5 Jan 03 - Diary
'Tis the time to make New Year's resolutions. But what happens if your life is sufficiently unstable that predicting what will happen in the next two weeks is impossible. What good are resolutions then? Why bother to make them.
This sounds trivial, but it isn't. One of the biggest problems that us bipolar persons have is the despair that we can't make plans for the future. At least ones we can believe in. And having no plans makes it hard to continue on. It's no wonder that our suicide rate is so high.
Having gotten caught in this trap myself, and not being able to figure out how to extricate myself, I promptly made an appointment with my therapist (other people go shopping, I see a therapist - sigh). So far, we have spent some time tossing this problem around, which includes the despair and the identity issues that are part of this problem. But I also wanted a practical solution. How do I make plans for the future?
The complaint I made is quite straightforward, and my therapist's response is elegantly simple. Here's how the conversation went.
I was complaining and carrying on about I couldn't plan anything. I wanted to get my psychology degree, but this meant taking classes. And classes have deadlines and times to be in class and end of term exams. Given my inability to meet deadlines consistently, how was I supposed to succeed in any class I took.
I also wanted to lose the little roll of flab around my tummy (don't we all), and I kept setting goals such as I will lose 5 lbs by the end of November. And of course since I still have the little roll, somewhat enlarged, that goal failed miserably.
The plans for work are in a bit of tatters. Some of the projects I wanted to finish in 2002 aren't finished yet. Some aren't even started.
And so on.
So after listening to me carrying on for a while, and my complaining that all tasks nowadays are time based and deadline based, and therefore I can't do them, my therapist made the wonderful comment - "What happens if we take the time factor out of the things you want to do." So I opened my mouth to say how does that help, and then the statement actually settled in.
So I shut my mouth and thought about it for a bit. And I thought, well, this might actually work for quite a number of my goals. My therapist then continued saying that if my problem is with trying to achieve things by some future date, why allow myself to get hung up on which might happen in the future. Why not try to deal with the here and now. After all, all goals are made up of a series of tasks. So instead of focusing on the goal six months from now, focus on the one task that can be done now that gets you one step closer to your goal. And when that task is done, focus on the next task that can be done. And so on.
The procedure my therapist suggested is elegantly simple.
Generally a goal contains two parts (a) what you want to achieve and (b) when you want to achieve it by. Once these two things are set, then the goal is subdivided into tasks to do. But I can't deal with item (b) - the "when" part of the goal.
So instead the goal is reformulated. It still consists of two parts and the first part is what you want to achieve. But the next step is simply to immediately splinter the goal into the tasks that need to be done. So I have a (a) what I want to achieve and (b) the tasks needed to achieve it. In this procedure there is no due date. I complete the tasks as I am able to do given my mood swings. It may take me 6 months or it may take me two years. But as long I am completing the tasks that constitute the goal, then I am moving forward and I know that I will achieve the goal at some point.
Therefore, instead of believing that I am a failure because some date has come and gone and I have not achieved what I want to do, I measure my success on what I have already done. And although I divide my goals into tasks, I try not to look too far ahead in time. Since I can only reasonably predict what I can do for the next two weeks, I only look forward in time for two weeks and determine what tasks need to be done during this time. And when these two weeks are gone, then I look forward to see what tasks I have to do for the next two weeks. And so on.
Remember earlier I was saying that I could not predict what would happen in the future and therefore I thought I could not make plans. But this method of splintering my goals into tasks and limiting my time horizon to only the time where I have reasonable control over my life adds back the one element that has been missing from my plans recently. I can believe in them.
And that makes all the difference in the world.
Here's the difficult part. It's not so easy to shift from time oriented goals to task oriented goals. It actually requires more work up front to determine what the tasks to reach the goal are. And of course there is always the danger of writing the tasks in so much detail that you look at the list and become discouraged. There is a balance of writing enough detail of the tasks needed for the goal to keep you going and writing too much. And it is very difficult to leave off the time factor - as in "this task has to be done within the next three days." It takes a while to get it working reasonably.
With this system, the tasks get done when they get done, not when you would like them to get done. Don't try to fight the fact that the mood swings screw us up. Take them into account when you plan and assume that things can and will go wrong. Focus on the things you achieve and how they have racheted you up so that you can do the next task to achieve your goal. Do NOT focus on the time that has passed - therein can lead to despair.
