I do. Mine haunts me. I can never seem to beat it.
There are the odd occasions when I do really well against it and I win. It feels great. I could walk on air.
Sometimes they last for a short stretch of time – a few days, a week – two if I’m lucky. I could fly.
it all comes
And it’s not just me who is affected.
It’s not a small thing with small consequences.
What happens, you ask?
Okay I’ll ‘fess up.
I don’t wake up. Or if I do – I drop right off back to sleep before I can haul by backside out of bed.
Then I am late for anything that I have on for the day – visits, appointments, ….work.
And we’re talking regularly 30 – 40 mins late during the mid spring and autumn – and every now and then it’s a couple of hours. It affects other people when that happens – workers, patients … if I don’t get my work done it slows down the process of referrals going through, information getting to people in hospital and their treating teams for planning, people going home. It means groups can’t run or other people have to cover me. I nearly lost my last job over it. Even when well I’m often 10 – 20 mins behind my start time. I survive because I start before my boss and I always work back – but I can’t keep it up.
And it doesn’t seem to matter what time I ‘m supposed to start – I’ve adjusted starting times. It’s simply the process of getting out of bed and waking up in the morning.
Once I’m up, my sensory routines are helpful. I’ve started to experiment with some mindfulness exercises when I get time – which help a lot. But actually waking up and getting out of bed is jolly hard work.
The other thing that happens to me is that I lose time in the mornings. I do. Even when I’ve gotten up on time and have been running on time something happens – I space out in the shower or getting myself a drink and meds and time just vanishes.
I started a new experiment earlier this week that I think holds promise for the latter issue – I’ve started using a mindfulness breathing meditation exercise as soon as I get up that goes for about 10 mins to raise my level of alertness. If it keeps working at keeping me focused, I’ll be writing about that in a couple of weeks. But for it to work – I need to get up in time to have time to do it. It doesn’t need to be earlier – because I’ve worked out that I do everything else more efficiently when I do it. But I need to get up.
At present I use two alarm clocks set 5 mins apart – one to arouse my attention if I am in deep sleep so that by the time the second goes off I won’t sleep through it even if I sleep through the first. Part of me wonders whether it’s worth investing in a bed vibrating alarm clock – they make them for deaf people. It might be uncomfortable enough to help me move out of bed more easily. Has anybody ever used one?
I know the rules – go to bed early and get up and the same time every day. I’m awfully undisciplined at doing that.
Take your meds at the same time every day. I tend to get lazy and just take them on the way to bed – which admittedly is probably half of the problem. There are some very sleepy meds among my cocktail.
Every day is a new day with no mistakes in it – yet. Thank you, Anne Shirley – but other people remember and I need to work out the best way to deal with their memories and keep myself focused on the present so that I don’t drown in fright.
So here it is. My arch-enemy. The alarm clock. That moment in time that I’m supposed to get up. To get moving. To get started with the day.
Please – anybody with your own ghouls – what helps you haul yourself out of bed every morning?
There’s something centring about looking after yourself. Basic self-care. Hygiene and grooming activities. There are things among them that have qualities that can relax and alert us if we are mindful of what we are doing. A couple of posts ago I wrote about mindfulness and the senses in Send in the Senses . Today I would like to show you some of the ways that these principles can be integrated into everyday activities.
Warm water over the skin is relaxing. It’s soothing. You can just stand there under warm water in the shower or sit in a warm bath and let it calm you. (being conscious of your water consumption of course)
Or if you want to you can make it more soothing you can add a scented cleanser and smooth it on with your hands or a soft cloth. Then again – if you want to jazz it up a little, you choose a more uplifting stimulating scent and a courser cloth or a loofah. And okay – so the guys mightn’t be so into the scented soaps as the girls – but the rest still works as well for them even without the scents. On top of that are the sounds of the water and visual stimuli of the water running over you and the shower or lapping against the sides of the bath and the intricacies of your own bathroom and showering routine.
After washing, you think about how you are going to use your towel to dry yourself. Vigorous rubbing will invigorate the senses, while gentle strokes with the towel are likely to be more soothing. Alternately, you might wrap yourself in a towel or terry towelling bathrobe and wander around the house until you dry naturally.
