomanic Versus Manic

Tags

bipolar, diagnosis, dx, hypomania, mania, symptoms

Am I experiencing mania or hypomania? It’s a pretty common question among people with bipolar disorder. Part of the reason we care is that it’s the number one differentiating factor between diagnoses of bipolar I vs bipolar II. Another reason is that while hypomania has potential to wreak havoc, mania is downright dangerous to self and others.

The uncertainty in the distinction between the two is such that I’ll routinely use “hypo/mania” to describe an elevated mood state because I’m just not sure. As far as I know or anyone has told me, I’ve never been fully manic. I can think of situations that might be eligible for the label if I spilled the beans about specifics, though I’m not sure what that would accomplish.

But it can be hard to know where the line is drawn in terms of subjective experience. The DSM-IV-TR defines the two states with these criteria (differences in definitions are in bold):

Diagnostic Criteria for a Hypomanic Episode

• A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
• During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
  1) inflated self-esteem or grandiosity
  2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3) more talkative than usual or pressure to keep talking
  4) flight of ideas or subjective experience that thoughts are racing
  5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
  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)

• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
• The disturbance in mood and the change in functioning are observable by others.

Diagnostic criteria for a Manic Episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
•  During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
  1) inflated self-esteem or grandiosity
  2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3) more talkative than usual or pressure to keep talking
  4) flight of ideas or subjective experience that thoughts are racing
  5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  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)

• The symptoms do not meet criteria for a Mixed Episode.
• The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The updated DSM-V is proposing to change those definitions to these (differences from DSM-IV in bold):

Diagnostic Criteria for a Hypomanic Episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day (or any duration if hospitalization is necessary).
• During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
  1.  Inflated self-esteem or grandiosity
  2.  Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3.  More talkative than usual or pressure to keep talking
  4.  Flight of ideas or subjective experience that thoughts are racing
  5.  Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
  6.   Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7.   Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

Diagnostic criteria for a Manic Episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
• During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior:
  1.  Inflated self-esteem or grandiosity
  2.  Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3.  More talkative than usual or pressure to keep talking
  4.  Flight of ideas or subjective experience that thoughts are racing
  5.  Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
  6.  Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal directed activity)
  7.  Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

There are some differences between the old and upcoming versions of the hallowed DSM, and the new version does clarify a little. There is a lot more detail in the hypomania definition, and the changes seem quite sensible to me. Some of the wordsmithing is a bit better too.

But can you really tell the difference between mania and hypomania from these definitions? Sure, there are guidelines according to episode duration, but as many bipolars can attest, hypomania can last just as long as mania.

There’s also the psychosis factor. Pretty straightforward there. Similarly, in the current DSM, mixed episodes (both manic and depressive symptoms at the same time) also qualify you for a bipolar I dx, but that’s been updated to an equal-opportunity symptom in the proposed revisions. I would hazard a guess that mixed states could look pretty different for bipolar I and II.

The bit about severity is actually the key variable to consider. But can you confidently make a call as to whether you’ve had marked impairment in social or occupational functioning? I still find it hard to know what where some of my experiences would fall on the spectrum of functional impairments. A lot of extreme symptomatic behavior was written off as just being those wild college days – which I supposed everyone had. And they did, but not the way I did.

So in cold clinical terms, these criteria may make plenty if sense. But for understanding your own experience, they don’t shed much light on things. You can glean a senses of it from examples, but in patient communities I’ve seen the very symptoms and behaviors that I’ve called hypomania labelled as mania. Is it sloppy use of terminology? Conflicting applications of the diagnostic criteria by different doctors? A difference in severity that does not come through in a post? I don’t know, but it adds to my confusion.

Distracted, Distressed, Disabled

Tags

Adderall, ADHD, adult ADD, Concerta, dx, meds, symptoms

This is a long-overdue post on what it’s like to have adult ADHD/ADD. I was presumed “precocious” as a child, so my smartypants ADHD behaviors really went unnoticed. When I got to the adult grind of office work, I started having panic attacks, in part because I was massively overstimulated and unable to function appropriately (I still work best home alone.)

Is this my brain on stimulants, or is it an anemone that’s been manipulated beyond recognition with Photoshop?

I was diagnosed with adult ADD at age 23 or thereabouts. I started off with Concerta and it was a huge improvement. About 10 years later, as a PhD student, I switched from Concerta to Adderall (and then to Adderall XR.) Where I saw a 100% improvement in symptoms with Concerta (methylphenidate), I had a 1000% improvement on Adderall (dextroamphetamine-amphetamine salts), and even slightly better on the extended release formulation.

