Clipping My Face On: Getting Back to Work

Every day when I leave for work, I'm secretly afraid that I've forgotten my ID at home. Not so much because I wouldn't be able to get into the office - I'm sure someone would let me in eventually - but because all the women's bathrooms in the building are pass-key enabled to make us more secure. I just can't hold it that long.

But I digress. 

Now that I'm finished rTMS treatment, I've started back at work full-time, though admittedly without the ability to control all metal objects in my vicinity with magnetic superpowers like I was promised. 

I was thinking about it on the way to the train Monday morning, and I realized this would be my first five-day work week since I went into hospital in January. I was nervous, to be sure, but also excited. Not disabled any more!!!  I felt like shouting! Of course, that would entail that people in my office knew why I'd been out...presumably they've been thinking I was kidnapped by aliens? 

The week seemed especially long and insurmountable from the perspective of Monday because I knew I'd be working late on Friday, every week, to make up the time I miss on Tuesday to go to my psychologist appointments. I discussed taking the time unpaid, but my manager made it subtly clear that it was either the opportunity to give the time back every week or using up vacation time. Given that I've spent, like, twelve weeks on sick leave this year (holy crap!!), this seemed fair.

I was all set to make this a post about look how awesome I am, I'm completely better, I went back to work full-time and it was great! There are ways that this is true: I was tired, but it was a normal tired. I'm moving at a normal speed. I'm making good production statistics in my data handling jobs, and I didn't do too badly my first day back on the industrial scanning machine. I was all like I am a success story!! Haha psychiatrists who thought I was pinning too much hope on neuromodulation! I was still having mood fluctuations, but I was so, so much better.

This is true.

But there are ways that this is not true. 

Today was my second day using the scanner this week, and my day started out poorly. I had an insurmountable system error at the first machine I tried to work at, and I couldn't manage to fix it using the process notes. In the end, I had to change machines and ended up beginning to scan late. As I tried over and over to fix my machine, I felt like putting my head down on the desk and weeping, or walking out the door and never coming back. The machine I moved to is not built for someone as small as I am, so I couldn't reach anything. The stacker door slammed on my hand as I was retrieving a document that got lodged in the gears of the machine. Everything was slowing me down, and I knew I'd never make my production target for the day. I was near hysterical tears. I was all like, everything was going so well, and I'm messing it all up, with my moods and my failures. I was thinking, thank goodness I have those xacto knives in my bag, I can go slice up my arms during lunch, or maybe I'll wait until I get home where all my bandaids are, because I shouldn't get blood on people's documents. 

And I was thinking, why aren't I better?

I've always been...something of an extreme person when it comes to myself. I'm very forgiving and flexible with other people, compassionate even, but I just can't tolerate my own failures and weakness. Maybe because I just have so darn many of them. I need to be the fastest, the smartest, the best. And, for a lot of my life, I have been. I expect nothing less than perfection. And isn't my recovery just one more thing to be perfect about, all in one swift go? I want a gold star on my exam, goddamit!

But maybe I'm wrong. Maybe it's not all one thing or another, but a shading and blending of both. I am a lot better. The right treatment has broken depression's crushing grip and I feel like I can breathe again. I am better. But I'm still fragile. My emotions are out of kilter. Sometimes things are too bright, and I feel that edge that comes on when everything is going too fast, when I'm thinking too fast, and moving too fast, and I feel like any moment it's going to spin out of my grasp in a million different directions, and all I want is to stand still. 

I've been sick for at least twelve years. I've accumulated ways of thinking and behaviors that are fundamentally maladapted to living a healthy life. I'm not sure I know how to live a healthy life. There are things I need to learn, and things I need to unlearn, and it's going to be a lot of work, and take a lot of patience, and demand a self-compassion that I still need to discover. I am finally in a place where I am well enough to start doing that work, instead of just treading water or trying to dig myself out of crisis. 

Just because I almost burst out crying at my work station doesn't mean I am not better. It doesn't mean I should give up on moving toward wellness. In the end, no one else could fix the machine either, and my manager had me switch stations with somebody taller so I wouldn't hurt myself. My day got better, and so did my mood. I left the office exhausted and hopeful. 