If you’re looking for a basic activity that is inclined to stimulate the senses, then look no further than brushing your teeth. A toothbrush in decent condition with toothpaste on it brushed over the teeth and gums will arouse the senses of touch, taste and smell. Flossing is great if you’re anxious or need to slow down or focus because you have to do it deliberately and if you want to do it properly, you can’t do it quickly – so it forces you to slow down and focus your attention but gives you a task to do it with.
Painting your nails is great for the same reason. There is a need for controlled movement – so you need to slow down and focus your attention. Great for regulating anxiety. It is also something that can make you feel nice after you’ve finished. So nail painting incorporates controlled touch, slow and controlled movement, a stimulating smell – which is not necessarily why you’ve chosen the task – but it won’t put you to sleep. I was stuck in one city while the rest of my family were in another when my Grandfather died and I couldn’t be with them. I was very unwell with depression at the time and quite distressed. In the end, painting my toenails is what I did to calm myself down to a point where I could think reasonably. Then I could start to deal with my situation and emotions more logically.
For those who like a face mask – this is a beauty. Deep touch is relaxing, so you apply the mask with a firm touch. You follow the directions and wait while it sets, then when it is done you rinse it off. Now to rinse it off, follow the directions on the packet but remember: warm water – calming, cool water – alerting; and soft cloth and/or gentle strokes with firm pressure when rinsing will be calming, while a courser cloth and/or more vigorous or uneven strokes while rinsing will be more alerting. My own preference when using a mask is to rinse with a course cloth but gently with firm, smooth strokes in warm water.
If you need to shave, this is a good example of an activity that involves slow, deliberate movement. Focusing on the movement and the sensations of the shaver on the skin can be very effective. Most would find that this would alert touch and movement sensations, potentially smell also depending upon things like shaving creams and so on.
Another one – very touch and movement based that I find therapeutic at time is waxing. Great for anger management. Rip into the leg waxing. It’s systematic. You have to regulate it. You eventually slow down because the waxing process requires you to. But it’s also a useful buffer for stress, a way of alerting the senses to wake up when you’re weary or just getting rid of unwanted hair… Waxing is rich in touch (temperature, pressure etc), it involves controlled movement and you are using your sight to inspect your work.
Brushing or combing your hair can be either relaxing or alerting depending upon how you go about it, although if you use a comb it is more likely that the result will be an alerting sensation. When using a brush however, if one uses long smooth strokes the effect is quite different to brief, sharp strokes. The former is calming, the latter more alerting. Experimenting with different styles of brushing can be a great way to explore ways that touch influences the senses.
Think about all of the self-care activities that you do on a regular basis. Washing and drying yourself, washing your hair, styling your hair, cleaning your teeth, washing your hands, washing your face, moisturising, using deodorant, brushing your hair, shaving and/or waxing, cleaning your ears, dressing, cleaning your nails – anything you can think of … Take some time to think about what sensory qualities there are to the tasks. What movements, use of vision, scents, smells, touch, sounds, tastes are associated with them? How are you positioned for them? Where is your balance? Your centre of gravity? Which of these have alerting qualities? Which have calming ones? Are there qualities to any to the tasks that you do regularly that could be useful to you in other ways?
I don’t know about you, but I was very sceptical about relaxation exercises for a long time. I would always think back to school days when guidance counsellors would take us through guided imagery sequences featuring a calm blue ocean or some such scenic place and tell us how we relaxed we were while the class clown made farting noises, his followers giggled, the teachers reacted and everyone else just rolled their eyes and waited for the session to finish. At other times, attempting to relax has been more stressful than relaxing because the facilitator just wasn’t on the same wavelength as me. I find it annoying when that happens.
It took a long time to realise that relaxation was a skill that required practice. It has taken longer still to discover that there are many different types of relaxation exercises that you can do. Recently while looking for a site for someone, I found one that had a variety of sound tracks for relaxation exercises ( http://www.allaboutdepression.com/relax/index.html ). I decided that I would sample all of the relaxation exercises on this site to see what I thought of each of them – to give each a chance. Today, I’d like to share with you a little about the exercises that I did and my thoughts on each.
I thought that these were very useful. Each of them was effective, and they were particularly effective when used in series. The educators recommended that for those with anxiety disorders, your levels of anxiety will reduce by doing breathing exercises regularly as maintenance – and I can believe this given the difference that it made in the amount of tension in my body.
