I have a tendency to move my decisions from nice, logical decision trees into an underground network of convoluted root balls. Aboveground, choices are determined based on simple, bifurcating factors. Underground, no such rules exist.
Sometimes my decision root balls are so confusing that they’re also wrapped up in other trees’ roots. Those aren’t even my trees! When this happens, it feels like there’s just so much to think about that I can’t consider all of it at once. I’m left with a horribly overwhelming feeling that makes me want to say “no” to everything. It’s like going a million miles an hour and coming to a sudden stop, somehow at the same time.
Overthinking Decisions
I’m a habitual overthinker. I feel compelled to organize all possible plans and outcomes before even considering making a choice. The anxiety stems from the powerful feeling that I have to make the “right” decision, or else. The “or else” is vague and in most cases, probably entirely fictional.
And yet, often, I don’t have a specific worst-case scenario in mind. It’s just a sudden feeling of doom. Once I get myself to slow down and think through the choice in actual words, the real overthinking happens. The pros and cons of each choice are easier to hold onto, but they go straight into the center of a decision root ball. Then they get tumbled around for a while before I get frustrated enough to make the decision.
Untangling a Decision Root Ball
I’m learning that, for slightly longer-term choices, I do better when I force myself to not try to make a decision right away, but to instead let it sit for a day or two so as to avoid my immediate reaction. Of course, I can’t always stop myself from thinking about it all the time and being anxious, but I can reduce the pressure a little.
When I succeed at this strategy for overthinking, I’m much better at choosing the option that’s scary but leads to more growth. The positives start to outweigh the anxiety. The decision root ball starts to become a little less constricted.
For shorter-term decisions, I’ve found that I have to do the opposite of the long-term strategy. If I let myself waffle too much, I become paralyzed and am overwhelmingly likely to pick whichever option involves the least uncertainty.
To illustrate this with a mundane example, imagine me considering the benefits and drawbacks of various food court establishments. If I’m overwhelmed by attempting to balance the benefits and drawbacks, I will pick the option with the least uncertainty and go home empty-handed. And by benefits and drawbacks, I mean things like the length of the line, how harried the employees look, the likelihood that I’ll have to shout to be heard, and how chaotic the space around the line is. I mean, seriously. Sometimes, I’m deterred by not knowing what sizing system they use for their cups. It’s a wonder I can function at all.
Maybe someday I’ll progress to making decisions on the spot with minimal anxiety, but that sounds like an expert-level endeavor. For now, I’ll stick to gradually pruning my decision root balls and trying to say “yes” to some things.
It bothers me periodically that I’ve lost interest in my hobbies. I used to enjoy going to the library, but I don’t read anymore. I try every once in a while to draw something or start an embroidery project, but I usually just end up staring at the materials for a while and then giving up. Art has always been something I do sporadically. I have periods of inspiration and periods in which I set it aside, but I always cycle back through. Not lately. I feel like I’ve lost all motivation to create anything – even in writing. My drive to write on my blog has been exceptionally low, even though I maintain a desire to keep up with it. It’s a frustrating space to be in.
Part of my problem with visual art is that I get too caught up in making it match my mental image. It leads me to give up or not start at all. It occurred to me that it might be easier to get started if I tried to make something after taking a ketamine troche. I have tried writing while dissociating on ketamine, but something about articulating my thoughts in full sentences proves to be very difficult, and I usually abandon it.
Turns out, painting is entirely different. I sketched out a landscape based on a photo and pulled out my watercolors before taking a troche.
I found the process of putting colors on the paper to be engrossing, and I think that since I was curious to see how it turned out, I wasn’t so worried about it looking “bad.”
By the time the ketamine had worn off, I had made it to this point:
It was unfinished, so the next day, I went back to it with all of my faculties and spruced it up. I still don’t love how it turned out, but I can label it a ketamine experiment and be content with that.
Other hobbies I’m attempting to resume include running, drawing, and volunteering. Each of them is in the tiny beginning stages, but I have to start somewhere.
