// μ = m // dayvan cowboy // music is math

These mayonnaise posts might be annoying from the point of view of the reader and sure hurt my googleability and reader attention, but there’s so much context involved in most post and it’s kinda tiresome introducing it as-needed, not to mention forcing anyone who really wants to understand this story to decipher through the breadcrumb trails scattered over short-ish, this-is-now posts.

My psychiatrist. My psychiatrist is a psychopharmacology geek who has studied under who he consider his Master, a psychopharmacology geek from Spain. I mean, he went all the way through med school, but he still holds a special place to this Master.

What being a psychopharmacology geek means is that we’ve gone through a lot of meds trying to optimize my experience. Most psychiatrists will give you lithium or Depakote and expect you to cope — actually bullying you into coping and keep taking your meds — and while that does work wonders, statistically — as in preventing relapse for N weeks, where N is a function of the size of your research grant, I for one know that I would have lost a lot in life if I had been in Depakote monotherapy, even if that meant avoiding a few hypomanic flip-outs.

He’s actually cool with me doing some psychopharmacological experimentation — not taking other people’s drugs, I guess, though I never had the chance, but fiddling with my doses in general and being discretionary about my clonazepam and ritalin in particular. I did earn his trust by being responsible, extremely well-informed and being fantastically aware of my moods so psychopharmacological experimentation can lead to optimal experience. I think he’s glad I don’t have major psychological issues that interfere with him being a psychopharmacology geek working with psychopharmacological optimization.

Maybe he wouldn’t be such a good choice of psychiatrist for someone with major psychological issues like someone with a borderline or histrionic personality disorder, but I’ve never seen him in action with anyone else — and he has this calm, reassuring demeanor that might be very helpful, even if he doesn’t have the Movie Psychiatrist Looks. I do think he’s glad I don’t have major psychological issues and that psychopharmacological optimization is somewhat of a thrill ride for both of us.

My psychiatrist is the kind of guy I’d probably become friends with “in real life” if he wasn’t my psychiatrist, and it often seems he feels the same. He actually decided to become a psychiatrist after dealing with deep Major Depression with Psychotic Features (ICD code F32.3). Maybe that’s why I don’t feel he comes with the sense of superiority most doctors will come with, particularly psychiatrists.

I actually saw another psychiatrist before, a friend of my parents who despite having a psychiatry degree was a naturopath/orthomolecular fraud, and he did have the superiority attitude to my complaints of apparently random symptoms of a disorder so complex he wouldn’t be able to grok anyway. I only went through two sessions with that idiot because I was just so fucked up I couldn’t give my ordinary scientific skepticism a shot, and even after I found out after my first consult that most of what he said was whack, I went through another session where he prescribed Bach florals because my parents weren’t particularly keen on paying for a psychiatrist (though they got stung in the pocket because I had to to take a very expensive, utterly useless blood exams according to this nutcase’s methods). I did know about the blood-brain barrier and that whatever the “blood serotonin” level meant, it was pointless.

I both dumped him by never going to another session, but he also moved to another part of the country about the same time. I didn’t go to another psychiatrist for months, until I was fucked up enough that I could talk my parents into getting me another psychiatrist. I said “just go into the phone list and find someone cheap and near”. I got lucky, really lucky in getting a psychopharmacology geek who is the medical equivalent of a functional programming nerd and managed to put together the puzzle after an hour and a half of me talking randomly.

My diagnosis. When you first go to a doctor for a private consult, any kind of doctor, the first thing he’ll ask is “how can I help you”. I will never forget my first words: “I.. can’t keep my life organized anymore”. I felt I couldn’t handle remembering when to got classes anymore, and when I did I often didn’t have the energy to.

Then I started speaking randomly about how I felt and what had happened in the past few years — and by randomly I mean “in no apparent order” until I had a horrible headache and felt exhausted. After I stopped talking, he calmly said everything pointed to a mixed state in bipolar disorder, and draw some graphs of possible time courses of bipolar disorder and how I fit perfectly into one of them. My parents were kinda supportive — though my mom can’t swallow the idea of takings meds as a solution — and initially paid for the twice a month consults and the medication.

Then a month or so later, I got a job, something that would be impossible to imagine just a month earlier, when I barely could handle going to two classes a week. And despite all the stress and the erratic course of my productivity and how I often feel my boss doesn’t really trust me, it appears I’m not about to be fired. But I digress — the point is that I can now pay for my own consults, as frequent as I desire to (I had weekly consults during some periods, during others — like right now — once a month is enough). I can also afford buying my meds, which means I don’t have to deal with my parents freaking out about the pharmacological escalation of my cocktail.

Everything — from careful examination of my past and my parents telling me about aggressive episodes I don’t remember to the meds doing what the meds are supposed to do — the antimanic effect of some of them actually mellowing me down instead of making me depressed — and even the fucked up dysphoric manic flip-out I had when taking a weak antidepressant often used as a smoking cessation aid — everything points out to the diagnosis being correct. Hell, I flipped out with the initial antidepressant effects of low-dose lamotrigine (everyone has to slowly titirate lamotrigine up because doing it too quickly increases the chance of Stevens-Johnson syndome), which is supposed to be a mood stabilizer.

The major thing probably is that I never had prolonged periods of depression anymore. I do get the blues sometimes — like yesterday, when I was discussing how lonely I felt and how hitting the nightclub scene stopped being fun — and even call friends in a suicidal mood, but it never is something longer than a blue night. I did start getting stronger and stronger manic episodes, even though the interval between them is getting longer, but all that points out to the initial diagnosis of a mixed state in a bipolar disorder being correct. And for someone whose memories are all about being depressed (even though slowly I’m starting to remember some good times), getting manic episodes is fun for a change.