For those who do not have anxiety – like me … I did my mood diary scoring after I did relaxation exercises and my scores were significantly higher than they had been on any of the recent days leading up to these times. I have been experimenting recently with http://www.moodscope.com which is a computer based system – so I was not simply giving myself a better score out of 10.
Progressive Muscle Relaxation
Progressive Muscle Relaxation is a favourite of mine. It essentially involves tightening a group of muscles, holding them tight and noticing the tightness, then releasing the tension entirely and noticing the absence of muscle tension. You then systematically work through to the next group of muscles and do the same thing.
I will usually start with my toes, progress to the soles of my feet and calves, the upper foot and shins, my thighs, my butt, then my hands, wrists and arms, elbows and biceps then shoulders; then I go back to my trunk and tighten and release my abdomen, then lower back, upper back, chest, shoulders (again), front of neck, back of neck, tilt neck left then right, then I work through my face so my forehead, nose, cheeks, mouth, jaw and tongue (pressed against the roof of my mouth). Then I finish by either breathing exercises for a while or by standing and shaking out my arms and legs and stretching. But that’s me and that takes anything from 10 to 20 mins depending on how many repetitions you do of each muscle group. Sometimes for really tight groups, I’ll repeat the actions a couple of times eg shoulders.
The progressive muscle relaxation sequence on the All About Depression site goes for 8mins40sec and is nice and efficient while still covering what needs to be covered (http://www.allaboutdepression.com/relax/pmr/pmr1QT.html ). I found it satisfying and was pleased with the result at the end of the session.
I need to be frank here and admit that I am not someone who is a great fan of guided imagery sequences. I find someone else’s descriptions of a place that they think should be relaxing for me to be kind of distracting. I’d much rather be left to breathe or if there needs to be an image, then I’ve done sequences where the person guiding the sequence has left room for the person relaxing to select a place they like and guided by asking questions like “what can you see?”, “What can you smell?”, “Look around you and explore the colours.” I found that kind of guided imagery more engaging.
I came to this exercise expecting it to be grossly annoying and to loathe it. It was actually one of my favourites. I’m not sure whether it was because of the sequencing of the exercise, or the conscious repetition of phrases (I repeated most of them in my head because I found that doing it out loud made it difficult to breathe deeply and evenly), but this exercise really worked for me. I want to go back and learn the phrases and the sequence to use at any time. http://www.allaboutdepression.com/relax/phrases/phrases1QT.html
Mindfulness Oriented Relaxation Exercises
Mindfulness is about being ‘just in the moment’. In this context, the relaxation exercise is about focusing oneself on relaxing just into the moment. A lot of the rationale for this is that a lot of distress occurs surrounding things that have already happened or have not happened yet and that sometimes the sadness, anxiety, pain or negative feelings are easier to bear in the immediate moment if we are not contemplating past or future at that point in time.
This is one of my favourite relaxation exercises. It starts out with breathing, then gradually asks you to notice things with your other senses, in particular where your body has contact with other surfaces, the feel of your clothes and the sense of the weight of your arms and legs as you’re supported by your chair (in my case) or where ever you are resting. I loved the sensation of my clothes on my skin as I was breathing – I was wearing a particularly soft shirt the day that I did the exercise for review. A definite must in my books (http://www.allaboutdepression.com/relax/mindfulness/mm21QT.html ) although regulars will know that I’m a fan of mindfulness as a strategy in general.
Mindfulness with Guided Imagery
Remember what I wrote earlier about guided imagery? Well it’s no less true where the imagery is attached to mindfulness strategies. That said – in the first exercise Sending Thoughts Away on Clouds (http://www.allaboutdepression.com/relax/mindfulness/mm31QT.html ) I found the clouds a great way to dismiss unwanted or intrusive thoughts – the idea being that where a thought that was a distraction from the scene or your breathing came into your consciousness, you were to send it away on a cloud. I could picture this as though just blowing the thought away. Sending Thoughts Away on Leaves (http://www.allaboutdepression.com/relax/mindfulness/mm41QT.html ) didn’t feel as natural, although it kind of worked. In this guided image I was taken to a clear forest stream to enjoy it.
