Going back to work was hard

I didn't want to go to work today. I didn't want to be at work. I felt lazy. I felt irritable. I know that I was just feeling the effects of having been off of work for several days- and transitioning back to work. I tried to remind myself of this- that it is not the end of the world. It was still hard.

It also seemed very unfair to me that I had to stay at work past sundown- there had been such beautiful sunshine earlier in the day. There ought to be a law against it. Give me my sunshine. Well, I did go out for lunch and ate in my car- I didn't want to come back in knowing that this was the last I would see of the sun for the day.

Tomorrow is a late day, and I plan to get some walking in before work. But I always plan. It is the implementation that is hard. I'll have to see what happens.

I had a good Christmas

I spent Christmas with my brother and family. Normally they go to my sister-in-law's parents but this year she was too close to her due date to fly, so they stayed home. It was really nice to spend time with them, and to spend Christmas with a 3-year old.

How did my brother become so normal? And I mean that in a good way- I actually think that he is a really extraordinary person. But of me and my cousins, he is the only one "making it"- living the life with a wife and kids and house and now a car and high powered job. Plus he has hiked the entire Appalachian Trail, served in the Peace Corps, lived and worked overseas in several very dangerous countries. Oh yes, and he has run several marathons.

I think my brother has a combination of a strong will yet resilience and adaptability. The strong will sometimes got him into conflict growing up- but due to his resilience and adaptability it didn't seem to hurt him long term. And his strong will has definitely been an asset in accomplishing what he has.

My niece seems to have his strong will at times- but mostly she is just amazing and delightful. She has such an imagination. And- she will do the same activity over and over again (with shrieks of delight), reminding me of how we need repetition to learn- and relearn (for my stroke patients).

It is amazing how advanced her language it. How is it that she was born just 3 years ago, and is talking so well now? And how could people have every thought that Skinner was right about language learning or development- that it is all reward and reinforcement? There has to be something preprogrammed into the brain, guiding language development. But this goes back to my graduate school days in research psychology- when I wanted to have two cats, one named Skinner and one named Chomsky. If I ever have cats again- they are all going to be named after scientists. That is what I decided.

The next time I go to visit I will have 2 nieces. That will be really exciting.

I'm still on the higher Zyprexa. I think that, when things are good, 5mg is okay. But things aren't good all that much. I have more resilience on 7.5mg. Maybe after I finish the DBT group I will have enough stability that I can try going down on it again. I really don't want to hit 50 on the higher dose- it is post-menopausal women who have the greatest chance of getting tardive dyskinesia. But at least until I finish the group, I will take the higher dose. I need some stability in my life.

Finally some good news

It is benign. I had my follow up appointment with the breast surgeon this morning, and it was benign. I am so relieved. The past couple of days I had started to obsess, and I was actually reading about DCIS- which is what it probably would have been if it wasn't benign. And while my surgeon had said that it wasn't that serious, very easy to treat... they typically do a lumpectomy and radiation for that. Not something I would want.

Today my mood was better- but it has been pretty bad at times recently- but then I had the insight that some of it might be low blood sugar. I need to eat carbs in the morning- sometimes I don't, like yesterday- and I just didn't think I could go on living by noon. And I take 1000mg of metformin twice a day (because of the Zyprexa, not diabetes) and my A1C is 5.1, the lowest it has ever been. I need to have more than a protein shake with 2 grams of carbs for breakfast. But that has been my lazy breakfast recently.

Last night something weird happened. I woke up in the middle of the night, feeling extremely anxious and my heart pounding. I felt fine when I went to sleep. I took a klonopin- a whole half milligram- and went back to sleep. That doesn't usually happen to me. But it had me a little foggy today.

