What everyone loses in a suicide

Sulome Anderson’s feature last week, “How Patient Suicide Affects Psychiatrists” is a great inversion of a big social problem. Most features on suicide and mental illness (including the great The Cost of Not Caring series by USA Today) tend to focus on the individual who committed suicide and the impact on their family and community. Anderson did quality journalism to create this feature, which helps humanize doctors who naturally become the bad guys in some of these cases.

Personally, last year someone I knew tried to end their life- I had talked to them the a few hours prior to the attempt, having a short conversation about family relations that turned out to be much more important in hindsight (they wanted to know if I had special insight on why I have a good relationship with my parents, and they had the opposite. I wasn’t helpful, though I tried to be). When I visited this person the following day, they were still attempting to die in the confines of the hospital room. Never have I seen desperation more fully realized. It’s profoundly disturbing, and the feature gets across that this sentiment crosses all lines of profession or experience. You don’t become truly adjusted to suicidal people in your life, even if you chose psychiatry as a profession.

Personally, I thought that my history of mental illness would help deal with this experience. I’ve never been particularly suicidal, but my choice to be an activist and socialize within the community has put me into contact with many people who are open about their past with suicide. Turns out that was all (I suppose) wistful thinking. It’s horrible to witness, even in the context I had, where I had some time to mentally prep.

This feature helped develop a three-dimensional picture of the tragedy, which I wish was available with all social problems. Everyone loses someone in a suicide, and we each lose a part of ourselves when someone we know personally attempts or completes it. And yes, as Anderson comes to- sometimes there is nothing that can be done. Zero suicides is an ideal to strive towards, but no free society can ever attain it.

We are all humans with flaws and we are not omnipotent. There is only so much we can do for those we love. All we can do is our best.

Involuntary commitment: it needs to be on the table

There is a great, blunt editorial by a man named Tom Zoellner published, “Reforms shouldn’t protect ‘Big Mental Health“. Though the issue is contentious in the mental health community and among those living with mental illness, Zoellner is absolutely right: involuntary commitment could save lives if it could be used more. This is both in more public situations (mass shooters with obvious symptoms and warning signs), and to save the lives of individuals who will otherwise kill themselves.

Charles Krauthammer is wrong about most things (he’s just a more intellectual-sounding Rush Limbaugh), but his experience as a psychiatrist and his work with mania is extensive and undeniable. Thus even in a column where most of his logic is shaky, like this work after Newtown, his point on mental illness is correct. Several social problems persist due to inadequate resources to treat those who suffer from psychosis, major depression, and mania. And if involuntary commitment was a possible option in more states and situations, some prominent shootings would likely not have happened. Jared Loughner and Seung-Hui Cho (the Virginia Tech shooter) had plenty of warning signs that teachers and friends recognized, but this didn’t filter up to the relevant authorities, and even then their hands can be tied by personal rights and privacy.

This is a balancing act, which is par for the course with mental health. People shouldn’t be locked away like in the days of the massive mental facilities, but they shouldn’t be left to rot when they reach the point where they can’t help themselves. People should be entitled to their privacy and autonomy, but there are times when an imminent threat exists, towards self-harm or harm of others. People should be treated with empathy, but should recognize that involuntary commitment can be an expression of that empathy. The heartless thing is to nothing when nothing is not the best option.

The opening point of the oped, that Republicans currently have a better understanding of what needs to be changed than Democrats do, is correct. Though given the Republican interest in reducing healthcare spending, that basic good idea shouldn’t mean they get the keys on overhauling the system. It points to a need to look at American mental health policy and figure out what works and what does not. Zoellner is right that services may have no track record of success. It’s true that services are redundant and mismanaged- I’ve volunteered at the county level and it’s a complete mess. Even experienced people are finding new groups and services year after year they didn’t know about. The uniting factor is that most of these places get government grants and subsidies; transparency about where this money goes and whether it is overlapping is key.

There are two ways to look at mental illness, where neither is full right nor wrong. One is that anyone with a diagnosis is incapable of living independently and needs to be locked up. The other is that someone with a diagnosis should be given full privacy and any suicidal or dangerous statements shouldn’t be communicated to relevant authorities. It’s key to see involuntary commitment as a tool that shouldn’t be used carelessly (like in the past), but it shouldn’t be ruled out entirely. There have been points where I was in a dangerous place, and the last thing I wanted was a culture of silence where nobody felt obligated to get me more direct help.

There is no normal

It’s common to hear those living with a mental illness to refer to normalcy. They may even wish to be normal. In my teens I was part of that camp; bipolar disorder was isolating, isolation being the common denominator of all mental conditions.

But then, the thought drums at the back of your skull. It grows until you have to face it – what on earth is ‘normal’? What are its characteristics, and why have I aspired to be it?

