Dosages and Desperation

It has been long enough since the most recent Zoloft dosage increase to evaluate its efficacy.  There was at some point, very briefly, a barely perceptible improvement, and now I have begun to backslide. 

It is a little complex because different symptoms are taking different paths.  Part of what comes with my depression and/or anxiety is irritability and paranoia, basically taking everything that is said or done in the worst way and over-reacting.  Thankfully, this cluster of symptoms has consistently been disappearing over the course of my treatment with Zoloft.  As of now, bouts of reactionary jackassery are very infrequent, usually extremely brief, and I usually figure out what is going on (or more to the point not going on) and make amends in time to salvage what remains of the interaction.  As a result, my illness is perceived as improved by others because I am getting along better with others.  There is an internal component to this, of course.   I'm simply more philosophical about how I perceive, contemplate, and respond to stimuli.  I find it easier to put things in a perspective that make them smaller rather than bigger.

My internal life is not going as well as that.  Part of how I deescalate perceived negative stimuli is through a kind of fatalism, realizing that things will be as they are and I am powerless to change them, so why bother getting upset?  I also internalize a lot of perceived negative stimuli through a belief that I deserve it, that I brought it on myself, so once again, what point is there in reacting in a way that can only make it worse?   Finally, and most importantly, I realize that most of the negative stimuli that I perceive is simply manufactured in my own malfunctioning mind.

So while I am being less of an overt asshole, I am still being passively upsetting to others by simply not performing the few simple duties I have in life well, consistently, or in some cases, at all.   I do a lot of sleeping, or trying and failing to sleep, and other forms of doing nothing but letting time pass.

So, that is how I am doing, or not doing, in terms of my effect on the lives of others, but what about selfish me?   How am I doing?   Very not well is the short answer, and getting worse rapidly.

Shortly after starting Zoloft, I found myself able to resume in-person public interaction with old friends and acquaintances, and through those connections accumulated a few new associations.  I was meeting with a group of people at "Karaoke From Hell", a recurring show at Dante's, once or twice a month.  Singing has always been important to me, and I once again was able to convince myself that I could sing well enough at least to enjoy it, even if I couldn't perform as well as I believed had been able to about 10 years ago.

Abruptly, the last two monthly attempts started well enough, but I found myself feeling out-of-place, foolish, and painfully aware of my vocal shortcomings, well before the evening was over.  I went home both times feeling depressed and convinced that not only could I no longer sing well, but that the belief that I had once been a moderately good singer was a delusion.  I was also acutely aware of the age difference between myself and most of the other people present, and could not imagine that my presence could be as welcome as they pretended it to be.  They were being kind to a pitiful and foolish old man.

Most of my time since my life sort of collapsed, first in 2000, and further in 2003, has been spent on a myriad of pointless digital projects, mostly playing around with reworking other people's existing music and films.  Now I am finding that I am performing poorly at even these indulgent diversions.  It takes me longer and longer to make progress.  I context switch between projects too often, and don't document my process so I often am at a loss as to where I left off when I return to a project.  I do a lot of tossing out untold hours of work and starting over.  And remember, this is stuff I am doing purely for my own interest, contributing nothing to the lives of others.   Self-indulgent obsessions which rob time from my household duties.  I can't even live up to my own standards of goofing off.

My cognitive function seems very inconsistent and degrading.  A vague but heavy malaise drags me down and saps my energy.  I am overwhelmed with thoughts of many things I was sure I was going to do someday, many of which have been started and lay unfinished, will never be done.  I don't know how much time life has left for me, and everything I do is going slower and not well.  Even relatively trivial goals I now realize are beyond what is left of me.

I am rapidly approaching the state of mind I was in when I started Zoloft, a feeling best described with the single word "done".

I'm at 150mg  of  Zoloft.  The clinical limit is 200mg.  I'm trying to hold out and delay asking for that final increase for as long as possible because after that, there is literally nowhere to go.  If it doesn't work, or if it works and then gradually starts failing, I have nowhere else to go.  True hopelessness.  As for anxiety, a lot of old symptoms are coming back, but I am not quite in the hell hole I was in before I started Clonazepam.  But I know I will be back there at some point, I feel myself descending towards it, and there is nowhere to go there.  The 4mg daily dosage I am on already would be considered by many clinicians to be absurdly high.

Before I once again declare myself "done"of my own volition, it seems likely that life and medicine will have decided for me.  I'm sorry to be so absorbed in self pity in a world full of people enduring real suffering beyond my imagining.  I have cheated death so many times in so many ways, but it seems that the world, evolution, the universe and God all agree that I was not meant to live.  If I had been born very few years earlier, many of the medications and surgeries that have saved my life would not have existed.  Television and other media are filled with heartwarming and inspiring stories of people living meaningful, purposeful lives bravely overcoming illnesses and injuries far worse that my poorly wired brain and poorly plumbed circulatory system.  There will never be such a story about me because I am a selfish, self-pitying, self-loathing weakling who will continue whining and complaining until my bitter end.