I am watching Syfy's Ascension mini-series on demand. I just finished the second episode. I think it could have been a lot better. I think even the premise could have been a lot better. They keep saying, "Ascension is the lifeboat for humanity." Well, I thought that perhaps maybe the whole ship and crew were all simulations on a computer, and because humans had destroyed the environment, this was all that was left for humanity- to be simulations on a computer. Or maybe a plague has made the earth inhospitable- so they are living in the life boat. But by the end of the second episode, I still can't really figure out what their purpose is.

The show has way too much sex- and not enough science. Aren't there supposed to be a lot of smart, intelligent scientists on this ship?

I have one more episode to watch. And then I have to watch the finale of the Colbert Report. I will really miss him. I wonder what he will do with the late show. It will be interesting to see him "out of character."

I finally looked

My incision is bigger than I thought. It it more triangular than a straight line. I guess that is why no sutures- they let it heal on its own with just steri strips. Thankfully it spares the nipple, but it is pretty close. All in all- it is a little worse than I thought it would be, but I can live with it. Well, I'll have to anyway. I think I'll buy some good scar stuff to put on it. Assuming of course that this is it- that this is a false alarm. And that I don't have another surgery in my future.

I have enough scars on me already- arms, legs, even a few on my stomach. Even my appendectomy scar. Somehow this one is different- or maybe it is different because I don't cut anymore. And because I want to have sex again someday. There, I said it. I do want that.

Except that most of today I didn't want that- I didn't want to be alive. It was a rough day. I am tired of these bad days. I was tired of the fight today. If I didn't have moments when things weren't a fight- then maybe I would have an easier time accepting that life is just a struggle and get over it. But I have moments when it isn't, and then I think that is how it should be- and then I hate the struggle even more.

Thankfully I saw my therapist today. It gave me some perspective, made me realize some steps I need to take- although how to take those steps remains the challenge.

Had my biopsy, wasn't so bad

The hardest part was being still. There is this table that looks deceivingly like a massage table, only it is bigger and has a hole for your breast to stick through when you lie down on your stomach. Then they can do what they need to do. It was a stereotactic core needle biopsy. Afterwards I had to go next door and get another mammogram to make sure they got the right spot- they leave a metal clip in afterwards so that it will always show up on my mammograms where I have had my biopsy.

Everyone was very nice. But now I just have to wait until Friday. That is when I go for my follow up.

What is nice about this (if you can say that anything is nice about this)- is that it is all paid for. They are all take insurance and are in-network. I have met my in-network deductible, and almost all of my in-network out of pocket maximum. Very different than my mental health care.

Although it isn't just mental health care. We have a neurosurgical group that operates out of our hospital that doesn't take insurance. As of January 1st, we can't even use our hospital insurance towards payment to see them, if we needed that kind of care.

But for the moment I will be glad that my breast care is covered- and hope that Friday I will get the news that I don't needed more care. And not just because of the money.I really hope this was much ado about nothing.

No salvation in a self-help book

I am halfway through my book on Acceptance and Commitment Theory and I am giving it the thumbs down. Maybe it is better in person- by book it is too cognitive, yet too simplistic. But what self-help book isn't simplistic? What self-help book doesn't assume that your life isn't really terrible screwed up and you just have to change your emotions and thoughts?

I love when it asks me to write the story of my suffering- and gives me one and a  half pages. Where do I even start? And what does that even mean? What is suffering? It is not all unitary, not all of the same source. And then it tells me to keep the facts- but write the story in a different way. No need. I do that all the time in my head. I am all too often in "problem solving mode" as my therapist would say. I try to figure things out a lot.

That has always been my problem with cognitive therapies- either my mind is numb and blank, and I don't know what I am thinking- or it is so full of thoughts that there isn't any one in particular that is giving me most of my pain. Plus, when I am seriously depressed, if you point out to me that my thoughts aren't logical, I usually won't care. I will think that somehow the thought is still true in my case.

Meanwhile I am battling terrible anxiety today- and I think it might just be partially biological. The IBS has been really bad- maybe not getting full effects of meds. Plus I think I have been drinking gallons of water over the weekend. It is just really dry in my apartment and at work and my lips get so dry that they crack and bleed, so I have just been drinking water. So maybe my lithium is low. That, plus I wanted to go into work for paperwork (won't). Plus breast biopsy tomorrow.

