Thursday, January 7, 2010

The Lynch pin

Today was my appointment with BossPsychDoc, to re-evaluate medication and decide whether it was appropriate to discharge me from Public Mental Health Case Management.  I had an extraordinarily (even by my standards) night's sleep last night, and really I don't feel like I slept for more than two hours, broken. It was just that 'barely floating below the surface' sleep, broken every 20 minutes or so by awakenings. I think it was somewhat exacerbated by the nervousness I had about today's appointment. I was supposed to get a home visit from the Case Manager in the morning, but she rang to cancel as she had been called away to an Emergency. I was ok with that, she is very reliable and this was just one of those things. But it was somewhat of a bummer in that I really could have used the opportunity to have a chat and organise my thoughts with her, before the appointment this afternoon. Like everybody else, she got the 'blase, I'm fine' demeanour from me on the phone this morning, but she did suggest that I take a moment to just write notes on everything that I wanted to say, to take in with me. I did try to sit down, and organise my thoughts, and chart an accurate picture of where I was at, symptomwise... ie anxiety level, depression level, self-harm thoughts, sleep ect. But I just couldn't get my brain to co-operate and this coupled with (D's) warning from monday, made me quite nervous. I started trying to plan out in my head how I was going to approach my current issues, and the crap that therapy throws out, without the safety net of Case Management, and also how I was going to afford a Private Psychiatrist after I was discharged from the service. I was certain that I would not be able to talk to the consultant honestly, and he would just take 'Game Face' Ophelia at face value, and decide all was well to discharge. I did manage to write out a list of all of the sleeping medication that I have been prescribed at various times over the past 10 years... it looked like this:

Over the Counter Meds
Valarien (Sp),Restavit
Prescription Meds
Temazepam, Valium, Stilnox, Clonazepam, Prazosin (A blood pressure med that has been found useful in diminishing PTSD nightmares), Xanax, Serepax, Largactil, Seroquel and Avanza (my anti-depressant chosen as it also has sedative qualities).
Other than that all I managed to scribble out note wise for what I wanted from the service was- Sleep! If not- Continued support from someone I already know (Case Manager) until therapy can allievate the sleep situation.

So, 2.30pm came around and I set off up the street to the "Grey Amorpheous Building of Doom- AKA Public Mental Health) handily located a way up the main road that I live on. I'll confess, I did have a little tumble off the wagon, and smoked a cigarette on the way up. But, so far in 7 days I have only had 3 smokes, so I don't think I am doing too badly. I got there quite early ( I tend to get everywhere embarrassingly early, but I'd rather that than stress about the possibility of being late). I presented to the front desk and then sat down with my MP3 player on, planning on taking a bit of time to focus and calm myself before going in. But a minute or two later, (M) my Case Manager came to collect me from reception, I guess they were running early today. So, the three of us (M), BossDoc and I made our way to a tiny meeting room at the back of the building. (M) asked BossDoc if he wanted her to try and see if there was another larger room free, as it was very small and claustrophobic with three people (and I think she was empathic, knowing how much these rooms freak me out) But Boss Doc thought we'd be fine, so we all piled in and got on with it. I will have to say, he was actually quite lovely (I had not really had much contact with him prior, bar some short interviews while in hospital) but I was still finding the whole situation quite anxiety-inducing and was quite glad to have (M) in there with me. Funny to think that just a few months ago it was meeting with her, in those horrible rooms, that used to push my panic button!

So, he began asking me about how I thought I was going at the moment, and I think I was starting to annoy him a little by bringing everything back to sleep. Seizures? Increased, but thats due to lack of sleep. Anxiety? High, but that is exacerbated by sleep deprivation, ect. But what can I say, sleep is the lynch pin! Sleep or extreme lack thereof, rather, manages to unravel any progress that I  manage to make in any other area. And the feeling of extreme exhaustedness far supercedes any other emotion you may have. Until you peel that away you can't even begin to really identify or deal with underlying emotions. He asked about the changes to my medications over the past 5 months or so, and whether I thought that they had been helpful or not. Once again, back to sleep. I don't know if my current anti-depressant is working better than the older one, because my mood improved briefly after I started taking it as well as the sleeping meds that provided a small period of good sleep, but once the sleep started sliding down hill, so did my mood. Because the AD wasn't working well or because of the sleep? Can you see how complicated it is to unpick it all? But I think I was overthinking it a bit for him. He ended up asking if I was experiencing any side effects from the AD and when I said know, he reasoned that it wouldn't do any harm to raise it, and it might do some good. Fair enough.

