unusual cases

The scale let out a beep that seemed louder and longer than necessary. What if I wanted to discreetly weigh myself? The thing might as well have stood up on two feet, strutted out of the bathroom with its hands on its hips, and bellowed down the stairs, “LARDO PUT ON SOME POUNDS!!!”

177.4 pounds. Four pounds in just over a week. I knew I had gained weight, I could tell by my growing muffin top and my chafing thighs—they call that “chub rub.” And I knew my eating habits would not be without consequence. Just  a few weeks before, I had bought a new pair of running shoes and a winter running shirt, and I had even gone out in the cold for a run more than once.

But then I injured my knee because my body was unaccustomed to all this activity, and was like, Why are we moving like this? Where are the cookies? While on a work trip, I had to hide a painful limp from the clients and colleagues I was working with, and I became resigned to the reality that I was unlikely to just hop on up and get into shape real quick. “I’ll just keep an eye on my diet,” I thought.

I knew binge eating could happen. It was listed as a potential side effect, and I was not immune. How many matcha green tea lattes had I sucked down, all thick with honey and whole milk? Or green tea frappuccinos from Starbucks, each with 88 grams of sugar? How many sleeves of Biscof cookies and pirouettess had I taken downtown? Not to mention the occasional Dairy Queen run or other indulgence that I prefer to enjoy in the dark shame of my car. And this is just the obvious, excess sugar. How many over-sized helpings of pasta had I shoveled into my maw? How much cheese and chips and ranch dressing was I eating?

When I first went in to meet my new psychiatrist, I planned to talk to him about starting me on Prozac or Zoloft. I had done some Googling, and those medications are compatible with breastfeeding. They are also in the same class of drugs as Lexapro, a drug I credit with saving my life in 2007. A drug that broke my world wide open because the way I suddenly felt made me ask questions like, People feel like this? Like, regularly? People just wake up and feel rested and interested in life and have little to no desire to lay down and die? But I had to be taken off Lexapro after only a few weeks because I went blind in one eye for no apparent reason while I was taking it, and we had to be careful about anything that impacted my neurology. Although they couldn’t prove the drug was the culprit, we couldn’t take chances.

Given that they are in the same class as Lexapro, the doctor was hesitant about Zoloft and Prozac. He wanted to reserve those as the last resort option. Another consideration when evaluating me for a new medication was that I have cervical dystonia, a neurological movement disorder, and some drugs can actually cause dystonia. So that was two physical ailments that impact the drugs I can and cannot take to manage my brokedown brain.

We spent longer than the allotted, expensive appointment time, and I tried not to think about whether he would charge me extra. He bent his right leg at the knee and set it on his left knee, creating a “4” with his long limbs. He leaned back in his chair, his fingers on his temples and his thumbs at his chin. “Okay, let’s think about this,” he said to himself. “We’re gonna stay away from the SSRIs, but you also had bad side effects with non-SSRIs like Effexor, and Lamictal didn’t seem to work well.”

“Actually,” I interrupted, “It’s hard to say if Lamictal worked well because I was on it with steroids, so who knows.”

He leaned forward, planted both his feet, and wrinkled his brow while he listened. “Okay.” He put his head in his hands.

I realized that I was witnessing his creative process. He couldn’t just prescribe me happy brain drugs and send me on my way. He had to think through possible landmines and figure out what might actually work for me and have a minimal negative effect on my life.

He turned toward his computer, typed a few keystrokes, and then started to scroll through a drug database, mumbling to himself. I stared at the room. It was sparsely decorated. There were car posters on the wall and model cars on the bookshelves. I was perched on the edge of my chair, and I sipped my green tea latte while I waited.

“Okay,” he clapped his hands as he turned back around to face me. “So, I think I’ve got one. Wait, you said you did try Abilify?”

“No, I didn’t,” I said. “At least I don’t remember trying it, anyway.” I was nervous. “Guess I should write this stuff down, huh?” I let out a self-deprecating and too-loud HEH.