My experiences with ketamine troches have been varied. Sometimes it hits me, and I decide that being horizontal is better than attempting to sit up, so I get in bed. I’ve definitely noticed that remaining still makes me less likely to get nauseated, but it also makes it harder to perceive the dissociative effects of ketamine. I frequently think that I’m past the dissociation and get up, intending to go walk the dog or clean the kitchen, only to realize upon standing that I most definitely am not ready to practice such advanced life skills.
Then again, sometimes it seems like nothing happens when I take a troche. This is somewhat disappointing, given how much mental preparation goes into overcoming the revolting medicinal flavor. I could just swallow the troche without letting it dissolve, except the edges of it are sharp. Believe me – I’ve tried. It’s painful. The best way I’ve found to take ketamine troches is to sip lukewarm tea while it’s dissolving in my mouth. It helps with the flavor, and the liquid speeds up the dissolving process.
My first few troches were more intense than subsequent ones, and overall, I’ve found that they produce much less absurdity in my mental images than ketamine infusions did. Troches tend to lead me down memory lane or explorations of personal questions rather than bizarre, imaginative storylines.
I think that because taking prescription ketamine at home still seems strange to me, I often ponder the question, “How did I get here?” My experience with mental illness started early, so naturally, my childhood comes to mind when I pose that question to myself. Sometimes, when the ketamine kicks in, I begin to review my life as if I were watching a movie, skipping ahead and replaying certain parts. It either leads to me feeling like perseverance is my path or just feeling utterly lost. When I separate from myself a little, it often just adds to my pre-existing sense of confusion and nonbelonging.
More often than not, I cry when the ketamine kicks in. I don’t know if that’s common or expected, but it’s definitely a pattern for me. And it’s interesting because I don’t cry with much regularity in my everyday life. I’m not sure why dissociating would make me feel my emotions more, but it seems to me like it does.
I do feel a bit better, but I’m not sure whether I should attribute that to being back on lithium, the ketamine, or the new medication I’m taking, Mirapex. Historically, lithium has been very helpful in tamping down my suicidal thoughts and allowing me to be more functional. It doesn’t usually do much about the anhedonia, which leaves me feeling the need to accomplish things but not getting much satisfaction from it.
I also started taking Mirapex a few weeks ago. It’s a dopamine agonist used for Parkinson’s disease, restless leg syndrome, and – off-label – depression. I’m in the middle of increasing the dose, and so far, I’m not sure whether it’s helping. It certainly could be part of the combination.
Listening to music during ketamine infusions usually helped me generate a flow of images connected by associations that were often mysterious to me when the infusion was over. Sometimes, I would be faced with settings or items that had made recent appearances in my life, and other times, the things I saw seemed entirely random. It was always different.
However, there was one commonality between many of my infusions. I often felt as though I were sinking in deep water. It was peaceful but also evoked a feeling of hopelessness, which is what I wrote in my posts at the time. Some of those infusions gave me the sense that water held some significance to my subconscious. I tried to draw some meaning from it – to spin it in a positive way or discern some kind of symbolism. I could only guess that the unsteadiness the ketamine made me feel was connected to the sensation of being underwater, and that my day-to-day sense of hopelessness was intruding on me during my infusions. It made me feel like I was drifting down through a vast body of water, and there was nothing I could do about it.
At some point, the water-based visions stopped, only to be replaced by a similar experience in which I was buried in sand at the bottom of an empty well. I concluded at that time that “my perception of depression [was] manifesting itself as unbeatable natural forces in my ketamine infusions. In my visual experience of ketamine, depression feelslike sinking alone in the dark, open ocean. It feels like being buried in sand at the bottom of a well while people far away can only watch.” I don’t know for sure why I had so many experiences like those, but I felt the comparison was apt; depression was pulling me down, and it would be easier to not resist.
I found myself in a similar place when I took the ketamine troche the other day. Deciding which playlist to start proved to be difficult, so I removed my earbuds for the first half and just listened to the sounds of the room around me. Allowing my thoughts to wander on their own without the influence of music might not be the best option for me. Although my mind touched on dark topics during infusions, the progression of one song to the next helped keep my thoughts moving, and frankly, the intensity of the ketamine made controlling my thoughts difficult. They floated from one image to the next automatically. With nothing to pull me along and just enough mental control of myself to not get distracted by random stimuli when I took the troche, I became stuck. Eventually, I found some music to listen to, but my mind was already trapped in a negative space and it seemed to be too late to change it.