The final image was quite different in what it did with distracting thoughts. In this the idea was to be Sorting Into Boxes (http://www.allaboutdepression.com/relax/mindfulness/mm51QT.html ) thoughts that intruded, the boxes being one for thoughts, one for emotions and one for sensations eg aches and itches. This was more bizarre to start with and I found myself distracted by the boxes – but after a while I settled down and just focused on my breathing again and that helped. For a while however, I think I was almost inventing itches and filing the thought ‘this is stupid’ over and over again. Once I went back to breathing and visualisation the boxes became background scenery – a bit like a picnic basket when you’re not actually eating. I can imagine this being helpful though if you were being flooded by intruding thoughts and feelings – you could just label them without processing them and put them to the side by the rules of the exercise without it being an intrusion on what you’re supposed to be doing – which is staying in the moment, just breathing and picturing a scene.
MY TOP 3
My favourite three out of these audio tracks in no particular order would have to be:
Progressive Muscle Relaxation
Why not take the time to try a few? What were your favourites?
And if climbing back on aft’ one spill weren’t enough –
Alas – staying on top is an art!
For most of us who have passed though one episode of depression – or other forms of mental illness and come out the other side, a common concern draws us. We don’t want to go back there.
Some have a harder battle ahead of them than others. Some have different forms of depression; different forms of anxiety; different forms of mental illness that are more or less responsive to the things that we do to treat them. Some are more vigilant than others – often this makes a big difference … and sometimes life’s not fair. Some do all the ‘wrong’ things and yet never have another episode – but that’s unusual.
What’s usual is hard work with a need to use a range of strategies to stay well. Things like good sleep, exercise, a nutritious diet, keeping up social support networks and getting out of the house, exposure to sunlight and fresh air, use of medications and talking therapies are just some examples of these.
But how do we know that we’re winning? What can we do at the times when we’re worried about how our mood is going to try to prevent it from tipping over the edge into something we can’t manage? How do we know if that new medication is doing anything to change anything at all?
One of the things that is helpful to do at times is to track your mood. How do you do this? You use a mood diary. Ever done it?
The purpose of a mood diary is essentially to get a profile of what pattern your mood is following on a day-to-day basis. At their most basic level, a mood diary will ask you to rate your mood on a numerical or incremental scale every day while you keep it. Some will additionally ask you to record other information such as your anxiety levels, your irritability levels, how much sleep you had the night before, significant events and triggers throughout the day and/or the medication that you took. The good thing about doing some of these other things is that they provide a much fuller picture of what is going on.
If you don’t already know what they are – this process can help you to work out what your early warning signs are as well as your triggers. If you know your triggers and early warning signs, this can help you to monitor them. For that reason, I recommend choosing a mood diary that records significant events in the day. I would also recommend one that includes the amount of sleep that you had the night before as this tends to be pretty universal and fairly influential.
Talk to someone close and ask for their help if you have trouble working out if you were irritable or if they noticed anything in particular that seemed to set you off if you are having trouble identifying these kinds of things – but the object of the exercise is to make observations about yourself – so do what you can on your own as well.
However, asking someone close to you whom you trust to help monitor your mood and to help you get to know your warning signs and triggers is a good strategy. They sometimes see things that you are not in the right place to see or notice when you’re not well because your self-awareness can get a bit skewed. They also see the ways that you differ from the way that you would normally be – so they can measure you against you and not somebody else. Yes, it might be their perception – but it will still be your behaviour and actions and the things that you say and the responses and facial expressions that they are used to that are part of you. Choose someone who you trust and talk with them and let them tell you about what they noticed changing last time and as you have been working through your recovery.
Do I use a mood diary and self monitoring systems all of the time?
Not on a daily basis. When I am well I keep regular tabs on how I am going by talking about it with a good friend and checking over my early warning signs and triggers list regularly to ensure that my awareness of them is good and that I am alert to high risk periods. I use what is called a WRAP – a Wellness Recovery Action Plan where I have identified what I am like when well, what my triggers are, what things are hints that I’m not as good as I could be, my early warning signs and so on …. I go through this regularly. Some people do monitor their mood daily and find that it works well for them. People with things like rapid cycling Bipolar disorder often find that they need to until it slows down and is brought under control. At first I needed to chart my mood a lot more than I do now.