Instead I took extra klonopin and even a little Zyprexa- I am still anxious. This sucks. I want to to be late enough to go to bed. Just to go to bed.

I'm not worried about the biopsy- just the waiting part. I can't believe I am doing this. There are times- and fairly recently- when all I wanted was some fatal illness. The only reason I started doing mammograms was because I was being hounded by my PCP.

I haven't felt that suicidal recently, but I have wished for death. I just want to stop the fight, I want to stop trying. I can't say that it hasn't gotten easier- sometimes it is- but it is clearly still a fight. And even the damn ACT book is depressing, emphasizing that it is still a fight. OK, you feel lousy you don't want to do anything. Ignore that  (sorry- accept that). Do stuff anyway. Can you live your whole life that way?

If the paperwork doesn't get any easier, I have decided that I can't work 40 hours a week anymore. But it might be easier when we go electronic. No- I know a lot of the electronic documentation is worse- but I won't be drowning under stacks of paper, losing scripts, and I will be forced to do my notes in a timely manner. I am hoping that saves me. Otherwise I have to cut my hours or go somewhere where I can work fewer hours. Fewer hours means fewer patients means fewer charts to document.

I'm tired of fighting paperwork. My anxiety and depression. My weight. My fatigue. Sometimes I just want to give in to everything. But I know how that ends, and it is not good. So I keep fighting.

I guess I just can't drink at all

I'm not much of a drinker, never was. I know that it tends to make me depressed- I learned that early. Believe me, if alcohol was an antidepressant for me, I'd be an alcoholic.  But I do like a good glass of wine every now and then or a good ale. I'm a social drinker, but I'm not very social- so I don't drink very often!

Last night we had our work holiday party and I had a small- very small- glass of white wine. This morning I got up and then couldn't figure out why I was so sleepy and tired after sleeping so long and went back to bed for 3 hours. I'm finally better- but this is the problem with me and alcohol- not what it does to me when at the time, but the after effects the next day. I just don't feel good.

I know that my meds, especially the effexor, delay metabolism of alcohol, so it probably sticks around longer. I can live without alcohol- I just wish I could have the occasional glass of wine. Still- I'd rather give up wine than coffee! Although I am cutting back on the coffee because of heartburn... it sucks to get old. Coffee is my favorite drug, and it really has an antidepressant effect for me.

Now that I am up I am trying to do home things- marathon laundry, some cleaning, etc. I gave up on walking today because it will be dark before I am done with laundry. Maybe I can do some dumbbell exercises at home. And I did my meds/vitamins for the week.

Last week I didn't take my supplements because a lot of them increase bleeding and I have the biopsy on Monday. But I shouldn't have stopped my fiber supplements- my IBS is getting bad again. I started taking them again today, and it seemed to have helped some already I think. It isn't what you would expect- that fiber would help with diarrhea. Meanwhile I am trying to figure out what to eat- I had been able to get away with not following the FODMAPS diet too closely for a while, so I don't have a lot of safe foods in the pantry. I was going to eat broccoli and cauliflower with cheddar cheese for one meal today, but that is probably one of the worst meals I could eat.

Does torture work and does that question matter?

There are two separate questions- does torture work, and should we torture. And they may not be all that related. Because if you think torture is wrong- then if even if it works, we shouldn't do it. And if you think torture is a necessary show of force- then it doesn't matter if it works either. Admittedly for some people there is a gray area- it is okay if it works, not okay if it doesn't work.

Today the Obama administration came out with its report on our bad behavior regarding treatment of prisoners. I'm not sure it was necessary. I don't know how much was new, what we learned- and the cost is inflaming the enemy. But it is what it is. I am hardly following the news these day- other than listening to NPR in my car. It is just too depressing and there is nothing to do about it and some of the really serious stuff affecting our future no one talks about or gets really wrong.

