Saturday, April 27, 2013

Where Did the Self Go?

In tomorrow's New York Times Magazine, you can read an article by Linda Logan, 
"The Problem With How We Treat Bipolar Disorder."  Ms. Logan writes, in a tender and tragic way, about her own struggle with a severe, treatment-resistant mood disorder, and how her psychiatrists attended to her symptoms, but not to what she calls her loss of self.  

Ms. Logan writes:

How much insult to the self is done by the symptoms of the disorder and how much by the drugs used to treat it? Paradoxically, psychotropic drugs can induce anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of depersonalization, psychosis and suicidal thoughts, while being used to treat the same symptoms. Before getting to the hospital, my daily moods ranged from bad to worse, each state accompanied by a profound depth of feeling. The first drug I was given was amitriptyline (Elavil), which, in the process of reducing my despair, blunted all my other emotions. I no longer felt anything. It was like going from satellite TV to one lousy channel.
While some medications affected my mood, others — especially mood stabilizers — turned my formerly agile mind into mush, leaving me so stupefied that if my brain could have drooled, it would have. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away. 

I would try to talk to my doctors about my vanishing self, but they didn’t have much to say on the subject. Instead they focused on whether I could make eye contact or how much expression I showed in my face. They monitored my lithium and cortisol levels; they took an M.R.I. of my head. I received an EKG, was exposed to full-spectrum lighting and kept awake all night for sleep-deprivation therapy. Nurses jotted down their observations; my scribbled lines in art therapy were inspected. Everything was scrutinized — except the transformation of my self and my experience of its loss. 

She describes hospitalizations lasting for months, trials with many, many medications, psychotherapy, support groups, desperate episodes of mania and psychosis, and the toll this took on her as a person, as a mother, as a wife, and as a professional.  Even as a psychiatrist, I found her story tragic, though by the end, we do have the sense that she has gotten so much better and so much more functional.  And sadly, while Ms. Logan longs for a treatment paradigm that addresses not only the illness, but the loss of self, aside from acknowledging that both the illness and the treatment can strip you of who you are, and working towards getting yourself back is a worthwhile goal, I'm not sure I have much to add.  As always, I'd love to hear your thoughts.


Randall said...

Perhaps this is why I found so many mental health professionals around me when i started studying shamanism. We were all looking for better ways to help our patients. While this may conjure up images of savages dancing around a fire there are books describing this practice in your office. The latest one, if I may post it, is "Spirited Medicine: Shamanism in Contemporary Healthcare" edited by Cecile Carson, MD.

Anonymous said...

I have treatment refractory major depression. This article ran true for me. When I cycled through too many medicines, I felt like I did lose myself. The depression never seemed to lift, but I was left with never ending sleep, or tachycardia, or diarrhea.

I finally learned to cope with the help of a therapist who gave me permission NOT to take the medications. She watched a series of drug trials and realized that they did nothing except for leave me feeling lost. I had a psychiatrist fire me during that interval, siting my "non-compliance" and refusal to consider ECT. (Geeze...when the psych medications don't work you expect to try something that could truly rob me of my personhood?).

With my therapist, I learned to accept that my moods and life just weren't going to be like others. I finally moved to a community where no one knows my past history. As I have aged, I have either learned to cope better or the dark times are not quite as dark. The darkness recently came back for no good reason. I hate hearing that "oh, she's a grouch, watch out," but that's better than hearing "I don't know how people like YOU think."

In medicine we have a tendency to refer people by their diseases. Is that part of the loss of self? Yes, but with acute mental illness, it goes far beyond that. For some, the treatment may be worse than the disease or at the very least, exacerbate the disease in ways that people who haven't taken the medications may find hard to appreciate. At this stage, I feel like I can better cope with what can be profound depression, because I know it. Profound depression altered by anti-depressants was not me (and worse at some level).

This is not meant to be an indictment of psychopharmacology. When I finally had a person who was willing to work with ME rather than the disease, that's when I learned to cope with me. Once again, if you haven't lived this, it may be impossible to understand.

leanne said...

to quote anon - very simply, "if you haven't lived this, it may be impossible to understand."

Dinah said...

Thank you for adding your story.

I'm sorry that medications were not helpful to you and I'm glad you found someone who was helpful to you when conventional treatment was not.