He asked what I was looking for as far as support from Case Manager. I told him that I realised that my Psychotherapy was going to be a hard slog through yuck, before I could come up on the other side of 'possible improvement', but that for the moment the ability to call (M) who I had a therapeutic rapport with, rather than having to call stranger on a crisis line, if I couldn't get a hold of my therapist, was really important to me at the moment, for those times when the sh*te hits the fan. I also said that I didn't necessarily need to catch up with her every week, it was just important to me that she remained available via phone calls for emergencies. He asked whether I was able to call (M) when I needed support, or whether I generally waited for her to contact me. I answered honestly ( I think sometimes they really just wish I'd give a yes or no answer!) that the majority of the time I was able to take the responsibility of reaching out for support when needed, as a part of my crisis plan, but that there were other times when apathy and the head space I occupied did not allow me to. However, I stated that I believed that this was me making a choice not to call, and thus my responsibility to deal with the consequences. Imma big girl now, huh? (M) who remained pretty quiet for the whole meeting, nodded her agreement that I was generally pretty good about calling if necessary, and there was no annoyance registered on her face, so hopefully that means I haven't 'overcalled'!! We agreed to reduce the scheduled contact, I'm not sure to what yet(?) and I would continue to make phone contact when needed. So, all in all I was pretty happy with that outcome.

We touched briefly on home, uni etc. And then we spoke about sleep. He looked at my list (which of course he had in his records anyway, but I just wanted to be thorough) and said that he had reviewed my file earlier in the day, and the only sleeping medication that they prescribe that I haven't take yet was an anti-psychotic called 'Zyprexa'. He said it was an off the label use i.e. big expensive private script, and that he really didn't like prescribing it as a sedative particularly, or really at all, in general unless he absolutely had to. He stated that it made most patients put on ridiculous amounts of weight, more than Seroquel or Largactil he added, as I looked wryly down at my already protuberant anti-psychotic belly. The price didn't worry me so much, as the gap would not be that much between medicare and private health insurance rebates, but the weight thing did, particularly since it was not really proven to be any more effective than the anti-psychotics I had already tried. He said there was one other benzo (I forget the name) but once again it was a private script and not really anymore effective than what I had tried. He then suggested that we start back up the top of the list of meds I had gone through. He said that sometimes when a patient developed tolerance to a drug years back and hadn't taken it for a while, it can be effective again for a period of time, as it had been washed from the system. I guess it kind of made sense. So we started back up with Temazepam. This conversation unexpectedly brought tears to my eyes, and sat there dumbly nodding, as I tried to keep myself from crying. I knew I had tried quite a few different sleeping meds but the idea that I had practically run the gamut was pretty damned depressing really. And the idea of cycling through meds that might work for a couple of weeks and then sliding back into sleep deprivation torture, is really a bit more than I can handle it my current head space. I can unequivocally say, my first thought was I just want to go and jump off a bridge right now... I just cannot handle the idea of going on as I am right now. Makes things seem pretty hopeless.