GOALS
Old Version GOALS
New Version
Do Exercise Program
Start: 26 Aug 2002
Finish: 26 Nov 2002
Specific Goals
Lose roll of flab around stomach
Get 28" waist
Increase muscular strength
Change posture and increase flexibility
Requirements
One hour a day for exercise
Half hour a day for stretching / posture Do Exercise Program
Specific Goals
Lose roll of flab around stomach
Get 28" waist
Increase muscular strength
Increase flexibility so I can touch my toes with my palm on the ground
Tasks (all are weekly / ongoing)
Yoga on mornings
40 minutes run / cycle / swim 3 afternoons
Hashing on Saturdays
Sunday morning cycling / runs
Work on Web Site
Start: 26 Aug 2002
Finish: 28 Feb 2003
Specific Goals
Answer all e-mail daily
Create a section on the medical / physiological aspects of being bipolar
Talk to MIT about acting as a resource.
Requirements
Two hour daily for e-mail
5 hours per week for ancillary development. LivingManicDepressive Web Site
Specific Goals
Put answers to e-mail on web site
Create a section on the medical / physiological aspects of being bipolar
Promote website
Tasks (ongoing)
Answer e-mail
Tasks (sequential)
Redesign website
Then promote website on search engines and awards
Then redesign once or twice a year
Write section on friends and family
Then create section on the medical / physiological aspects of being bipolar
Then write section on college life
Contact Alumni Association of MIT regarding assistance to students
Study Psychology
Start: 26 Aug 2002
Finish: 31 Mar 2003
Specific Goals
Research and write up information on being bipolar.
Research and write up the physiological aspects of hormones and neurotransmitters
Requirements
Treat as different classes:
Basic physiology of neurotransmitters (Fall 02)
Manic depression with a slant to neurotransmitters (Fall 02)
Basic physiology of hormones (Spring 03)
Problems with hormones. (Spring 03)
Each class requires seven - ten hours weekly per subject (14-20 hours weekly) Study Psychology
Specific Goals
Write up information on being bipolar in everyday English.
Concentrate on the physiological aspects of hormones and neurotransmitters.
Tasks (sequential)
Read up on basic physiology of neurotransmitters
And write up bipolar thoughts / theories using information
Then read up on manic depression with a slant to neurotransmitters
And add or modify information on what was already written
Then read up on basic physiology of hormones
And add or modify information on what was already written
Then read up on Problems with hormones.
And add or modify information on what was already written
Merge writings with website as needed
Start Relationship
Start: 26 Aug 2002
Finish: no finish date
Specific Goals
Get C. back
Court as a new partner everyday.
Requirements
Get help in getting C. back
Do something special at least once every two days. Start Relationship
Specific Goals
Get C. back
Don't ever take C. or any partner for granted again.
Tasks (sequential)
Get help in getting C. back
Then if it fails, start looking for new partner
Tasks (ongoing)
Do something special for my partner at least once every two days forever.
Office - Update Computer Systems
Start: 26 Aug 2002
Finish: 31 Dec 2002
Specific Goals
Implement Inventory System
Implement Job and Holiday Pay Systems
Implement Roster and Posting Sheet Systems
Implement Training Information
(Extra)- Link Roster to Pay System
Hire Data Entry Operator
Requirements
Spend one full day per week at office working on system Office - Update Computer System
Tasks (sequential)
Implement Updated Pay System
Including Write User Manual
Then Implement Inventory System
Then Hire Data Entry Operator
Then Implement Job and Holiday Pay Systems Then Implement Roster and Posting Sheet Systems
Then Implement Training Information
Then (Extra) - Link Roster to Pay System
I've also been realising that the exercise seems to be stabilising me substantially. I've always known that this was true, but I have never been able to get the exercise to prevent the onset of depression. However the increase in exercise that I've been doing does seem to do that now, or at least work substantially better than before. I think that perhaps there is a threshold amount of exercise that I need to do before the exercise prevents the depression from happening, and I've recently crossed this threshold. Perhaps. I'm currently running between 10-12 miles on a Sunday, running shorter distances once or twice during the week, and doing 20 minute power builders (interval training) three times a week. It sounds a lot but it isn't really.
An alternative theory is perhaps it is the quality of the exercise that I have been doing. Perhaps it is the amount of aerobic work that I have been doing that makes the difference. The running has been substantial and most of the other exercise has been aerobic. In the past I tended to do more gym / weight training.
Well, whichever reason it is, it's working. And I'm not about to argue when it works. If it ain't broke, don't experiment with it.