Really, when people have some kind of isolating characteristic, they aspire towards a statistical concept. Normal is the mean, or the median. It’s not a real, tangible thing. It’s like the all-American family with their 2.4 children. The 2.4 can’t be applied to a single, ‘normal’ family. And all these normal, average metrics are just a combination of variation, and include extremes. 2.4 is averaged from many zeroes, along with reality-show families with two dozen kids.

In the end, I am normal. I’m a part of the average, with a lot of people like me and a bunch that are totally different. Dysfunction and function exist in a complicated relationship – what is weird or immoral varies over space and time. Ask the next ten people you talk to if they can define what ‘normal’ is to them. You’ll get >1 ideas from that sample.

Part of ending the pain of isolation is to end self-isolation- in which people define themselves as outside certain boundaries and barriers. These barriers can be real and tangible, but they are also self-assigned. Even if certain legal and economic obstacles are removed in the struggle for racial equality, people must emerge from those feelings of inferiority or superiority that came with those policies. Just because those with mental illnesses don’t get locked up for decades at a time that often doesn’t mean the separation ceases to exist.

Misdiagnosis, fear, the journey towards recovery

from the Mayo Clinic
from the Mayo Clinic

The San Jose Mercury News has a fantastic news feature out- “Misdiagnosed Bipolar: One girl’s struggle through psych wards before Stanford doctors make bold diagnosis and treatment.” It relays the experience of a middle-schooler (Tessa) who developed a series of violent and bizarre symptoms- not over a long period of time like many mental disorders, but within a couple of days. Several successive psychiatrists diagnosed Tessa as bipolar, although two Stanford doctors (Jennifer Frankovich and Kiki Chang) believed her symptoms matched a new and poorly-understood condition- Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Her brain wasn’t out of balance- it was under attack from its own immune system.

Misdiagnosis is all too common. In juveniles there is an ongoing war between psych professionals as to what bipolar disorder even is in that context. For the DSM-V standards, a controversial new disorder, Disruptive Mood Dysregulation Disorder (PDF), has been added. It will help better explain the huge spike in children diagnosed as bipolar, but don’t meet all the criteria. Or maybe DMDD doesn’t exist. Depends on who you ask.

A fear I have had is that when I switch to a new psychiatrist, they won’t understand my unique case and diagnosis. My current psychiatrist has a decade of data on my mood, symptoms, and reaction to medication- but that doesn’t all carry over to another person. That’s why I went to the Stanford Bipolar Disorders Clinic some time ago, and got a full intake with one of their experts. In short, that person agreed completely- I fit the criteria for bipolar II disorder, my mood swings are seasonal and rarely linked to stress or other aggravating factors. Together, there is a solid dossier of important information of who I am, and what the last nine years have been like for me.

A major issue some with bipolar symptoms have when they walk into a clinic and meet a doctor they’ve never seen before. Unless they’re actively in a manic or hypomanic episode, they may be diagnosed with major depression, and be given anti-depressants. This is a numbers game- more people have depression than bipolar. Looking at official numbers, it’s about 3:1 if you include chronic minor depression. However, anti-depressants are the worst thing one could prescribe for a bipolar. I have personal experience on this issue.

In 2012 I had a long period of chronic fatigue and depression- it was decided that a jolt of antidepressants for a short period could help break that.

And it did! Oh boy it did.

The situation was more complicated, however. Part of the reason I was so tired was that I had some untreated infection that eventually cleared. My body was getting more active and energetic on its own. The medication just shot my mood into the stratosphere. It wasn’t a typical manic episode (as type II I shouldn’t get those), but it was more intense than any episode before. This was my last major crisis; chain of medication aggravating the situation.

It’s terrifying to develop strange symptoms suddenly. Anyone who has had it happen in their family or among their friends knows the sense of anxiety and fear. That’s the nature of mental illness; it can happen to anyone, and each case is unique. Medication that works well for most may be worthless. Rare side-effects can crop up, even for people who had never had adverse reactions to medication before.

As with PANS, there may be other considerations that we don’t even know at this point. It’s 2014, science has made gigantic steps in the past decade, let alone the past century. Yet many neurologists think PANS is bullshit, and research on it is in its infancy. If Jennifer Frankovich and Kiki Chang are correct, then many families may get their children, wives, husbands, siblings back from the darkness. Still others are waiting for a diagnosis and a treatment.

 

Holding your two selves together

BipolarColor
Image by Andrew Mackay.

Growing up, I was diagnosed with anxiety at an early age. From age seven onward therapy was a regular aspect of my life- it was just another after school activity. Some kids went off to learn viola, I went to a biofeedback room to learn how I could control the fear and unease that ruled my life.

That was the diagnosis up until just before I turned fifteen- anxiety. General anxiety, social anxiety, separation anxiety. It was something, a vague combination of all the ways one can feel out of place and time. There were constants. To this day I hate calling people on the phone, which dates as far back as I can remember. But it was in flux. Maybe some of this was obsessive-compulsive disorder (a psychiatrist theory). Or just a weird adolescence. Perhaps I suffered the same fate as many ‘gifted’ children- a dysfunction around others, even those I had a lot in common with.