It was a really slow work day today- I had a lot of cancels for various reasons- which meant it was a very good paperwork day. But I went home with a stiff, aching neck. And I felt like I had been at work for much longer than I was. I went home brain dead.

I am signed up for a DBT group in my town starting next month that I found on Psychology Today. I am really glad there is something local now- other groups are an hour's drive away- something I don't have the energy to do at the end of a work day.

I am so mad about the changes to my insurance and no out of network benefits next year. I can't believe they would do that. It is really hard for mental health, because so many providers do not take insurance. Psychiatry has the highest rate- 50% of all doctors who do not take insurance. Of course my hospital does have a clinic- and I'm sure they would want me to go there- but I have not heard good things about it. And they have a long waiting list anyway.

I am using the breast surgeon at my hospital- they have a good program. Somehow I thought she would have access to my records from my PCP- because I see one at the hospital. But no, they had to have all my meds faxed over. So much for electronic medical records.

I wonder who I would use for carpal tunnel surgery? I am having more symptoms recently- although today was better. I think I just have to get back to using my braces at night. But sometimes I wake up in the morning and they are off- I must have taken them off during the night.

Once I had a patient who told me that his splint kept falling off. I kept adding straps- until I realized that he must just be taking it off during the night and not remembering. I think that is what I do, especially when I am hot- and my bedroom is hot. My living room is freezing and my bedroom is hot- there is no way to set the thermostat to have a cool bedroom and a living room that I don't need a winter coat in. Sometimes I just give up and open the window.

I saw the surgeon today

She was great- really down to earth. This is nothing to worry about. It was a very small area of calcification. It probably isn't cancer, but if it is it is in the earliest stages and we can take care of it. So next Monday I am scheduled for a breast biopsy. Now all I have to do is move my patients. 

There is a part of me that thinks God wouldn't give me both bipolar and breast cancer. I know that is not rational- but there is that feeling. And then there is the thought that I could never have anything as trendy as breast cancer. If Sheryl Crow and Angelina Jolie have it, I probably don't. I know, not rational. They say bipolar is in these days, but no one is going around wearing ribbons for bipolar. I wonder what color they would be?

It is really a testament to the movement that breast cancer is so out there. Two taboo topics- breasts and cancer- and now people can't stop talking about it. Colon cancer doesn't seem to be doing as well in the PR department- even though it kills a lot of people too- maybe even more, I can't remember. And the evidence for colonoscopies is better than the evidence for mammograms.

My mom has offered to come up for the biopsy. But I don't know how she would manage it with my grandmother, even with the help they have. And I think I would just be reassuring my mom the whole time.She didn't even want me having this biopsy- she wants me to go the alternative route. So I said no. They said I can drive myself. But that I should stay home for the rest of the day. I had better go grocery shopping before hand.

Where is the dialectic?

I am about a third through my book on Acceptance and Commitment Theory. Some of it is useful- but it seems a little all or nothing. There seems to be even more acceptance involved than in DBT. And, taken to its logical conclusion (and I take everything to its logical conclusion), it seems to be incompatible with the use of mediation- because that is a form of trying to run away from your pain- at least if you have depression, anxiety, or dysphoric manias. If you are medicating euphoric mania, I'm not sure where that fits.

So I'm looking for the dialectic. If I can take medication, get physical activity, regulate my sleep, eat healthy, etc., because I know that this will result in less mental pain- isn't that a good thing? And can't that be integrated into a theory that also involves acceptance- and getting on with life in the face of this pain? Maybe this happens later in the book.

What I am taking away from it right now is the emphasis on not over-identifying with internal states and not over-interpreting thoughts as real. There was a term for the latter, but I can't remember it. So anyway, this afternoon, when I felt my mood start to dip- I told myself that I am experiencing feelings of depression and having discouraging thoughts. Did it help? I don't know. I also had a piece of carrot cake- I probably would not have had that if I was feeling better. But a couple of hours later I did feel some better.