I’m planning to find a guided meditation or an audiobook to listen to next time. Perhaps if I begin with a positive intention and impose a framework of some kind, I can herd my thoughts toward something more helpful.
So far, the dissociative effects of ketamine have been limited to a roughly one to two-hour window. Thankfully, it seems that the extended visual and auditory hallucinations that I experienced after a few infusions (notably, this one and this one) were due to the combination of ketamine and Emsam, which I’m no longer taking. I haven’t noticed any giddiness or restlessness after taking the troches, either, which troubled me toward the end of my time getting infusions. That may have also been because of Emsam.
The plan is to increase the dose and continue taking them twice a week. Hopefully I’ll start to notice something positive.
I wrote in my last post that my ill-advised attempt to get off my medications is not going well. Not much of a surprise, I suppose. My psychiatrist suggested I try an oral formulation of ketamine, known as troches (pronounced “tro-keys”). These are dissolvable tablets that you take home and administer to yourself on a schedule. I’m doing it twice a week for two weeks.
One of the main drawbacks of troches is that the ketamine is less bioavailable compared to IV ketamine, which makes precise dosing a challenge. The risk of addiction can be minimized by carefully monitoring patients’ responses and prescribing ketamine troches in small batches with limited or no refills. An Osmind article written by a physician notes that the ketamine doses that are commonly prescribed are much lower than typical recreational doses but that doctors should have carefully outlined plans for restricting use and halting patients’ access to ketamine troches if necessary.
I got ketamine infusions fairly regularly for two years and then stopped with no problem, so I’m not very concerned about my own risk of becoming addicted. However, a cautious approach seems prudent.
An article on RX Insider describes ketamine troches quite positively, saying that they are a more affordable option than infusions and that they offer relief for patients who may not have access to other forms of ketamine due to logistical constraints or COVID-19 safety concerns.
Even with the experience I have from ketamine infusions under my belt, I was nervous about trying troches. In general, I’m uncomfortable with the idea of not being in control of myself. I managed to let that go when I did ketamine infusions, but the medical monitoring involved in that alleviated some of my anxiety. The uncertainty about what to expect when taking ketamine at home put me on edge, but it has turned out to be fine so far.
What Do Ketamine Troches Feel Like?
I’ve tried two ketamine troches and had very different results each time. Having some idea of what to expect based on my experience with ketamine infusions, I tried to set myself up for a smooth ride. The dog had been walked, my curtains were closed, and I had no obligations waiting for me. I wore comfortable clothes, arranged my weighted blanket on my lap, and chose some gentle-but-compelling instrumental music to listen to.
The first time, I put the troche under my tongue, waited until it dissolved (about 10 minutes), and then waited about 5 more minutes before spitting it out. I may have felt something, but it passed quickly, and I felt completely normal about 5 minutes later. It was so mild that I wasn’t even sure whether I felt it because I expected to or because the ketamine actually had some effect on me. I’d been advised to spit the ketamine out to minimize nausea, but when I reported feeling pretty much nothing, my psychiatrist told me to wait ten minutes after it dissolved the next time and, if I still didn’t feel anything, I could try swallowing it the following time.
A few days later, I tried it for a second time and waited longer than recommended. I think the ketamine that was absorbed under my tongue gave me a very mild dissociative feeling, but it again passed very quickly. This time, I took notes on my phone so I could keep track of the timing. I started at 2:45 and didn’t feel anything until 3:04. I felt a very low level of spatial wobbliness – a lot like how I feel when I’m a little overwhelmed in a busy grocery store. It felt like things were getting a bit hard to track with my eyes, and I felt ever so slightly floaty. By 3:15, it seemed like the effect had already peaked in a mild way and worn off. I felt pretty normal, so I swallowed the ketamine, and a second wave came a few minutes later.
At 3:30, I noted that my fingers felt a little numb and that I was going to close my eyes. Seven minutes later, I wrote, “Music too intense. Felt like being carried on a river of sound.” What does that mean? I no longer know. You might think that I was completely zonked, based on that tidbit, but only one minute later, I held a brief conversation with my mom and managed to seem totally coherent. Compared to ketamine infusions, troches seemed to create a more fragile dissociative state. I was much more able to pull myself out of it when under the influence of troches than I was when I got infusions.