When I am in a high risk period I watch things more closely and have recently resolved to keep a mood diary through high risk periods because I still find myself at sea sometimes and feeling like I’m losing my grip. I am particularly vigilant about my warning signs and triggers as well as their corresponding action plans during periods of high risk. I have to be. Recently I let things go at home and let the dishes and the housework pile up around me – a sign that things are getting away from me and didn’t act and it triggered me (it becomes a cycle). I couldn’t face getting up to look at the house. I didn’t want to go into the kitchen to prepare a decent meal because it was a mess and I didn’t feel up to cleaning it up – so of course my nutrition level went down, my budget blew out and thus the cycle continued. In the end it took a cleaning weekend to put me back on track, followed by a week of very early nights and a lot of discipline. It’s too easy. So I have decided that I need to do something to catch myself more quickly before it gets away from me. Not simply cleaning, just lots of little things. This time of year I need to be very careful about relapse prevention. It sounds minor when I talk about dishes – but when it snowballs, I just keep sleeping and if I sleep through work or go in late consistently and am still going around in circles while I’m at work and don’t have energy or concentration to work – I could lose my job.
I’ve attached today some links to some self monitoring resources and different mood diary sites. I know there’s a lot, but different things suit different people and I think these are important tools. Most mood diaries have room for the full spectrum of mood disorders – both mania and depression.
Warning signs and triggers are important. Monitoring your mood is tedious sometimes – but there are times when it is necessary.
There are a lot of things I hate about Depression. Take your pick – the effect it has on your self-worth, your energy levels, your mood, how sociable you feel and act, your self-image and presentation, that non-expression on your face … or the medication – weight gain, constipation, tremors, medication for the tremors … the constant need to micromanage your life to prevent relapse routine, exercise, diet, sleep, early warning signs, triggers, medications, appointments and to cap it all off there’s the increased incidence of things like diabetes and heart disease in people with depression. Some of these are direct results of depression. Some are spin-off effects from symptoms played out in the lifestyle. Some are medication related. But by far the effect that I loathe the most is the ‘fog’.
Thinking in ‘The Fog’ is like those movies where a character moves across a misty set barely able to see what is in front of them, working to make out the shadowy forms in the haze before them until the mist folds away just before they meet it to reveal what is there – yet the objective never quite within sight. When I am not well my mind is in stupor. Gears creak. Cogs struggle to turn. I forget things constantly. I lose my place in what I am trying to communicate to someone. These are things I was once very good at. As I get better I can do all of the things that I used to do – but many of them I do more slowly than I once did. It now takes me longer to process things in my head – arithmetic, deciding how to express something carefully, making a decision, figuring something out. Some of this is because of medication – but not all of it. Some is the Depression itself. It has slowed my once quick mind. Recent changes to medications have freed it up a little, but it is still not what it once was.
It is not obvious to everyone. Mostly only to people who have known me for a long time before and after the Depression left its mark. When talking with a friend and therapist with whom I once worked once told me that the difference had made her cry. It was such a relief to know that another person was grieving too.
I had an ongoing dilemma with medications until recently that centred around a Lithium fog. After years on a tricyclic that kept me well in tandem with Lithium, I eventually had to stop the Lithium so that I could use anti-inflammatory meds for chronic back pain that wasn’t responding to any other form of treatment. The result was that the back pain settled reasonably quickly, but it was difficult to keep my mood stable on the tricyclic alone. In the end, my Doctor suggested that a medication change was the way to go and I finished up on a combination of Lexapro and Edronax. Beautiful. I could think. However, like the tricyclic (which I’d been on because SSRIs on their own didn’t work), in reality my mental state was still not really robust. Finally, after much resistance on my part, I restarted Lithium as an augmenting medication to bolster the main ones – and, for stability I did need it. But it really stank. The fog was back. Lithium, I find does slow me down – preferable to relapse and job loss – but still unpleasant. My best news has come with the release of Valdoxan. Given how much I hate and object to the use of Lithium, my doctor has trialled me on this in place of the Lithium as my augmenting drug and it is working beautifully and without fog. So what is now left that is attributable to medication is as low as we can get it.