The lay of the land changed when the moods formed a pattern and my problems found a name. Ever since, life has been about reconciling old issues with newer ones. What is anxiety to me? Where does it fit now? Is it fully independent of bipolar, its own sovereign disorder- or perhaps that they feed each other in a cycle much like the steady sin wave that governs my mood swings and struggles with the extremes of bipolar disorder.

Anxiety, as it stands shortly before I turn twenty-four, is a symptom. A special sort of symptom, fed by hypomania followed by depression. It is the metaphorical headache that comes with reconciling two wildly different, but very real persons. After engaging in stupid or dangerous things while manic, my depressive self must deal with the social ostracism and humiliation. I’ve heard classmates and friends telling me they prefer the funny, hypersocial me- the same one I fear and hope never reappears. Each cycle one self creates commitments, strange friendships, debts monetary and not- then the other self must sift through them. A constant reminder of behavior that is both at times shameful and bizarre. Why did my depressive self let all this crap pile up? Why did my hypomanic self blow all that money?

To me, bipolar disorder is not just the two selves with little in common. It’s the attempt to be sinew, and connect the various fractions into a coherent self. It’s difficult and demanding- and gives me great anxiety. But anxiety is not a standalone issue- it is the water gushing from the crack on the dam. You can buy all the buckets you can find, and gather the water to keep it from flooding what lies below- but the water will never stop. The crack needs to be fixed. Thoreau spoke that “There are a thousand hacking at the branches of evil to one who is striking at the root”. Day-to-day maintenance is so overwhelming that in the past I could rarely ponder “why am I anxious?”

This present period of stability is incredible. It far surpasses the most raucous fun of hypomania, and it is the most treasured possession I have. It has allowed me to understand symptoms from a new perspective- the major cause is being controlled, so what still bothers me?

And anxiety is still there. I don’t like calling even close friends on the phone, or knocking on a stranger’s door. The anxiety is less widespread and reminds me more of my pre-bipolar past, talking with a soft-spoken psychologist and trying to control my breathing and body temperature with biofeedback. This is what remains, once the anxiety of reconciliation is kept to a dull roar. Like the tremor in my right hand from lithium, it’s okay that it exists. I can handle it. I’m okay.

The first day of the rest of your life

Yesterday the last of my college responses came. For the last four years I’ve been in and out of junior college, dealing with a bipolar disorder that was resisting treatment. Besides that, I realized in the fall of 2009 that the prep school utopia was not for me- I couldn’t switch from pressure cooker high school to a pressure cooker college, on to a pressure cooker career. That was a road with an unhappy conclusion. But I felt ready to try to transfer.

I got into all the places I had applied. When I first applied to colleges out of high school, I visited one and bought a lovely heavy long-sleeved shirt with the name on the front. When I did not get into that particular school, it always felt a bit strange (though the shirt was lovely and I couldn’t throw it away). This year when I visited my favored place I got a hoodie and played the same game of chicken. I’m glad it’s a reminder of what could be in the future, rather than a past hope.

There’s a comforting haze when the schools have yet to respond. The paperwork for the next step of my life was filed, but the mystery keeps it all from sinking in. I’m going somewhere in September to try for a degree. The junior college limbo period has ended; I’ve picked up enough pieces now, and in the process figured out what I need and what I can live without.

The commencement speech cliche that ‘today is the first day of the rest of your life’ hits home. Of course, that’s true for every day, but only at certain points does the perspective of that quote resonate.

Coming out…as living with a mental illness

In a perfect follow-up to my earlier post on mental illness and stigma, Al Jazeera America has posted a lovely feature about Elyn Saks, a distinguished legal scholar who “came out” as schizophrenic in 2007.

I think her story helps demonstrate a parallel between combating stigma about mental illness and combating stigma about being LGBT. Friday’s celebrity news was dominated by Ellen Page coming out as lesbian. The more people that are open and public about their sexuality, the easier it becomes for those who are still tentative about coming out. Saks, by deciding to emerge as a genius academic living with a serious mental condition, sends a clear message. Having bipolar disorder, or schizophrenia, or major depression isn’t a personal failing, and it doesn’t guarantee a life of missed opportunity. There is power in her story, where she went ahead with her dreams despite pleas to choose a less ambitious career.

There are many traits that can isolate us- being LGBT, having a religious or political philosophy at odds with our family or community, and yes, living with mental illness. The reason I choose to live openly as a bipolar is that I’ve come to learn that I am not alone. There are other people like me, hundreds of thousands in the United States. When Saks and those like her talk about their experience in public, it helps to show that the struggle you are having is not unique.

And that it’s not something to ever be ashamed of.