Feeling paralyzed

I have things to do and I feel like I can't move. I just can't get myself going. It doesn't help that it is dark and rainy out- I need my sunshine. I just want to sleep, or at least do nothing. But I have said that I would make it to my dad's by dinner. And I have two errands to do before then. And my apartment is a complete wreck. And I have to pack my overnight bag because I am staying overnight.

I guess that is a muscle that I have to build- acting when I feel paralyzed. It is no use wishing that I didn't feel this way- or worse, thinking about the kind of life I could have had if I didn't have to so frequently fight just to act.

The problem is, my old weapon used to be cutting, and I really haven't found a new weapon- other than sheer force of will or telling myself all of the bad things that will happen if I don't act. Those can work, but there is only so much I can use them before I just start to feel like life is too much bother.

I haven't quite figured it out. I haven't read very far into Acceptance and Commitment Therapy, but I think that they are going to say to ignore- no accept- how you feel, but do your life anyway. Which is very hard when you feel like you physically cannot move.

But at least there may be a physical reason for this, which is the lack of synthroid last week. I'm back on it, but maybe it takes a while to get back to normal.

My own personal energy crisis

I have been really tired- not sleepy tired but physically tired and light headed, starting in early afternoon and lasting the rest of the day. I dont know what to make of it- I can only hope that it is the effect of running out of synthroid (which I finally got today), or from now taking all of my Provigil in the morning instead of breaking it up to twice a day.

But it makes me good for nothing later in the day, and it makes me worry. Not so much about my health, but rather the effect this has on my ability to have any kind of life. It is only in the mornings that I can be productive and do notes, etc. The latter half of the day is awful. The days I work evenings are truly awful. Yesterday my last patient did not show and I left early.

I suppose I have to give the synthroid some time to get back into my system. And them maybe try to splint my Provigil dose if that doesn't do anything. And then, if that doesn't work, go to the doctor. But I don't want to go to the doctor while I am still dealing with the breast biopsy stuff- one thing at a time.

And then I tell myself maybe I just need to exercise and lose weight- maybe that is catching up with me. Or maybe I just take too many meds.

Anyway, I am a year older. Google Chrome knows it is my birthday- and that is scary. I recently read a study which said that happiness in Americans is at its lowest level at the age of 47, and then it climbs back up. So in theory I have just had the most miserable year of my life and things can only get better.

I am currently reading a book on Acceptance and Commitment Theory. I need something. Maybe that- or to get back to DBT seriously. I need something. I need to change my life.

I've become a klonopin wimp

When I was first put on klonopin, way back when, I was taking 10mg a day. These days I take a quarter to a half milligram a day. Yesterday turned out to be a really bad day, and I was tired of bad days- and realizing that Zyprexa was not doing it for me. I decided to take klonopin until the screaming inside my head stopped. I think I took all of 1.5mg.

It worked. The screaming stopped. Although I was holding on to furniture to go to the bathroom and realized that I couldn't drive to the nearest store to get food. I was an impaired driver. Eventually I slept. And woke up- feeling okay. Not drugged. But I fully expected a hit of anxiety or panic to hit me today at work as the rebound effect kicked in. Surprisingly, I didn't have any anxiety. Instead, around lunch time, I got very tired and lightheaded. Now, I get that a lot- but this was really bad. Like I knew there was no point in going home sick because I couldn't drive. Like I wondered if I should go to the Emergency Room. And then, magically, it started to lift a couple of hours later. Just in time for my rush of afternoon patients. Still not an easy day, but I didn't collapse.

But I didn't make it to the pharmacy at work to fill my Synthroid. I have been out for 2 days. Not good. They have such limited hours that I have to go during lunch, and during lunch I could barely stand up.

I am still feeling tired and weak and a little light headed, but not anything like I was. Hopefully tomorrow I'll be back to normal- physically, at least.