What has been affected is what I will call my ‘working memory’. The part of the brain that is operating and pulling everything together at any moment so that I can think, move, find information that I know, solve problems, come up with ideas and take action of any kind. It is where what is needed from my short & long-term memory, senses, visual-spatial understanding, communication and organisational understanding and my level and focus of attention are is pulled together and used to observe or interact with the cues, instructions or things in the environment around me to guide my actions in a certain way. It is where, to a large extent I can regulate the speed of my actions also. BUT here’s the thing. When I’m not well my level of attention is affected so I miss information from the environment and not all of the information that my mind needs makes it in. The speed of the working memory slows down, my memory is fuzzier and less accessible, I lose the flow of operations I am doing. It’s like if there is a little man inside my memory coordinating all the information, he ages 100 years and can’t manage all of the information when I’m depressed. When I’m well he returns to almost his original age and moves reasonably well; but he’s been left now with some injuries – back strains and a touch of arthritis that slow him down just a little on the fine and detailed work or when handling really heavy stuff. He can handle it, but he’s not as fast as he was before the injuries that the sudden aging episode left on him. And nor am I.
At times I think walking with a black dog is like walking through the high mountains where there is rarely a day unaffected by mist – not necessarily always pea-soup fog; yet always just a light haze. Not enough to hamper most of the time, but enough to dampen the spirits and frustrate – especially one who is unaccustomed to fog. But the moments when the fog lifts and the sun shines through – Oh my! They are glorious.
I sat down to do my WRAP a few months ago. My Wellness Recovery Action Plan.
The idea is that you describe what you’re like when you’re well, what helps you stay that way, what your triggers are and what you plan to do when you encounter triggers to prevent spin-off effects; then what your early warning signs with an action plan for what to do if you notice them emerging; also what happens when you’re feeling much worse and again what helps in those instances. You also make a crisis plan, identify supporters and how you agree that they will support you/what you would like them to do for you, identify people who you don’t want involved in your care/treatment and people who need to be notified, your current meds etc. There are a whole bunch of different ways of a similar process. Mary Ellen Copeland’s Wellness Recovery Action Plan is the one that I have been using – and hence describing (see link to website). The point is then to read it regularly – she recommends daily and to stay on top of your management plan and to know yourself, to recognise when you are not yourself; to be watchful and vigilant for triggers, warning signs and symptoms and to act immediately, instinctively. Also she recommends to have a couple of others who check in with you regularly to help out and give you their perspective or who will tell you if they notice that things don’t seem right.
I think that almost the hardest part of the process to complete was the first question.
“What am I like when I’m well?”
It had been a long time since I had been well for longer than a few months at a time. What’s more, I have changed. I am not the same as I once was. This battle – this relationship with my dog has changed me. What am I like?
I was in my mid twenties when I had surgery for a massive aneurysm. Somewhere over the period of the next five years came the prodromal and early symptoms of Depression without being diagnosed until I was almost 30. I have been wrestling to learn self-management skills until reasonably recently. It has been a long time since I was truly healthy, although between brief periods of mood change or minor undiagnosed episodes in my twenties until my eventual breakdown with depression I’m sure I was fine.
My point? What am I like when I’m well? I don’t know anymore. What’s more, it always feels like such a silly question to ask other people. I mean – asking people to help me to identify what I’m are like when I’m not well … that makes sense because I know that my insight is not at its sharpest. But well? Shouldn’t I already know that?
Not that I was ever good at describing myself. Always self-critical, I was never particularly sure why people wanted to be friends with me after leaving school when I had hadn’t had many friends at school. But that’s school for you – start school somewhere awkwardly and the perception sticks with you til you leave. Even as an adult I struggle to have a clear picture of what I am like.
What am I like when I am unwell? What helps when I am unwell? These questions I can answer reasonably these days. I have even thought to discuss some of this with others or take notice of comments that they make.
But to know myself well. To know the self that has been changed by this dog of an illness, by periods of chronic pain, by a swollen blood vessel in my brain waiting as a time bomb for its final burst – but found before it could; the self that has been altered by periods of self-imposed hermit style living apart from the workplace. This is a person that I must relearn. This is a person whom I have lost and who has changed while she has been away. She is a stranger.
I need help to know this person. Friends. Family. Memories. Time to explore the things that interest me again, to develop new ones. To reflect. To do. To explore. To discover. To learn. To grow. To live.
I live with a black dog. It follows me everywhere. My philosophy now is that I need to plan for its needs when I plan for my own. I also need time out and restful places to enjoy the warmth of the sunshine on my shoulders.