21 Jan 03 - Diary
I started taking Wellbutrin (Zyban; 150 mg sustained release once per day) 5 days ago on Saturday. So far I like it more than Prozac - it's a much less intrusive drug with regard to side effects. In fact I haven't got any side effects except that I started having sinus problems and sneezing Saturday night. It felt as if I had an allergy reaction similar to hayfever. Except that I don't suffer from hayfever. Of course I had the flu as well, so I wasn't too sure which one was causing this. But I had had the flu for a week before and I didn't sneeze at all. Then I start taking Wellbutrin and I start sneezing continuously. Very suggestive.
The sneezing was actually quite annoying - ask anyone with hayfever. But because it felt more like the flu and less like a side effect of a medication, it didn't feel as if it was the Wellbutrin's fault. So even though the Wellbutrin did affect me substantially, I don't feel as if it did and I still like it.
Although the Wellbutrin has had no noticeable effect, that may be because I took it on one of my up cycles. It may be somewhat camouflaged by my mild mania. I have a sneaking feeling that the Wellbutrin is contributing to my mild mania, but because I'm still in the "high efficiency" section of the cycle, I'm not worried. I'll worry when I get into the "I can't think clearly anymore" phase.
Just for comparison, Prozac would have brought me off the mania by now. You can see why I like Wellbutrin more.
I've started taking back an antidepressant mostly because I will be going on a one month pilgrimage in February. I'm expecting it to be reasonably high stress and I don't want to get depressed while I'm on it. Hence I've started on medication two weeks before I go to make sure I'm primed, and I'll stay on it. We'll see how this works.
I'm also writing this at 3 am. In order to get rid of my cough and the sneezing, I went to the pharmacy this afternoon. Just for the record, it is now almost impossible to get a tablet just for sinus problems or a cough syrup just for cough suppression. Most tablets have combinations of drugs - pain killers, antihistamines, decongestants, expectorants, cough suppression ingredients, and occasionally codeine. This might be all fine for the flu, but I have to worry about drug interactions between all these and the Wellbutrin and I'd rather get each drug separately. Anyway after spending nearly twenty minutes reading labels I finally got a cough syrup with dextromethorphan (the most common cough suppressant medication) and a tablet for my sinus problems.
And so I went home and then spent half hour on the internet looking up each of the active ingredients in the medicines and looking to see if any had warnings not to take with Wellbutrin. No obvious drug interactions or warnings. Then I had a good meal, took the Zyban, took the cough syrup, thought about it and held off on taking the sinus medication. And then I went to sleep at about 9 pm because I was tired.
So, it is now after 3 am and I am wide awake and alert. I actually got up close to 11 pm after two hours of sleep. The cough is gone completely and so is my desire to sleep. I'm betting that the dextromethorphan in the cough syrup is interacting with the Wellbutrin. My sinuses are clogged and painful because in addition to everything else they don't particularly like being awake at this hour, but I'm afraid to take the medication I brought. Who knows what will happen if I do that.
So off I go. What can one do a 3 am?
2 Feb 03
A lot has happened in the last week. Probably the most important was that I ran support for my cousin for a marathon. She's just about 5 feet tall, is the mother of two kids and she ran 26.2 miles. Right. I want to be like that. All I was able to do was half that - 13 miles.
Still thirteen miles wasn't too bad. More importantly, I was able since before Christmas to stay stable enough to take part in the training for the marathon and take part in it. This is a far cry from the November experience when everything failed me. Perhaps things are looking up. I'm optimistic but cautious. When I stay this stable for about six months, then I'll feel that I'm getting somewhere.
Meanwhile, there is a four hour adventure race taking place in May and a 100 mile bicycle race taking place in July and I want to participate in those too. Ye hah!
In case you are wondering about the sudden spurt of exercise, I have happened to have fallen into a group of friends who take the exercise stuff seriously. Well, not too seriously because we have a fun time doing it all. Still, we are running and cycling and kayaking when we can. And because we aren't competitive with each other and because we provide lots of support for each other, we've built a cohesive group and we spur each other on.
I've been realising that groups are my salvation for stability. I am able to spread any support I need among many people instead of burdening any one person. Also because in any group people often take a week or two off and then rejoin, my absences due to depression aren't as problematic. The group continues even if I am not there. And it is there for me when I'm no longer depressed.