Thank you, also, for the way you phrased your comment -- it was not at all an indictment of psychiatry -- but simply your recounting of what did and didn't work for you, and I very much appreciate that you told us your experience without suggesting that medications should be illegal or that no one should try them.

It is certainly true that our treatments don't work for everyone, that sometimes the cure is worse than the illness, and that what treatments we have don't address every aspect of the illnesses. For some people, they work wonderfully, for others they seem to cause more harm.

Anonymous said...

Dinah, it is good and not the least bit sad that you have nothing to add to as story about a self that is not your own and again, to quote anon as leanne did, if you haven't lived it it may be impossible to understand. I would take out the word may and just say it would be impossible. I have never peed standing up and don't plan to give it a try for very good reasons.There is only so much you can learn in school or from a book or from hearing people talk.

Sarebear said...

I have been thinking lately about how my bipolar, esp. the mania, impacts my self in various ways.

Thinking about how bipolar is a thief, but it doesn't just steal, it puts something insidious in the place of the monkey idol it is stealing from the Indiana Jones-style archeological temple. It changes you, not just by what it steals (your judgement), but by making you desire that which you'd always been taught was a sin only the next rung down the ladder from murder. It makes you feel things and disregard things that you fight as hard as you can, until the invincibility/not caring about consequences gets so high that, well, the reasons to fight make about as much sense as someone saying the sky is neon green. Actually, when manic, at least that'd be interesting . .

Perhaps I'm seeking excuse, in the bowels of the illness. I always take responsibility when I return to a state of mind where I can do so, as that is yet another thing it steals from me and I will not let it remain so. Even though it's a wierd dichotomy of taking responsibility and seeing the ways in which the illness affects or takes so much judgement away that one's capacity is so reduced that perhaps there is some understanding as to how a person could do certain things . . . within this dichotomy I seek to find some way to live with myself, with the illness. And I've never been good at balancing acts.

How can all that not affect the self? I wish in treatment there was more to address this, as well, although at present I'm not sure exactly what lack I'd point to, other than this in general.

Anonymous said...

Fortunately, like Linda's Dad I have taken Lithium 3 pills a day for the past 28 years and have been sympton free, only concern is long term effects on the Kidneys. Now working with a Psychiatrist to titrate medication

Anonymous said...

"With my therapist, I learned to accept that my moods and life just weren't going to be like others."

I think this statement is the most important one. I stopped taking antidepressants because the loss of feeling outweighed the benefits of feeling the pain. I was able to do this, though, because I had a therapeutic relationship with my therapist. When I wanted so badly to be wired differently, he reassured me that acceptance was a better strategy than wishing I were different. Acceptance and validation are crucial.

Anonymous said...

Acceptance and validation are crucial, yes, unless, like me, you were persuaded to accept a misdiagnosis and subsequently changed your life because of it, only to get a new doctor and learn that you weren't bipolar after all.

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Anonymous said...

What I am curious about is why her husband left her after sticking by her through so many difficult years.

Anonymous said...

Several things:

There are so many ways to lose a self. I'm probably glad that I've got a bipolar disorder in remission(after a decade of raging treatment resistance) instead of being a paralyzed athlete or a deaf musician or a brain-damaged lawyer or a bereaved mother.

I suspect that we'll look back someday and conclude that our medications, while necessary, did enormous harm. Every time I hear of hypomania in a patient who has had antidepressants, I wonder if it had to happen. In this case, I wonder if her father would have had such an uncomplicated result if he'd started with all the modern drugs instead of, or in addition to, lithium. I strongly suspect that I myself would not have cycled so much or been quite so psychotic if we'd been more restrained with medication.

We obviously cannot afford to provide people with the extended talk therapy that helps one reconstruct a self. The best I can come up with is to set a paradigm for short-term therapy that strongly encourages people to reestablish community ties. Every little commitment I made outside of my home gave me more of my self back. I do wonder if permanent support-group membership reinforces an illness-only identity. There came a time when I knew I needed to step back.

Yes, the end of her marriage is sad and unnerving. It is difficult to live with someone who is not all the way better, and with the memory of how bad things have been. But there is an awful lot about the marriage that is left unsaid.

Other than that, so many of the details of this woman's life map so perfectly on to my own that I have to ask the professionals: Tragic? Aren't you seeing a great deal of this? Have you seen more over time?