I don’t think of dropping all my meds as often as most bipolars who come out and tell their story do. There’s a chance I could ride increasing highs and live an Andy Behrman story (and by Jove, I need to feel alive) but there’s a chance I could just get dysphoric manias where no one understands where I am anymore. I was always the intellectual type, and even my euphoric manic episodes always have an intellectual episode to it, and dysphoric mania in someone smart just means being fucked up and alienated from the world.

Mixed states. Psychiatry manuals will often refer to “mixed state”, “dysphoric mania” and “agitated depression” as being the same thing. I wonder if the external manifestation — the way other people see it, including psychiatrists– is so similar. But let me tell you something, conflating the three into one “weird mood that isn’t depression or mania” umbrella term is bullshit.

The official party line is that if you’re not trapped in your bed unable to do anything, you’re not clinically depressed. That is a half-truth, and while I’m all for keeping it as the official party line to sort out the vast masses of people who don’t really have neurological problems and just need someone to teach them how not to be such a loser, the other half of the truth is that the range of “depressed” states that do count as clinical depression is a little bit wider.

Clinical, neurologically-based “depression” is not limb paralysis. You might be clinically depressed and be able to get out of your bed. You probably will have a kind of anxiety that is not angst — existentially-based discomfort — but something that makes life insufferable to go through, like you’re walking in a sea of mud, deep until your shoulders, knowing what you have to do and that you have to do it, and the sheer effort makes your heart burn though no one else can detect anything wrong with it. You might be “just” clinical depressed and get psychotiic features. You might become aggressive, start rejecting everything and everyone, insulating yourself in an entire world where every wall is coated with a thick veneer of this pastel-color tint of pain.

Agitated depression is about feeling, uhh, like a freak on a leash, unable to distance yourself more than a few meters from that core of pain you dare not look into, and trying to run, run, run — to no avail. Agitated depression is about having the energy of mania, and yet being unable to do anything but jump and shake the bars of the cage you’re stuck into. Agitated depression is about feeling ugly, tainted and sometimes trying to blame the world for your current state as a desperate attempt to not fall in the trap of blaming yourself and slipping into the core of major depression. Agitated depression is about quarreling everyone and knowing you’re just fooling yourself out of assuming responsibility for what you really feel is your fault.

Dysphoric mania is first of all about being manic. The energy of mania, the grandeur of mania, the thought disorder of mania — speaking so randomly and jumping between tangents that people can’t follow you, unless you’re intentionally dense and try to regard them as three year-olds. Except there’s no euphoria, there’s no elation, there’s none of that larger-than-life feeling that you can do anything and be anything because no one can understand you, no one can keep up with your rhythm and ultimately nobody cares. Dysphoric mania is about being agitated and doing things that make no sense at all, or being stuck thinking which thing that makes no sense at all you’ll do first, knowing that all that stuff is pointless and yet having to pour all that energy building into you somewhere. Dysphoric mania is about shaving your head and smashing your guitar and randomly quarreling people — not because you want to shift the blame of your shitty state onto them, as you would in agitated depression — but because they failed to fit into your half-baked idea of perfection. Dysphoric mania is about being pissed off about things not being perfect and yet not taking steps into fixing them but raging out and making everything worse because, fuck, if the world can’t fit your — the supreme being’s — ideals, so fuck everything and stab it dead.

A mixed state is, uh, a mixed … state. I like to tell people that manic-depressive illness is not about mood, but about energy, and now that we’ve established that besides deep major depression and elated euphoric mania there are two additional archetypal states to bipolar disorder — agitated depression and dysphoric mania — we might as well mix everything up. I do remember feeling in a mood that doesn’t fit either agitated depression or dysphoric mania but shares symptoms of both. I guess there are as many kinds of mixed states as there are mixed states episodes in all of bipolar people, but there are some things I can remember distinctly about my mixed state when I first met my current psychiatrist. Women would “fall in love” with me online all the time and yet be scared of my anxious control-freakishness about things and the impossible standard of perfection I stood them against. I’d oscillate between being fascinating and terrifying all while running away from my core of pain, doing the whole game of fascinating women online into falling in love with me to avoid thinking about the pain and yet being virtually unable to get out and meeting real people — because the online women would freak out before we even met, or generally being freaked out and fascinated-infatuated at the same time. I was everything and I was nothing at all, and I was so busy running away from the pain I couldn’t manage my life anymore.

Which is just what I told my psychiatrist the first time I met him — “I can’t keep my life organized anymore”. No surprise — my life was organized around not feeling pain.

The pain. I guess being mentally healthy means being able to face the pain. Everyone has a core of pain and being healthy should be about being able to rationally dissect the pain and rationally blaming yourself — accepting the responsibility and not hurting yourself further — for what is really your fault and constantly fixing things so they’re just right. I can’t say I’m already there — I guess no one can really say that, as most people are suavely running from pain, the difference being that they have such a long leash.

In a way, I’m healthier than the vast majority of my contemporaries, precisely because bipolar disorder has forced me to face the pain. Being an intelligent person with medications helping organize my thought does help. Not having a significant amount of time to clear my head off familiar and work pressures is an impediment. But I’m facing it, and I’m larger than it is, larger than my current state in life, larger than the brick walls life puts before me. They say football players do training with heavy shoes; having surfed the surreal waves of bipolar disorder, I can surf out whatever wave life throws my way. Bring it on. Bring it on.