Tag: anxiety

Anti-Suicide Safety Plan

It’s a good idea for people with suicidal tendencies to have a safety plan. A plan which may be consulted at times of crisis.

The time to create such a safety plan is while one is well. In light of this, my new Dialectical Behavioral Therapist Lori has suggested that I work on mine now. And since the purpose of this blog, way back when, was to share the results of my homework, I thought I’d present the results here.

My safety plan appears on a phone app called “mood tools”. It has four sections: Warning Signs, Coping Strategies, Reasons to Live, and Contacts. (Well, okay, the app actually has six sections. It also includes Places for Distraction and Other. But I don’t use those.)

My chief warning sign used to be suicidal ideations. But now those are chronic. I have them even on my best days. So, they aren’t really a warning anymore, just a nuisance. (“Sue” is almost always around.) Instead, the indication of real danger now would be an obsession with suicide and a felt urge to actually carry it out. I’ve also learned while in hospital that the last pleasure to go is social contact. My strongest suicidal urges correlated with no longer wanting to interact with anyone. Thus, a second warning sign would be losing interest in seeing people.

My anti-suicide plan also contains a long list of coping strategies. There are things to calm me, like: doing a meditation, especially a gratitude meditation; using “box breathing”, where I breathe in counting to four, hold for four, and then exhale for four; and various grounding techniques such as counting five things that I see, four things that I hear, etc. There are things to get me moving, like doing a run or cooking something. There are mantras that I recite. Saying to myself “change is constant, loss is constant, unfairness is constant, mistakes are constant, conflict is constant” helps me radically accept difficult things. I also have my new technique of naming the suicidal thought, recognizing that “Sue” is an invasive thought from a malfunctioning part of my brain, and stressing to myself that intrusive suicidal ideations don’t reflect my overall values. A third kind of mantra that I use for self-soothing involves reminding myself that, when climbing a mountain, sometimes one has to go down into a crevasse; doing so feels like losing ground, but in fact even the downward trajectory is a brief part of the larger success.

I also have a list of reasons to live. First and foremost is being able to spend time with family and friends. As I say, it’s only at my absolute lowest that I don’t enjoy that. Similarly, there’s time with my students, past and present. Granted, if I am super suicidal, it’s likely that I’ll be suffering from anhedonia and so won’t be able to just dig in and do enjoyable things. Nonetheless, I can tell myself that pass-times which I used to enjoy will come back again: the joy of reading, music, fishing, and travel have always returned in years past. A different order of reason for living is the knowledge that I can help others by staying alive, and that many people I care about would be irrevocably hurt if I gave in to the suicidal urge.

Next in my safety plan is a list of contacts. I have listed two suicide prevention hotlines: the local London, Ontario one, Reach Out at 866-933-2023 and the new national Canada-wide one, 988. I recorded the address of a “crisis stabilization space” – 648 Huron St. – which affords an attractive alternative to going to Emerg. The space has about a dozen beds for those in mental health crisis for stays of up to three days. I also have listed the phone numbers of numerous friends who have helped me in the past. The app has the power to directly dial these folks if I click on their name, so I don’t even have to open another program to get through to someone.

I have been doing a lot better since I left the hospital, and some of this looks unnecessary right now. But I know, based on past experience, that I am likely to face dangerous levels of suicidality in the future, so I should always have this safety plan handy.

Learning to Live with Suicidal Ideations

In my last post, I posed the question what’s “well enough” to leave the hospital. I said that a necessary condition was getting over my suicidal ideations. I wrote: “Until I can stand on a bridge without being aware of the opportunity it affords for suicide, I don’t think I’m ready.”

Yet, here I am at home, still having suicidal thoughts. What happened?

It turns out the medical team at the hospital were focused on a different question, namely, how much can they help? They concluded two weeks ago that I had benefited as much from hospital care as I was going to. In particular, they reasoned that medication adjustments were unlikely to take away the suicidal ideations altogether.

Now, the psychiatrist who broke this news to me asked what at first seemed a deeply puzzling question, viz., why was I so disturbed by suicidal thoughts? To me, that sounded like the question why I find pain distressing: both are things which are per se unpleasant. Surely, I thought, he must never have experienced a “suicide affordance” if he can ask why they are so unwelcome. Our conversation continued, however, and it emerged that there are thousands of people who have chronic suicidal ideations but who have learned to mentally distance themselves from those thoughts. Said the team, I’d have to learn to live with them as well, not letting them bother me so much. (How very Buddhist…)

My dear friend Gustavo noted that this is somewhat like game theorist John Nash, who famously suffered from schizophrenia his entire adult life. Nash wasn’t helped by medications. Instead, as he put it, he gradually began to intellectually reject the delusional lines of thinking. His voices didn’t go away; rather, he somehow managed to consciously resist them.

In the two weeks since I left hospital, I’ve been working on creating the requisite distance. My current technique has three steps. First, I identify the suicidal thought. I’ve given it the name ‘Sue’ for suicide. Second, I note that Sue is an intrusive thought, which comes to me unbidden and from a malfunctioning part of my brain. Third, I stress to myself that Sue fits ill with my overall values. Sue, in short, isn’t me.

It isn’t easy living with Sue, but maybe I can manage it.

A Month In Hospital

I’ve been in hospital for a whole month. The bad news is I was brought in feeling very suicidal; the good news is that I’m feeling better. In this post, I’ll explain how I got here, what it’s like, how I’m doing these days, and what the game-plan is going forward.