“No problem. Okay. I’m between these two drugs. One has a slightly higher rate of causing dystonia. And we don’t want that. But we wanna treat you, too. So we have to find the balance. The other one is one that I almost never prescribe because people are so unhappy with the side effects. Particularly the weight gain, that’s the problem people have with it. You know, it’s hard to say if it’s the drug itself or if people are just feeling better so they are eating more, or being more social, or whatever.”

I thought about my 172-pound body. I had lost 13 pounds right after giving birth. Down from 200 pounds to 187. I stayed at 187 pounds for most of my son’s first year of life. I was not in a hurry to lose the weight; I was mostly concerned with letting my body rest and heal from growing and expelling a human being. I dropped another 15 pounds mostly without trying, when my baby was about eight or nine months old. But that was it. I was still 25 pounds heavier than I had been when I got pregnant. And when I got pregnant, I was ten pounds heavier than normal.

Weight gain. Extreme bingeing. Fatigue. Major weight gainDip in your mood. Tremors. Increased appetite. Memory loss. Listlessness.  Weight gain.

Weight gain was the prominent side effect with this drug, and the reason most people were unhappy with it—the medication could cause serious weight gain. There are always side effects. Some people experience them, others don’t. I have taken around ten different medications over the past ten years to try and manage my mental health. I have not steadily taken medication, mostly because of the side effects. When I start to experience negative side effects, I power through for as long as I can, and ultimately I end up going off the drug.

The other issue I have is that not all drugs help me. And I cannot figure out the point of taking a medication that has minimal therapeutic effects, while dulling my senses and robbing me of the ability to create. I only minimally wrestle with “I don’t want to be on medication for the rest of my life.” Sure, that feels unfair and ridiculous, but if what I have to do go through life enjoying it instead of surviving it is swallow a pill once or twice a day—and with minimal to no side effects—I like to think I’d do it with gusto.

The trouble is, I am not simply depressed. I am not simply anxious. I have mixed-state bipolar II. That means, I’m depressed AND anxious AND irritable and that my mood swings. I have mood swings. My mood swings. Like a trapeze artist, it swings high and low and everywhere in between. The “II” behind bipolar means that it doesn’t swing high in that overused movie-plot way, where I get excited and happy and paint all the rooms in my house and go shopping. Instead, I just get annoyed. Like, really annoyed. Agitated. Irritated. Frustrated. My fuse is short and burns fast.

I cycle between being depressed and, when I have the energy, being a ball of anger. I barely have energy for more than holding down my job and taking care of my little beasties. I often don’t have energy for self-care or for nurturing my romantic relationship.

When I am at my lowest, the very act of taking a shower is painful. Although it feels good once I can relax under the flow of the hot water, just the thought of getting in the shower is so daunting that if someone tried to force me, I would be a cat with outstretched limbs and panicked eyes. And, sometimes, when I am really low, the warmth of the water is pins and needles all over me, the act of washing my hair and shaving my legs and getting clean makes me cry hot, angry tears because it is draining and now I have to run through a mental list of items that I can neglect since I’ve spent all my energy on the shower that was absolutely necessary because my hair was plastered to my head with grease.

When I am at my lowest, I do not feel sustainable joy. Everything is wrapped in anxiety, listlessness, fear, and sadness. Everything feels wrong somehow. Every choice I make or action I take feels like a slog, anxiety-infused and fraught with a certainty that whatever I do, it will not be the right move.

When I was about halfway through my pregnancy, Matt and I had to fly to Austin for a work trip for me. We were flying on Southwest Airlines, which means there were no assigned seats. This used to cause me intense anxiety because I was not sure which seat I wanted, where to sit, what to stow and what to carry, which row was best, whether to sit on the right or left side of the plane… and on and on. I used to feel an intense sense of Type-A Urgency when it was time to board, and I was prepared to elbow every last sumbitch outta my way to get to the plane. It seemed important to have our pick of seats, except once I had that many choices, I would shut down.

Matt does not share my Type A anxiety, and is generally more of a go-with-the-flow kind of person.* So, when it was time to board, he was not in a hurry, which served only to frustrate me further. When you feel like the building’s on fire, it can be confusing, frightening, and frustrating when your travel companion doesn’t see the flames. When we got on the plane, it was up to me to decide where we’d sit.