I am frightened by how much I'm affected when things go wrong. By how fragile my mood is, by how weak and vulnerable I feel. And that's okay. It doesn't mean I'm hopelessly sick. It means I'm human.

And there is so much more that I can grow.

Who We Are

Because of the nature of this blog - and in fact much of what I've written on the topic of mental illness over the years - I sometimes start to sound like a combination of broken-record and one-dimensionality. The truth is that I am so much more than this illness. I am not just depression. I am not just trauma survivor. I am not just chronic illness. These things have shaped the person I am today. These are things I have sometimes desperately concealed and sometimes spoken about in detail and at length. I think this is an important topic to open up about and, for me personally, a conversation that I need to have with myself and with others. But depression is not the sum of who I am, even when I am sunk so far in its depths that I can't move and can't breathe and can't feel anything else.

We are not just schizophrenics, or borderlines, or bipolars, or anoretics. We are not just antisocials, or anxious, or autistic, or alcoholics. We are people. People with hopes, and quirks, and struggles, and passions. We are people who love, who hate, and who are indifferent. We are teachers, and mechanics, and assembly line workers, and doctors. We are artists, and appreciators of art.

There are a number of art installations on the grounds of the Douglas, placed there for employees, patients, and visitors to enjoy. Here are some of my favorites. I hope you enjoy them as much as I have.

Choosing to Walk Under a Grey Sky

Well, my daily treatments of rTMS are almost done, and I've got a lot of competing emotions about that. This is good, because it means that I have more emotions than just crushing despair. Yay!

A few days a week, I walk from the metro station to the Douglas (or the reverse), both to avoid taking the bus and to try and get in some extra sunshine and exercise. Today, the sky was grey and it looked like it might rain. It's a pretty long walk to get from one place to the other, so I debated waiting for the next bus. In the end, I chose to walk and enjoy the refreshing breeze.

As I walked, I felt just right: it wasn't too hot, and the sun wasn't shining blindingly into my face. I came upon a grove of blooming crab apple trees, and stopped to smell the flowers. It was wonderful! I realized that I haven't smelled flowers in a long time, not even on my own pink tree. I began to notice the smell of fresh-mown grass, the sound of bees, the warm, dusty smell of the road. I felt like the world was opened up around me, as if I was suddenly seeing it for the first time, even though it's always been here.

I ate lunch outside on the Douglas grounds, and then wandered around smelling all their trees. I felt this lightness, this buoyancy within me, like air filling my upper chest and lingering there.

I realized that I was feeling...a lightness. A sense of calm. And something I think was happiness. I felt...happy. I haven't felt happy in so many years, this quiet almost-joy, unlayered with anything else.

When people ask me how my treatment is going, I point to the obvious cognitive and behavioral changes. I can concentrate and understand things better. My memory is improving. I am talking and moving at a normal speed. I am smiling more, laughing more easily. I am having an easier time following my meal plan. Colours appear brighter, my sense of taste has improved, my thought patterns have shifted. I even have less headaches!

It isn't perfect. I'm still tired a lot of time time, and I have less energy than optimal. I find being around people for long periods of time to be draining. I have trouble motivating myself to do things I know I have to do. And, of course, I have had to give up a significant portion of my time in order to pursue treatment and manage my illness. I still feel overcome by inexplicable waves of sadness and tears. But I don't expect to be happy all the time, or for everything to always go smoothly. That is unrealistic.

But all the weeks in hospital, and then in treatment, all the medication changes, all the anxiety over trying to change doctors and treatment strategies, all the time off work, and all the things I haven't been able to do...it was worth it, all of it, for this one walk on this one day, and the way it made me feel.

I will keep choosing to walk even when the skies threaten to open, because I'm starting to feel that the world is worth being in, and that life might be worth living.

My Pink Tree Is Pink

This will be my last year with my pink tree since I'm moving this summer, and I'm really going to miss it. Please enjoy these pictures!!

All Around Me: Travelling To and From the Douglas

One of the things that's true about living in a suburb on the North Shore of Montreal is that I'm really, really far away from pretty much everything I want to get to. This is especially true of my daily journey to the Douglas hospital, because it's in Verdun and itself pretty far away from everything else.