I think my anxiety about what would happen had me coming back to the room frequently, which resulted in a very fragmented experience. I would get sucked into a song for a couple minutes and then reorient myself and write a quick note on my phone about what was happening.
When I closed my eyes, my sense of where my body was and where certain parts of my body were in relation to each other was distorted. It’s a feeling I also tend to experience when I’m on the edge of sleep or when I sit still for too long. Sometimes, it’s only a small discrepancy, such as the difference between whether my hands are resting on my lap or next to me.
The sensation is cranked up on ketamine. This time, it resulted in me feeling like my head was somehow directly connected to my knees. I experienced this kind of bodily confusion frequently during ketamine infusions, so I knew it was nothing to be concerned about. I tried to let go of my desire to organize my body in a certain way and just float along in whatever form I had taken.
Every time I checked back in to the real world, I was surprised to find that only a few minutes had passed. It felt more like 20 or 30.
What I was seeing and feeling during those few minutes was nothing so detailed or bizarre as what ketamine infusions created, but I have the sense that if the experience had not been so fractured, I might have approached a similar level of immersion.
I remember one song evoking an image of the night sky as viewed from a very dark place, with the vast swath of the milky way stretching out overhead. Another song made me feel as though I were standing in my old house as it burned down, sparks and ashes falling around me. The wind had begun to howl outside in earnest, which makes me nervous these days.
At 3:48, Stella decided to sit on the window seat. She found the break in the curtains and pushed her way through, light streaming in behind her. The light held my attention for a few minutes, but by 3:53, I wrote that I was feeling more normal but also rather sad. I had a bit of a cry, noticed that time was jumping ahead in small increments, and then got up to go to the bathroom at 4:10. Looking in the mirror was an unsettling experience, but I expected that, so it wasn’t too disturbing.
By 4:22, I felt like I was completely past the effects of the ketamine. So, all told, the entire process took about an hour and a half from the time I first noticed the ketamine affecting me.
I haven’t noticed any improvement from the ketamine, but I have two more to do before the end of my two weeks. In the meantime, I’ve decided to get back on lithium. It seems obvious that stopping it was a bad idea and that I’ve clung to the hope that I could make it work without it for too long. I’m trying to keep the perspective that my experiment was informative, and it’s good that lithium helps me. But to be honest, I just feel defeated. The better I feel, the easier I am on myself for needing medication, so hopefully, this ultra-critical side of myself will quiet down when the lithium starts working.
When some questions about my diagnosis arose a couple months ago, I realized that my medications made it difficult to determine which symptoms were side effects and which were stemming from me. I’ve wanted to get off my meds for a long time, partly because I have an unhealthy tendency to blame myself for my illness and expect myself to fix it through willpower. But that’s a whole separate issue. Don’t do as I do in that regard.
I decided to get off Emsam first, as I suspected that was the main culprit when it came to the occasional hallucinations and sudden mood shifts I was experiencing. Decreasing my dose was difficult, but when I stopped taking it completely, I felt better. Not by a lot, but it was noticeable.
The next step was to decrease my lithium dose. That process has progressed in the reverse of how Emsam went. Lowering it was mostly fine until I got to 300 mg. I started to feel worse, but I hoped that if I stayed at that dose for a while, my mood would even out. I started napping again. If I have nothing scheduled in the afternoon, I spend it sleeping. Walking Stella was one of the only activities I was enjoying before I started changing my meds, and now I don’t even want to do that. I still take her on at least one long walk a day because she needs it, but I find myself getting irritated and impatient the farther we get from home. Sometimes we go to the dog park so I can stand in one place and throw a ball for ten minutes before we leave. It’s a good thing she likes fetch.
I stopped taking lithium over a month ago, and I’m still on the fence about it. I’ve definitely crossed into not-okay territory, but I’m stubbornly refusing to reverse my plan. Part of me thinks this is a bad idea and I should go back on lithium, but part of me wants so badly for it to work out that I’m willing to give it more time.