Except I was overwhelmed. I had gone off my medication a few weeks prior so that I wouldn’t be medicated throughout my entire pregnancy. Hormonal changes tend to be especially hard on women with mood disorders, and here I was—pregnant and unmedicated.

We had been bickering slightly over our different approaches to flying, and we were annoyed with each other. When I finally picked a random window seat, slid into it, and got situated, I stared out the tiny window and burst into tears. It felt like the wrong choice. Every choice felt like the wrong choice, I had felt incredible pressure to make a selection, and I had almost certainly chosen wrong.

In my experience, this certainty over my wrongness is at its worst when my depression and anxiety are at a crescendo. Every choice I make feels some degree of incorrect. Staying in or going out; what to wear; what to eat; saying yes or saying no; having introvert time or being social; when to go to sleep; when to get up; how to parent; how and when to communicate, what to communicate. That doesn’t even touch on my professional life, which is where the lion’s share of my choices happen, and where I am wound up tighter than an eight-day clock.

This is how my mental health functions when I am not functioning well. My brain tells me, way to go, that was probably wrong, and also, you’re a failure. Ugly and unlikable, too. Just thought you should know.

My rational brain knows these are lies. But your depression and anxiety brain is far more boisterous and obnoxious than your rational brain, and it yells over any attempt at rational thought by proclaiming how its IQ is one of the highest, how it has so many thoughts, it has all the greatest thoughts.

“So, you don’t usually prescribe this one?” I asked. “But the other one is more likely to cause or increase dystonia? And we have to stay away from Prozac and Zoloft, except as a last resort?” I pulled on the sleeve of my cup, up and down, until it was tight, then loose, then tight, then loose. A wandering finger from my other hand tap-tap-tapped on the hole in the plastic lid.

“Yeah, I mean, we can try those, but they’re really not for mixed-state bipolar, like, as a general rule, ya know?” He answered. “I mean, they’re great at treating depression and some anxiety, but, given your history and your symptoms, I think we wanna go with an antipsychotic or a mood stabilizer, ya know?” I understood that he was uncertain. I was a mathematical word problem. Mine is the kind of case that gets presented at clinical case seminars where doctors sit around and talk about their patients who present with atypical circumstances, and then they put their heads together about treatment.

Female. 32 years old. Presents with Bipolar II, characterized by depression, anxiety, extreme agitation, mood cycling. Secondary diagnosis of generalized anxiety disorder. Has cervical dystonia, intermittent Botox treatments and PT, pain medication regimen. Was treated for idiopathic optic neuritis in left eye in 2007. Regained full vision with Solumedrol drip followed by oral Prednisone treatment. Has taken Paxil, Lamictal, Celexa, Xanax, Wellbutrin, Effexor, Buspar, Lexapro, Cymbalta, Abilify to manage Bipolar II. Was prescribed Lexapro 10 mg once daily at time of optic neuritis. Can’t bear to shower.

“Okay, I think let’s try the olanzapine. I get that it has side effects, but it seems like the best choice, doesn’t it?” I wanted him to steer me.

“I mean, yeah, I think so because this other one can increase dystonia and I think we want to be careful of that, right?” He said, and sounded more sure than when he talked to himself about alternatives. “The Olanzapine can do the same thing at higher doses, but we can start you on 2.5 mg, which is way lower than the dose at which that side effect was recorded.” He shifted his legs again, pulled his left one up onto his right, with his hand gripping the shin right where his pants leg rode up to reveal white tube socks. They were paired with large, black shoes that looked like the decidedly unfashionable non-slip shoes I wore while I was serving in restaurants. People made fun of me, but they were so practical that I didn’t care. I smiled slightly, silently acknowledging our nerd comradery.

At the end of our session, the psychiatrist asked if he could present my case at his forum where he and colleagues would evaluate unusual cases together. “Sure,” I said. It felt like the right choice.

* This is also not without its pitfalls; it can be easy to accidentally become a “yes” person with poor boundaries, the kind of person who struggles to say “no” or assert what you want. We are both human, with unique complexities and troubles.

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