Luckily, the Douglas and its surrounding area are unbelievably beautiful.

The hospital faces some sort of body of water and the view is absolutely spectacular. This comes in handy if I've decided to walk either to or from the hospital. It's calming to look at the water while I wait for a bus, especially when the wait is a long one.

The Douglas grounds themselves are expansive and park-like. I can wander around, have a picnic, practice yoga in the shade. I love the smell and feel of the grass, the openness, the quiet, the chance to disconnect from a hectic, crowded, and noisy urban world.

I'm so grateful to have this space and this time, especially since treatment leaves me feeling incredibly drained and exhausted. I love looking at the beautiful trees and discovering the world around me. I feel like, in the middle of my days dedicated to my disease and its management, I have found a space just for being.

There is so much more to health than just the minimization or absence of illness. 

I get to the hospital much in advance of my daily treatments (because public transit is a fickle beast, sometimes), and it gives me an opportunity to be with the world around me. Over and over, I find myself thinking how lucky I am, which isn't something I've felt much of in the past years. It's amazing what impact being surrounded by natural beauty can have.

I'm not saying you should have all your future family picnics out on the grounds of the Douglas, but if you'd like to join me in sitting on the grass during my last week of treatment, you'd be more than welcome to share this time and space with me.

Why Yes, I Bought Myself a Card

One of the things I occasionally do which some people might find a bit on the odd side of the spectrum is that I buy myself cards. Sometimes. Sometimes it's because I like the picture or sentiment but don't have an occasion that matches the card. Sometimes, like yesterday, it's because I feel like the card is giving me something I need: it throws a challenge in my face about something I need to own up to, focus on, or just plain acknowledge. The card speaks directly to my soul, like some kind of voodoo psychic. It's watching me.

The card I picked up yesterday has this message in it:

I know it must be hard

having to stop

everything for awhile

and just focus on getting better.

But whenever you

find yourself

worrying about

the million and one things

you think you should

be doing instead

just remember...

This time is for you.

Your time to rest.

Your time to heal.

And nothing's more important than that.

Because you're important.

I've been pretty focused lately on trying to figure out some way to coordinate all my medical appointments with my upcoming return to work. To be honest, I feel like time is one of the things I don't have on my side. I was thinking I still had a week of 4 days left on my progressive return-to-work plan, but because of the way the director of my clinical trial filled out my medical certificate, my short-term-disability plan is requiring me to return to work full-time as soon as the treatment is completed. And, let's face it, it's not like a single day off would have made that big of a dent. It would have been more like a polite society lady nibbling a cucumber sandwich, and less like the way I tackle an ice-cream sundae. By which I mean a small, ladylike bite rather than an all-consuming bite of humongous gluttony. Beware my ice cream eating mouth of DOOM!!

It's just all so...overwhelming. I have at least two appointments with the psychiatrist at the Douglas once treatment is over so we can do an assessment; with the travel time, I know I won't be able to make up all the hours I miss work. I have to see my St. Mary's Psychiatrist at least once to adjust my medication levels, and probably a few more times for follow-up, which is time I won't be able to give back, either. This all strikes me as annoying, but ultimately manageable, as they are once-in-a-while things.

But I'm worried about the psychologist I've started seeing at St Mary's. That's probably going to be a once-a-week-thing, with me missing at least an hour and a half each time. For me, that means I'll be working an hour and a half overtime on another day, or spread out over a few days, to try and make up the hours I've missed. Every week. Until we've accomplished whatever our goals are supposed to be. I'm worried about it. I'm worried about always getting home late, and burning out a new and fragile remission. I'm worried because I know what disruptions to my schedule do to my mood, and my sleep, and my ability to do all of the other things that are part of my illness management. I don't know how I'm going to handle it all.

If I could work part-time, just until I get some solid ground under my feet, that would be ideal. Financially, I know I can do it. But, realistically, if I decided not to make up the missing time, that would mean a significant rate of absenteeism, and I'm not sure I could pull that off right now after already having taken so much sick leave. I wish I could have had treatment while I was an inpatient. I wish I could have left the hospital and returned to work having actually been better. When I think of all the time this illness has stolen from me this year, I find myself wondering what the point of it was, what it was all for. I worry that I will undo everything we've been working toward.