My determination to get off my medication, even though it has a slightly positive influence, seems confusing on the surface, and I struggle to articulate my reasoning for it. I always think that I’m not doing enough to help myself, and I have a long history of feeling ashamed of my reliance on medication. I think the most succinct way I can describe it is that I’d rather believe I’m failing at doing something possible than accept that it’s impossible. Truly accepting that I need medication in order to function would require me to admit that I don’t have full control over myself, and that’s a frustrating and scary thought for a perfectionist.
I’ve mentioned this in previous posts, but to be clear: I don’t feel this way about anyone else. It’s a bizarre thought distortion that makes me feel as though everyone else is perfectly justified in taking medication, but I am not. The more depressed I get, the harder it is to see the irrationality of that.
I’m trying to push myself to do things and go places because I want to support my mental health as much as possible while I make these medication changes. It’s hard, though. The holiday season is upon us, and the twinkling lights and pine-bough wreaths on nearby homes are making me sad. I automatically think about all of our holiday decorations burning up in the fire five days after Christmas last year. I felt like I was moving on during the summer, but the cold weather has caused a resurgence of painful memories. It’s probably not the best time for me to be messing with my brain chemistry, but here we are.
I’m just so frustrated with medications. The possibility that I have bipolar disorder offers a nice, neat explanation for why I’ve had such sporadic and limited success with antidepressants. Getting off everything so that I can tell where my baseline is (and whether I eventually cycle back into hypomania without the influence of mood stabilizers) might make a difference in my plan going forward. The diagnosis is arguably not as important as figuring out what helps me, but since I tend to spiral into believing I’m not actually ill but rather just low in the willpower department, having a name for what I’m experiencing would be helpful. I’m just not sure if it’s worth the difficulty of achieving confidence in one diagnosis over the other, and it’s obviously not going great so far.
In fact, my mood has sunk so low that I agreed to retry ketamine – but in a different format this time. My psychiatrist prescribed ketamine troches, which dissolve under your tongue. This formulation of ketamine can be taken at home, which would be new for me. I’m nervous about it – for one thing, it’s much less controlled, in the sense that an IV ketamine infusion can be stopped suddenly; once I take the troche, I’ll just have to wait out the whole dose. I started to really dislike the feeling of ketamine toward the end of my time getting infusions, and although I don’t think troches will feel as intense, the uncertainty is making me anxious.
I am, however, passively suicidal and having trouble keeping up with self-care. I frequently sleep in my clothes and re-wear them the next day, and my hair keeps developing hidden matted sections because I can’t bring myself to brush it. So, perhaps something like a short burst of at-home ketamine would help me get myself into a better routine.
My depression brain is yelling about how I got myself into this mess by stopping my meds, so I don’t deserve help getting out of it. But that’s not healthy at all, so I’m going to try to resist it. I’d like to do some research on ketamine troches tonight so that I know more about what to expect, and then I’ll try to pick them up from the compounding pharmacy tomorrow. Ketamine seemed to stop working for me after a while, so I’m interested to see whether taking a break has impacted its efficacy.
Writing has always been helpful for me, but I’m finding the motivation to do it hard to come by. When I was more actively questioning my diagnosis, having a written record of my symptoms and how different treatments have affected me was incredibly useful in trying to piece together a timeline, so I’m going to renew my efforts to keep up with my blog. It might come in handy later.
In late summer of last year, I increased my antidepressant, Emsam, from 9 to 12 mg. I was staying in a hotel at the time, and something odd began to happen. I started to hear music when the AC was running.
It is normal for people to hear tunes in the mechanical background noise of fans. It is not a psychotic illness – merely an odd perceptual idiosyncrasy. However, what I experienced was much more complex than any small, lilting buzz I’ve ever heard in a fan before.
The Musical Phenomenon and A Shift in My Mood
I was hearing soundtracks. Vocalists, instruments, the whole nine yards. I couldn’t decipher any lyrics, but there were distinct genres that ranged from pop to broadway to country. It sounded as if the music were coming from a different room, and for a while, I believed it was. But eventually, I began to get suspicious.