I'm still taking the Zyban. This is pretty impressive. I usually don't stay on any medication this long either because it stops working or because it causes me problems of one sort or another. Actually, I can't tell if the Zyban is working because I started taking it on when I was manic. And it has no apparent effects that I have noticed in all of the other drugs I have taken. On the other hand, I should have gotten depressed by now, and while I did notice a dip in productivity one day last week, I never was anywhere close to being depressed. So perhaps it is working.
To summarise. I'm not sure the Zyban is working. But I'm not depressed so perhaps it is working. But it could be that I just haven't had a depression period, so perhaps I haven't really had a chance to test it yet. I kinda feel like that joke about the guy who goes around waving a fan made of ostrich feathers. When asked why he does it, he says it's to keep the pink elephants away. And when he is told there are no pink elephants, he says "see, I told you it's working."
This is the kind of thinking that is enough to drive you crazy. I'll just not keep going in those circles and keep on taking the Zyban. The longer I don't have a depression episode, the more I'll believe that the Zyban is doing something.
I've also have a theory about why so many bipolar persons stop taking their medication. It has to do, in part, with the difference between how Prozac and Wellbutrin affect me.
Let's start with the basics. If I'm depressed I won't take medication. So I have to start taking the medication when I'm feeling good, and hope that it kicks in before I get back depressed. And here is where the difference between Prozac and Wellbutrin is. Prozac works pretty well against depression. I know this. Unfortunately it also tends to bring me somewhat down off my hypomanic moods. So from my point of view, if I start taking Prozac while I'm hypomanic (as I need to do), I actually have an immediate decrease in the quality of my life. Prozac does damp my depressions so that they are milder, but I still will notice that I am getting depressed. Psychologically, I will end up feeling that I am giving up my hypomania for no great improvement in my depressive episodes.
More objectively, if the damping effect of the Prozac on my hypomania is greater than the damping effect on my depression, then although the Prozac works as advertised, I end up a net loser. So I may choose to not continue medication, even though I will simultaneously admit that Prozac works well as an antidepressant.
(Actually what I check is if the drop in productivity because I am not as manic outweigh the gains in productivity because I am not as depressed.)
Since Wellbutrin has no noticeable effect on my hypomania, and it seems to decease the severity of my depression, I feel comfortable taking this when I am manic. I feel good during the period I am taking it, so there is no reason for me to stop taking it. So while Wellbutrin probably doesn't work any better on my depression that Prozac does, I am more likely to stay on Wellbutrin than I would on Prozac. As is the case. I take the Wellbutrin consistently while I am more ambivalent about taking Prozac.
The point is, it is not sufficient to look at antidepressant medicines as just wether they relieve depression. They also need to be looked at as to how they affect hypomania as well as it will make a substantial difference whether we actually take the drugs.
More on drug interactions with Wellbutrin. While it doesn't seem to affect my hypomania, it does seem to interact with almost every over the counter drug I've taken. And not for the better. I've mentioned how dextromethorphan (cough suppressant) and Wellbutrin interact to keep me awake. I've taken the common nasal decongestant (pseudoephedrine hydrochloride) one night and it seems to interact with Wellbutrin to put me to sleep the following day. Not helpful. Moreover, two beers interact very badly with Wellbutrin to make me nauseous.
Beautiful. I'm passing up on alcohol at the moment, and I'm now afraid to take any drug in addition to Wellbutrin. At some point I going to have to take Acetaminophen (the pain reliever in Tylenol), and I wonder what the drug interaction effect will be. I'm not looking forward to this at all.
To change the subject. My one month pilgrimage will be starting on the 4th February. I will see if I am able to stay on Wellbutrin all this time and if I don't get depressed.
Hope that I can report on the best news - that it goes as I plan.
17 May 03
For those of you who need a bit of encouragement, I took part in a 6 hour adventure race - running and riding off-road. My recommendation is never to torture yourself doing this, well, unless you really like to. But taking part and finishing the race did prove a point to me, that I can plan to take part in a future event and stick with it.
Of course, I was able to do so only because I am now taking Wellbutrin and it works in stabilising me. It took me five years and quite a number of trials and failures to get a medication that actually works, but I now have proof that if we experiment with our medications (with medical advice, please) we can eventually find one that works the way we want it to. So keep on truckin'.
For me, the great thing about the adventure race is that I've finally gotten proof that when I am stable I can do exceptional things and do them well. That's really reassuring to know. I am not a loser.
I'm back to answering e-mails, but please give me until Sunday night (19 May) to catch up. For people who are now writing me, expect that it may take me up to seven days to respond. And thank you all for your e-mails. Your help me feel good about myself and that keeps me going.