There was a woman in the hospital with me who was there by court order, and I remember her psychiatrist yelling at her that it was her time to get better, that it was her time to be well. I wonder what that would be like, really having that time, having someone in my corner who wasn't looking for a fix that would prop me up enough to keep going. I wonder if wellness would be worth that sacrifice, the cost and the effort involved. I don't know, I've never really done it, just taken the time to get better, work on all my shit. You'd think I would have done it when I took 8 months of sick leave from graduate school, but sadly my psychiatrist was not interested in exploring all the shit that was coming up and out of me, so I ended up stuck in the same place as before - except that I recovered less functionality. Win?

What I'm trying to say, I think, is that I bought the card for myself because in my fantasy puppies-and-rainbows world this is how things would be. But reality isn't like a skittles commercial, and ultimately I come away finding that what matters isn't so much me as it is my capacity to contribute, to be useful, to fill the roles that I am supposed to fill. I think I can do it: I've done it before. I'm just worried that I won't ever have the chance to really be well, which is - after all - what I was so desperately searching for in the first place.

RTMS (Or, What I Do Every Day)

When I first started rTMS last Monday, I didn't know what to expect. I didn't have the stamina to research anything about the procedure, and when I had been referred by my treating psychiatrist, all we discussed was that it was an alternative to ECT. I'm writing this post so that anyone else headed off for rTMS has an idea about what to expect. I also don't want to forget my experiences, and I know I experience memory difficulties when I enter periods of acute major depression. Plus, it's interesting!

It's worth noting that I am participating in rTMS as part of a clinical trial, which means data from my treatment will be collected and possibly used for research and publication purposes. I'm quite happy with this, as I believe in scientific advancement. I was relieved to know that this is not a randomized double-blind trial, which would have involved the use of 'sham' coils in some of the participants (in other words, a placebo coil that replicates the external conditions of rTMS but without the application of any actual current). Although I believe these kinds of trials are absolutely necessary for scientific advancement, at this point in my life - and at this point in my current depression - I would have been unwilling to try anything that would definitively have absolutely no effect at all.

Moving onward.

The first thing that happens is I go to the Douglas and look at this awesome sign in the waiting room:

Of everything I've been through, nothing quite brings home the fact that there's something wrong with my brain more than this sign. It's both comforting and daunting to think in terms of brains as the problem here. I can't reduce this illness to a moral failing, to not having tried hard enough, to some sort of problem in the way I make decisions and the effects of those decisions. Those are all factors in what it means, for me, to live with depression. But, somehow, I am not responsible. Because this is my brain, my body, going wrong. In a way I feel like I'm being betrayed by my own body, which brings up all sorts of old and new emotions. In a way I feel helpless, because my brain isn't something I can control in the way I could take responsibility for, say, consistent moral faults. In a way I feel relieved, because I can lay down the burden of feeling like my enduring depression is my own fault.

So, after looking at this sign for a while, the technician administering my treatment calls me into a room. I sit on a comfortable, mostly-reclined chair with a pillow on my lap that I can rest my hands on. RTMS utilizes a biphastic magnetic stimulator (coil) to indroduce an electrical field in a targeted area of the brain. The charge is greatest at the edges of the coil, and drops rapidly to null as you move further away from the coil. Hence, rTMS is much more targeted than ECT, and much less targeted than what would happen if you inserted an electrode (or 'brain pacemaker') into the subgenual cingulate (BA25) and turned it on.

During my first-ever session, and once a week for the duration of treatment, the coil was positioned over my left primary motor cortex, which you can sort-of visualize the location of  by putting a headband on your head directly in front of your ears; the motor cortex starts above the ear and follows the trajectory of the headband. The technician moves the coil around about 7.5 centimeters above the ear, finding the area that causes the right thumb to twitch. This feels very weird, and very cool. Your thumb really moves without any volition, it's awesome! The minimum intensity of current necessary to cause the thumb to twitch is called the motor threshold, and this measure is used as benchmark throughout the course of your treatment. The stimulation intensity during treatment begins at 100% of the motor threshold and is increased by 5% each treatment until you are receiving pulses at 120% of motor threshold. This allows a consistent measure to be used across the sample and provides a means of standardization. It is, however, somewhat problematic to assume that motor threshold is an accurate indication of activity in the prefrontal cortex, but this strikes me as a minor quibble. 