I walked around the hotel room, putting my ear to the walls, listening for a change in volume. I opened the door and poked my head into the hallway. I stood on the bed and listened to the ceiling. It was always the same volume. When the AC shut off, so did the song. A different song would start up after a few minutes of the AC running again. Sometimes, a sudden shift in my attention would cause the music to stop, even when the AC continued to run. It became clear to me that what I was hearing was not real, and it disturbed me.
A Mountain Escape
I was about to go to a new location – a trip with my mom to a small, mountain town for some wilderness relaxation. We planned to hike up to a lodge at 11,000 ft above sea level and stay for a few days. The hike up was arduous; it was the hardest hike I’ve ever completed, despite being shorter and with less elevation gain than other hikes I’ve done.
I remember that I wasn’t sleeping well, and my body just refused to cooperate as I forced myself up the trail. I had to stop frequently and lean on my pole, taking gasping breaths. At the lodge that night, I heard phantom hummingbirds zipping all around me as I lay in bed. In the morning, the sound was gone. I was unsettled, but I tried to put the experience out of my mind.
I was testy on that trip. My head was not in a good place, and my mind was filled with overwhelming irritation. I cried a lot. Neither my mom nor I were having a good time, so we left early and headed down the mountain to get a hotel room.
Upon reaching the hotel, a minuscule setback occurred, and it sent me over the edge. In a second, I went from chill to overwhelming, roiling anger. It was like calm seas to tsunami in the blink of an eye. I contained most of this energy, but some escaped in the form of expletives, fist clenching, and undignified, hurried marching on my way to our hotel room.
I am typically a very levelheaded, patient person. I strongly dislike being angry, and when I am, I make every effort not to show it. (Is that unhealthy? Yes.) In that moment at the hotel, I felt completely unhinged.
My dog had never seen me in such a state, so she hid under the table. The sight of her filled me with guilt and self-loathing. I immediately dissolved into dramatic, uncontrollable sobbing, which only frightened my dog even more. I was convinced that she would be afraid of me forever, a consequence for which I wholeheartedly believed I would never forgive myself.
Luckily, dogs are good creatures, and Stella came around once I had composed myself. Composure took a while to reach, but a hot shower helped.
Looking back, I feel like I was not myself from the very start of that trip. The rest of it passed fairly uneventfully, but I continued to hear sounds and music that were not real until a few days after returning home.
She forgave me quickly ❤
I’ve gone back and forth between 9 and 12 mg of Emsam since then, and the musical illusions occur sometimes when I take 12 mg. Sometimes it’s music, an incessant buzzing, or the murmuring sound of a group of people talking far away. Sometimes I can identify the background noise that accompanies it, and other times, it seems to happen on its own.
The Ketamine Incident
A couple weeks after returning from our mountain trip, I had a ketamine infusion that resulted in a bizarre, seemingly manic few days. I wrote a post shortly afterward that described my experience. I slept a couple hours each night but was compelled to keep moving. I worked on various projects for hours at a time, periodically bothered by the sight of small, insect-like dots scurrying across my visual field. I felt restless, productive, and somehow rather pressurized from the inside. I was also unsettled by dissociative spells in which I’d suddenly feel as though I were wearing my body, but it wasn’t really mine. Or, I’d walk by a mirror and be disturbed by my own face, which seemed unfamiliar.
When the strange symptoms ended, I plummeted back into depression.
I decreased my Emsam dose and my ketamine dose and had much more typical ketamine experiences, although I still found myself unbearably restless after infusions. The incident was strange, but since it didn’t happen again to the same degree, we carried on with treatment for a few more months.
Do I Have Bipolar Disorder?
I explained some of these experiences to a psychiatrist recently. I was being evaluated for ECT, although I’m not yet sure whether I want to do it.
The doctor interviewed me thoughtfully and asked a lot of questions about my symptoms. When we reached the end of the evaluation part of the appointment, he said that I might have been misdiagnosed with major depressive disorder, when really my depression is of the bipolar type.
It’s just a theory, but this would explain why antidepressants haven’t worked very well for me, or at least not for very long. The antidepressants actually seem to trigger these odd experiences.
There have been other times when my mood suspiciously shifted, like the first time I took Wellbutrin. A day or two after starting it, I felt dramatically better. I was motivated, energetic, and utterly thrilled with how well it was working. Of course, then I developed a rash and had to stop taking it, at which point, I spiraled in the other direction.