Yes, everyone has attention deficits, and ADHD is way overdiagnosed. It’s taken quite some time to figure out how to best express what the difference is, but the bottom line is this:
not everyone has attention deficits that are disabling.

By disabling, I mean that ADD can make it impossible to function at a normal level due to executive dysfunction in addition to problems with inattention, hyperactivity, and impulsivity. It permeates every part of my life, making everyday activities more difficult, and can cause great personal distress. That’s how I interpret “disruptive and inappropriate for developmental level” in the DSM definition of ADHD, slightly modified below to show only the symptoms that I exhibit. All symptoms must have been present for at least 6 months, but adults going for diagnosis need to present evidence from childhood as well.

Six or more of the following (9) symptoms of inattention:

Inattention (7)

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks.
3. Often has trouble organizing activities.
4. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time.
5. Often loses things needed for tasks and activities.
6. Is often easily distracted.
7. Is often forgetful in daily activities.

Six or more of the following (9) symptoms of hyperactivity-impulsivity:

Hyperactivity (6)

1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Is often “on the go” or often acts as if “driven by a motor”.
4. Often talks excessively.

Impulsivity (3)

1. Often has trouble waiting one’s turn.
2. Often interrupts or intrudes on others (e.g., butts into conversations).

In addition to the symptoms…

1. Some symptoms that cause impairment were present before age 7 years.
2. Some impairment from the symptoms is present in two or more settings (e.g. at work and at home).
3. There must be clear evidence of significant impairment in social, school, or work functioning.
4. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

I have the majority of symptoms from all categories and the severity is basically disabling for me. A more specific diagnosis would be ADHD, Combined Type. In addition to several diagnostic interviews (which all yielded positive dx’s), I’ve also taken the CPT II computer-based test. The results further substantiated the claim that my brain is simply screwed up in the departments that control attention, impulsivity, and (to a much lesser degree) hyperactivity. To make it all the more interesting, some of my bipolar symptoms overlap with the ADD symptoms, which made bipolar harder to detect for a long time.

To the symptoms above, I’d add inconsistent academic performance, low self-confidence and self-image, generalized anxiety due to cognitive deficits, executive dysfunction problems, underemployment, memory issues stemming from inattention, chronic insomnia, “noise” in my head, and delays in learning social norms of behavior. Almost all of these issues faded away almost as soon as I started taking stimulants. The symptoms that overlap with bipolar also improved substantially.

The meds made an enormous and unquestionably positive difference in my life. I only realized how unnecessarily difficult my life had been when I started meds. The drugs don’t just help with attention; there’s really so much more to it due to the pervasive effects of ADD symptoms. Being medicated solves a lot of problems for me and my quality of life is much better as a result.

People who don’t have AD(H)D typically cannot fathom how hard I work just to appear normal, suppress blatantly inappropriate behavior, and do certain everyday tasks that most people take for granted. It takes 5 times as much work for me to do anything when I’m off meds. Throw a bipolar episode on top of that, and I can barely function enough to get by. Fortunately, I’m pretty tenacious. Strategies I use to deal with ADD on a daily basis is the subject of another post, over on A Canvas of the Minds.

Where To From Here?

Tags

anxiety, bipolar, stress, symptoms, therapy, triggers

Pondering therapy: Thinker on a Rock, National Gallery of Art Sculpture Garden, Washington, DC.

At my last therapy appointment, Hippie Dude brought up the question yet again: what do I want to get out of this? The patient, he says, is the one in charge, and the goal of therapy is to not be in therapy. I’ve gotten past the most recent major stressor and although others are coming up shortly, what next?

I’ve been trying to figure out what to say when I go back next week. Part of the agreement with DBT is to stay in individual therapy, so at least a monthly check-in is in order. I’ve never been certain as to what I should get out of the whole therapy thing. At the same time, I’m not sure I’m “ready” to leave that safety net behind.

So here’s my short list of things to do in therapy:

1. Manage and reduce anxiety and stress: I’ve seen tip sheet after tip sheet. I’d like something that actually works, please. Something realistic, not just “take a hot bath.”
2. Figure out triggers: I know a few of them, like getting shorted on sleep or changing time zones, and apparently copious sunshine sets me off too. There’s got to be more to it than that. I’d like to know what to watch out for, but I don’t know where to look.
3. Detect symptoms and intervene: Much like item #2, I’d like to know what’s coming when it’s on its way. Figuring out prodromal symptoms and having a plan for managing the situation when they arise would be really helpful.

I could probably figure this stuff out on my own. But I don’t sit down and think, gosh, what are my triggers? I’m not good at drawing out the right details. I don’t have experience putting together a plan of action for situations that I’m barely conscious are unfolding. So I think that these are good goals for therapy moving forward.