Anyway, once motor threshold has been established, the coil is moved to the area of the brain that will be stimulated during treatment. The technician draws on your head to find the correct area, in my case the right dorsolateral prefrontal cortex. This is because we're using the alternative protocol: most people receiving rTMS for major depression will have the coil placed on the left side of their head. The theory underlying rTMS is that people suffering from major depression have lower levels of neural activity in the left prefrontal cortex than in the right. Ordinarily, rTMS uses 'fast' stimulation at a rate of 10 pulses per second (10Hz) for 4 seconds, with 26 seconds of rest between bursts. In my case, I am receiving 'slow' rTMS, at a rate of 1 pulse (1 Hz) per second for about 20 minutes. I'm not sure if this protocol was chosen based on my symptom profile, if it's because I also have PTSD, or if it was randomized. I hope I have a chance to ask!

'Fast' rTMS is excitatory, causing the stimulated left prefrontal cortex to 'speed up' to the same rate as the right. 'Slow' rTMS is inhibitory, causing the right prefrontal cortex to 'slow down' to the same speed as the left. In both cases, the aim is to synchronize the right and left prefrontal cortex. The DL-PFC is involved in executive functions like decision making, conflict or choice resolution, working memory, syllogistic reasoning, planning, and cognitive flexibility.

Because of the noise involved, I wear earplugs to prevent damage to the auditory canal. Because I have tiny, child-sized ears, I'm not able to wear things like ear buds, so I find the sensation of having earplugs in to be unusual and somewhat disconcerting. I think, for a normal person, this wouldn't be an issue. When the coil is active, I can hear the machine making between three and five sounds: I was also surprised that earplugs don't result in complete sensory deprivation! Of these sounds, I'm absolutely sure the machine is actually producing two of them. The first is the loud, hard-sounding sound make when a pulse is produced, and the second is the constant loud soft-sounding hum of the machine being on. Two of the sounds may be actually produced by the machine, but they might also exist entirely inside my head, either as reverberations or as products of my imagination. One follows the loud rapping sound of the pulse as a slight-delayed, softer, rounder sound that feels slightly fuzzy; the other is a constant low-grade high-pitched hum and may be a secondary sound of the machine being on. I find both these sounds to have a different timbre or texture than the first two. The third sound is one I only heard once, and it was a sort-of grinding or mechanical sound that happened when the coil was discharging. 

As some of you know, I'm sensitive to certain kinds of sounds, partly because I have difficulty filtering and tuning them out. This is one reason I'm glad we're doing slow rTMS, because the rapid-pulse-then-silence pattern to fast rTMS is the kind of sound I find acutely anxiety-provoking. Yay for alternative protocol!

When the coil pulses, it feels like someone is tapping my head, and the area around my right eye twitches a bit. It's not uncomfortable, just a little strange. All in all, the experience of rTMS is not difficult, and kind of relaxing. I like to spend the time focusing on my breathing and on the roundness and quality of the sounds I'm hearing. And of course cuddling with Puffy, my magical unicorn, who comforts me when I'm feeling stressed out and anxious! I hope this gives you an idea of what I do with my day. :)

In terms of whether or not I've seen any difference yet, here's the breakdown. One person has said I seem to be smiling a bit more. One person has said my online comments are more sarcastic, which he thinks is a good sign! Personally, I've noticed that colours seem brighter and more saturated, and I spontaneously decided that I wanted to start taking pictures again (wanting something! It feels so good to want something!!). I tasted a subtle flavor the other day: banana! I have an easier time reading fiction, although I still have attentional gaps. I feel like I have more emotional lability, and my voice is less flat. These are all good signs. I do have a lot of exhaustion, which might be a side-effect of treatment. I still have a lot of difficulty writing, especially posts like this one that involve recalling, synthesizing, and integrating technical or scientific information. All in all, I think it's going well.