The second time I tried Wellbutrin (the brand-name instead of generic), I wrote a post titled “Depression on Fast-Forward.” Wellbutrin didn’t make me happier that time, but it did make me anxious, jittery, and restless. I wrote about feeling “an almost constant low level of adrenaline” and feeling mismatched, like I wanted to sleep but was unable to. Was this just a side effect, or something more? Was taking lithium what made the second trial less happiness-inducing than the first?
The Antidepressant/Bipolar Controversy
These and the other incidents I can identify always happen in response to something, usually a medication change. The question of whether antidepressant-associated hypomania (AAH), also called treatment-emergent affective switch, or TEAS, indicates an underlying bipolar disorder is a controversial one.
Some people think that you can have unipolar depression and be reversibly pushed into hypomania by antidepressants, while others believe that switch indicates the existence of an underlying bipolar disorder or a shift from unipolar to bipolar illness. It has also been suggested that AAH should form the basis of a new diagnostic label, “bipolar III.”
I have experienced multiple incidents in the last few years that felt like a dramatic change, complete with insomnia, high productivity, perceptual disturbances, and euphoria or irritability. And yet, I find it difficult to verbally describe these events in a way that emphasizes the aspects I think are important. I habitually understate the severity of my symptoms, which doesn’t serve me when I really need help but can’t communicate accurately.
I’ve sought a few opinions from professionals on this matter, and I’m having trouble just reaching a consensus on whether my experiences count as AAH or were simply improvements in my depression with some side effects sprinkled in.
Even when I make a concerted effort to be more emphatic, the theory sometimes gets dismissed because the episodes I describe are too short by DSM standards to be mania, and I didn’t have racing thoughts, go out and spend all my money, take unreasonable risks, or have grandiose plans. These are all excellent points, so I’m really not sure what to think.
The DSM has strict criteria defining bipolar I and II, but that’s not the only way people conceptualize the condition. Some experts believe bipolarity exists on a spectrum, and that viewing antidepressant-associated hypomania as part of unipolar depression contributes to an overdiagnosis of MDD and an underdiagnosis of bipolar II.
On the other hand, some authors argue that bipolar disorder is overdiagnosed due to inflation of the diagnostic criteria, making the concept of bipolar disorder too vague.
Stopping My Antidepressant
Given the number of conflicting theories out there, it seems unlikely that I’ll get a solid answer about my own experiences at this point. One way to clarify the picture is to gradually get off my antidepressant and see what happens.
I thought for sure I’d go back to the excessive sleeping I was doing before I started taking it, but so far, that hasn’t happened. I’ve been off Emsam for a couple of days, and the insomnia continues to plague me.
It’s troubling to look back at the last few years and imagine that there may have been a process occurring outside of my awareness. At the same time, I’m ever so slightly encouraged to have a different direction to go in. It could offer an explanation for some mysterious things and provide me with more effective treatments. Then again, maybe I have major depressive disorder, and I’m looking into a problem that doesn’t exist for me. Regardless of how it turns out diagnostically, I’m relieved to be connecting some dots.
Having anxiety about therapy doesn’t mean that therapy isn’t “for” you or that you can’t benefit from it. Instead, it might be a fear you can change by adjusting the way you approach your sessions.
We often focus on the role of the therapist and how well we connect with them when talking about how to feel comfortable opening up in therapy, but we don’t often examine our expectations of ourselves. Self-criticism and high expectations had me feeling anxious about therapy until I changed the way I thought about myself as a client.
When I decided to start going to therapy in college, I was apprehensive about having to do the classic back-and-forth discussion with my chosen therapist. In fact, I’m still not always keen on it. But the expectation that I held for myself – that I would sit down and spill my guts and cry and reach some kind of catharsis every week – did not pan out. The more accurate picture was (and sometimes still is) one of me sitting down, saying I’m okay, shrugging a lot, and forcing my therapist to sit in silence with me while I wrestle with my thoughts.
I thought for a long time that I was bad at therapy. I was very critical of myself for inadvertently shutting down. Sometimes, I still feel guilty because I perceive my excruciating quietness as a waste of my therapist’s time.