I had my monthly meeting with Dr. Desjardins, my psychiatrist, on March 26th. She concluded that I was too suicidal to be safe at home and arranged to have me brought to Emerg at Victoria Hospital. I spent 47 hours down in Emergency, seeing at least three doctors who all concurred with Dr. Desjardins. At this time, I was issued a “Form 1” which allowed the hospital to detain me for 72 hours. I then spent about a week in what Saima labelled the “holding cell” (i.e., the detox and stabilization unit). Then as soon as a bed was available, I was brought to one of four additional longer term psych wards. For three weeks, “home” has been the 200 block of the 7th floor of B wing.

Regarding what it’s like, I think I can sum up by saying that the weeks fly by, but the days are so slow. I spend my time reading email, the newspaper, non-academic books; doing phone calls and video chats with friends and family from afar; receiving lots of visitors (for which I’m immensely grateful); and pacing the hallways with those co-patients who are verbal, and largely mentally competent. (There are about a dozen patients on my ward, about half of whom are able to maintain a conversation. A couple of co-patients from up here and from the “holding cell” have, indeed, become real friends.) I also eat a lot – seemingly all the time. The food is bland, but eating makes the time pass.

I am trying two drugs that are new to me. Nortriptyline is a tricyclic anti-depressant first used in the early sixties. It’s not popular nowadays – that is to say, after the development of SSRIs like Prozac and Zoloft – because it’s lethal in overdose, hence not given lightly to suicidal patients. If I stay on it post-release, I will be given only a week’s worth of pills at a time. Quetiapine is an atypical anti-psychotic which is deployed off-label for anxiety. It’s also a powerful sleep med. The combination of the two seems to have left me calmer and more stable. I have even had a positive outlook for the last few days. I’m hoping that’s a matter of cause, i.e., that it’s the pills that are actually helping. The alternative hypothesis is that merely being in hospital, in an entirely stress-free environment, is what has me feeling better; and this happens to correlate with starting new drugs. That would be unfortunate because then I’d presumably revert to my very suicidal state when released.

Speaking of release, the current plan is to discharge me on Tuesday, April 30th, 2024. By then, Anita will be home from the Dominican Republic, so I won’t be alone in the house. And I will be on a full dose of the two new-to-me medications.

I urgently need to find things to keep me busy once I’m home, as my Summer class on early Buddhist philosophy was cancelled, due to low enrollments and my troubling state of mental health. Suggestions for how I can spend my time are very welcome. So are invitations to visit!

How I am doing

My blog has been dormant for several months now. I thought it would be good to provide some kind of update on how I’m doing. I’ll divide it into the three aspects of my Bipolar symptoms: depression, mania and anxiety.

Starting with depression, what I think of as my severe grief symptoms – e.g., fits of crying and abiding sadness – are essentially in remission. The combination of electroconvulsive therapy and SSRI medications seem to have worked on that aspect of my mental illness. My suicidal thoughts are largely under control as well. Mostly, I have only passive suicidal ideations these days. For instance, I notice opportunities for suicide – “I could step in front of that bus”, “I could cut my wrists with that knife”, “I could drink that radiator fluid” – and sometimes I wish that I simply wouldn’t wake up. But I haven’t been in serious danger lately. What I’m really struggling with depression-wise is anhedonia, i.e., a loss of interest in activities that used to give me joy. I need to force myself to read fiction, watch TV, or listen to music. I have no great desire to go fishing even when the opportunity presents itself: I hardly fished in the Summer and Fall and didn’t get out even once while down in Uruguay. Another holdover from depression is that I haven’t had energy or focus. In particular, and as a result, I can’t write hardly at all. (Hence the long period without even an update to this blog.)

Turning to mania, I haven’t had a hypomanic episode in years now. Indeed, I wish I could trigger a manic phase, because that’s when I used to get so much done! I’ve made so much progress that I’m not even sure that Bipolar Type II is the right diagnosis anymore. I may need to change the name of my blog…

The really bad news is that, while I never experienced anxiety until five or six years ago, now it’s a constant daily presence. It has replaced the hypomania – and that’s an unhappy trade-off. I seem to be free of anxiety symptoms only when wholly distracted or when lying down. (Between the lack of energy and the desire to be horizontal to fight back the anxiety, I am spending a lot of time in bed.) The phenomenology of the anxiety is peculiar. It is free-floating fear with no object: often there’s no thing that I’m afraid of, I simply feel afraid. It’s as if there’s simply too much cortisol in my blood stream, and so my body and mind behave the way frightened creatures do (tensing up, being overly vigilant, feeling threatened), though there’s no threat. Surprisingly and sadly, no medications seem to help. There doesn’t seem to be an antidote that I can take and make the objectless fear go away.

An unhappy recent development, illustrating the anhedonia and anxiety working in tandem, is that I nowadays lack the energy and enthusiasm necessary to get out running; and I feel afraid on the relatively rare occasions when I do lace up my running shoes. Running is so good for my physical and mental health, but for a month or so now I can’t bring myself to do it, especially not by myself, but not even with a running partner.

I might sum up the curate’s egg that is my mental health these days by saying this: because I can’t bear the thought that it’s permanent, I’ve been telling myself that I’m in the anxiety phase of my recovery. Let’s hope that’s right.