(M) got called away for a minute for a phonecall, and whilst she was gone, he asked whether there was any other issues. I blurted out about the self-harming incident and the misuse of pills and alcohol incidents. I am quite ashamed that I resorted to these things after such a long time keeping it under control... I didn't really say much about the rampant suicidal ideation, and he didn't really ask... I don't know whether he just didn't think to ask (unlikely) or (M) had already filled him in to the extent she knew. I felt like I dodged a bullet on that one, because I really didn't want to discuss it, but I absolutely hate lying to peoples face, deflecting is fine... but I get all churny inside when I try to be honest to a direct question. He asked why I hadn't taken up the recommendation of a short term hospitalisation to restabilise, when things started getting out of control, as was talked about on my last discharge from hospital. I tried to explain my adversion to hospital, but I don't think I communicated to clearly. It's not just about not wanting to be in hospital (although I don't want to), it is also that I think that most of the time its actually a destructive course to take. I get depressed because I feel like a failure for being back in there, I get anxious trying to keep it from my family and if they do find out, they get all whack. It institutionalises and infantilises you. And the reality is, whatever benefit you get, brief respite in sleep, and removal from danger to yourself, is short term... once you are discharged its all just still waiting there to pull you under... its pointless. When I was discharged the discussion was that I would readmit to hospital for a short stay if my sleep got out of control. I think the number thrown around was two weeks consistently out of control sleep patterns. The flaw in this plan is that the improvement to sleeping post discharge tends to only last a few weeks, so by this reasoning I would be hospitalising myself a minimum of every two months or so... not going to happen. And realistically, I don't think the staff would be that happy. I don't want to be a frequent flyer. And if I am totally honest, sometimes I just think, that by 'managing' my suicidal crisises this way, its really just prolonging the inevitable. I can just see myself trapped in this cycle add in finetum. How long before its just ok to say, you know what... this is f*cked and i'm outta here, and give myself a celestial discharge. (I've asked many a mental health professional this, and althought most of them won't unequivocally answer, the answer is apparently....never... not much wiggle room there!) Anyway, he put his arguement out there for managed hospitalisations and then we brought the meeting to a close. Patient Ophelia...ahem..sorry...Client Ophelia to be reassessed for meds in a couple of months, Case Management Involvement to be reassessed sometime in the future. (M) quietly praised me as we left the room for being able to talk and be honest, I think she realised how hard it was for me. I gave her a wan smile back, and sat down in the reception to wait for my script. (M) brough it back out to me and sat next to me briefly, telling me to take care, she could see I was having a difficult day and to call her later if needed.

As I walked back down the hill, all I could think is..."you're screwed! You are never going to get any sleep". I envisioned myself just steeping out onto the busy main road, in front of a truck, and the tears I had held back began to flow. I am so exhausted. I know it seems like an overreaction... boo hoo, you are tired. But a couple of months of 2, 3 and 4 hour nights sleep, interspersed with entirely sleepless nights, and the ongoing onslaught of horrific nightmares... its really the worst feeling I can imagine... I would do anything for release... and there is that *forbidden* option that would give it to me.

I sat down at home, pausing only to ring Bachelor Number One yet again to cancel plans, I just could not face it. And I just sat there're thought you were probably screwed, but this confirms it. I tried to counteract it by trying to see how I may be not seeing the other more positive perspective of what was said re: sleep medication, but just could not compute. So I figured (M) was in the meeting, and she had a non-clouded view of what was said. So I called her, because I honestly was at the point of "What the hell.... lets just finish this shit, once and for all!". We spoke briefly, and (M) told me that sleeping drugs were rarely magic tablets for anyone (which of course I knew, but I guess unexpectedly, I was still holding out hope that I would walk in there and he would have the answer) and reminded me what he said about the previously washed out drugs possibly regaining some effectiveness. She said I needed to give my self a limit of lets try this drug for a month and or so and then re-evaluate and if needed, we could change to an earlier appointment after that and try something else. I think I actually laughed out loud. A month more of this....I really don't think I can do it, no matter what the potential long term reward is. Its literally inconcievable to me. She went on to say she knows that I am probably thinking there is another option (well, yes!!!!) but that I just need to ride it out and see if the change helps, maybe consider a short term hospitalisation (ummmm no) She reiterated that I was to call her if I needed to and that just because we were having reduced face to face meetings didn't mean she wasn't still available if I needed. (She has really grown on me, since our initial first disastrous meetings... that's the problem with having good MH professionals, one extra person to feel guilty about when you consider the big S.... but she is honestly very kind, and available and very patient, God Bless her cotton socks!) And then she said she would call me early next week to arrange our next meeting.

So. I am just wrung out. This day has definately taken it of my already exhausted soul. At the moment I am somewhat calmer and able to see that it is worth giving the med change a chance.... but I am honestly not holding out a lot of hope. Last time I was on Temazepam, back in 2002, it barely made a dint, and that was with the copious amounts of college student alcohol I was consuming practically on a nightly basis (naughty, naughty... benzos and booze) But tonight, when its 4am and I am still awake, watching the night slowly seep from the sky to tomorrow morning, I'm not sure that calm will hold.

I am just so God Damn sick of it!

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