Shifting My Perspective on Myself in Therapy
The longer I’ve stuck with it, the more I can see that this perspective of myself as something like a student who is expected to achieve success is preventing me from recognizing the progress I’ve made. As a perfectionist, I’m prone to thinking that no amount of improvement is good enough, and if I’m not meeting my own expectations, I must be failing. Perhaps even more importantly, my anxiety about therapy gets in the way of me focusing on what I can get out of the process despite and because of my difficulty with certain topics.
I have been trying to shift my perspective on my role in therapy to be more like that of an explorer or some kind of self-ethnographer. I go to therapy, I do my best to talk, and I observe whatever happens. I’m there to be curious, and if talking about something is suddenly challenging, that in itself is interesting information.
Why Go to Therapy if It’s So Uncomfortable?
I learned early on in my experience with therapy that although talking about myself is deeply uncomfortable, it feels worthwhile. I have always been quiet and reserved, and I tell myself that it’s a preference. But, finding myself unable to answer personal questions in therapy taught me that I have less control over it than I wanted to believe.
To Challenge Myself
When pushed to discuss something I’m uncomfortable talking about, I simply clam up. It frustrates me because it does not feel like a voluntary reaction. Obviously, I go to therapy to talk about myself – why can’t I override my tendency to shut down? It’s like a drawbridge lifts in front of me, and I can no longer get my words across the gulf between myself and my therapist.
To Practice Being Vulnerable
Ultimately, therapy led me to the realization that while staying quiet is comfortable for me, it is also lonely. I don’t intend to change my natural tendency to be reserved, but I do hope that by practicing being open about difficult things, I can allow my reservation to be a choice, not a barrier.
Everyone has secrets, and it’s perfectly okay to keep them private. But there are times when it’s good to share personal information, especially if it’s going to help you overcome a challenge in your life. Holding secrets out of an inability to put them down can be a deeply isolating experience.
Finding Ways Around My Anxiety About Therapy
I’ve gotten better at talking about myself in therapy, but it’s still hard. I still have sessions where I can’t seem to find the lever to lower the drawbridge and let the words out, and that’s okay. My therapist knows that I stay quiet not out of disinterest in the process but because it’s hard for me to engage in it.
On days when I don’t say much, I go home and write her an email with all of the words I couldn’t set free. It gives us somewhere to start the next time and lets me communicate in a way that’s easier for me. I still challenge myself to talk, but I know that I have a backup line of communication if I need it.
Whether I choose to discuss something or not is up to me, of course. My therapist is there to guide me, even push me a little, but ultimately, I decide what to talk about or not. If I want to set aside a more difficult subject in favor of discussing something easier but still meaningful, I can do that.
Considering the Therapeutic Relationship
I have found that for me, viewing a therapist’s role as that of a knowledgeable partner rather than an authority figure helps me stay intrinsically motivated and makes me more willing to push myself. We’re exploring my brain together, and I know that if I don’t accomplish something I set out to do, I won’t be “in trouble” with my therapist the way I would think I were if our relationship were less equal.
It’s a strange relationship to navigate — one that is inherently unequal in more than one way. You go to a therapist for help because they have knowledge and a perspective you don’t. You pay them, and you probably defer to their expertise. They are in a position to set expectations and try to interpret the implications of what you say or don’t say. It’s easy to start seeing your therapist as someone to impress, especially if, like me, you’re a chronic people-pleaser.
At the same time, clients have the option to stop going, the freedom to ask for adjustments in their treatment, and the potential to view themselves as indispensable experts on their own experiences. It can be motivating to think of therapy as something you get to take part in with your therapist rather than something you have to go to. Ultimately, I think the dynamic of a partnership makes me less likely to fear that my therapist might disapprove of or be disappointed in me for not achieving something or even for not talking enough.
I’m still trying to let go of my self-imposed pressure to be a wonderfully verbose client. I go to therapy to work on my depression and anxiety, and part of that involves being less critical of myself. I used to think I was a bad client because of my anxiety about therapy. Now, I think I struggle to talk about myself, and that’s part of why I’m in therapy.
Love, Your Brain 