The mix is better for now

My previous post was too early in the process of dosage increase.  I also complicated matters by being impatient and going from the intermediate dose of 125 to the new dose of 150 after only 5 days.

Again not any sort of manic happiness, just a more balanced perspective behind how I feel about things.  I am once again fairly consistently capable of gratitude, yet not completely crushed by shame over having been an ungrateful ass.  The process of making amends where I feel it is needed is often difficult because I have conditioned people to take a defensive and suspicious stance when interacting with me.

My biggest concern is that once again my condition will degrade over the course of very few months, and another 50mg increase puts me at the maximum of 200, and if that doesn't work or last, there is nowhere to go but things like ECT.

Mixed Results

Maybe it is too early to know.

As previously mentioned, I was perceiving a decrease in the efficacy of Zoloft at 100 mg/day.
I wasn't feeling nearly as "done" as before I started, but also not nearly as "glass half full" as I did some time after the increase to 100.

I'm not sure how long it took for the 100 to become fully effective.
I'm not sure how long it lasted before it began to decline.
I am very short on basic data.

After seeing my Psychiatrist, I ramped up to 150, and have been there for nearly a week.
There were a few brief episodes of what I might call "micro-mania", but is really what I believe should be my "normal", spontaneous and often extemporaneous singing during routine activities like driving, and a tendency to make the occasional bad joke or pun.
But those episodes are few and far between, and there may be no more forthcoming.
More importantly, the generalized "glass half full" attitude never came back.
In fact, my glass seems as broken and bloody as it was before the increase.
Maybe, just maybe, a little worse, but not with sufficient drama for certainty.

In the absence of significant external stimuli, my default mode seems that of an empty automaton, slogging through the tasks of existence with neither joy nor despair, thinking, apparently, about nothing most of the time.

My cognition seems to be impaired, and I don't just mean my usual memory problems, both short and long term.  I find myself making absurdly stupid mistakes with increasing frequency.  Things like waiting for a stop sign to change.  I am more easily confused if there is too much incoherent external stimuli, such as more than one person talking at once, or even one person talking while I am attempting to engage in a simple task.  All of these have been general low-grade problems for a long time, but they have become noticeably worse since the increase.

All of this feeds my already ample sense of worthlessness.

Other words and phrases are stumbling around in my head, but they refuse to line up in an orderly fashion and make useful sentences.  Useful.  I find the word almost funny enough right now to make me laugh, but not quite.

Is it possible that writing is not good for me?  Obviously, I am not a particularly good writer, but that isn't the concern I am trying to express.  Writing requires the exhausting effort of translating my chaotic and fragmentary thoughts into English sentences.  It forces me to try to think.  The more I think, the more I examine my own psyche, the more I hate myself.  The hate is twofold, first because thinking is hard and I am stupid, and second because what little I can put together out of what is inside me is boring and ugly.

OK, enough of that for now.  Time to take pills that make me sleep.

Too Much Introspection Makes Blah Blah Blah

As always, let's start with "I", the prison in which I live.

I didn't intend it, but this evening somehow I ended up re-reading a bunch of my Facebook "Notes", a minority of which have been re-published here as Blog entries.

It is a rabbit hole down which I have a history of falling, but have avoided for some time now.  I remember my own writing poorly enough to find it interesting to re-read, and will spend an absurd amount of time re-experiencing myself, and as noted previously, usually myself at my worst.

I actually think that some kind of compilation of portions of my incessant whining might make an oddly interesting book, and as such the only work product of my entire life.

This returns me to that dangerous feeling of being "done".  That feeling that led me to Zoloft, which provided some diversion for what seems like a remarkably short time.  I can't think of anything to add, and I can find much that is redundant.  I had started going to Karaoke From Hell again, something that is strangely important to me.  I had even been embraced by a whole new semi-organized group of regulars that had developed in my years of absence.  But then came the night that, a few hours in, I started to feel empty, foolish, self-conscious and out-of-place.  I started to notice how poorly I sing, despite the charitable compliments.

I had been very steady for a little while on my Zoloft/Clonazepam combo, but now I feel an intolerable urgency for this feeling of meaningless emptiness to just stop.  Fortunately, I have a very strong sense of, for lack of a better word, duty.  There are things that need to be done, and I have to do them.  There are people, very few but very important to me, who would be hurt, and I have to wait until I am sure they would be truly better off without me.  This does nothing to calm me down, or alleviate my suffering, but it keeps me back from the edge.

Clearly, it is time for another appointment with my psychologist.

If anyone actually reads this, please don't panic.  I'm all talk, all the time.

A Post of Uncertain Motivation

Mostly, I think I just remembered that I had a blog, and noticed that I had not written in it in a long time.   My best guess is that I only feel bloggy when I am depressed or otherwise distressed, and have this inexplicable urge to share the worst of me and my experience with my pantheon of imaginary friends.

So, am I depressed?  Sometimes, and with increasing frequency, as best as I can judge as the thing inside the black box of my mind.  I am approaching the point of considering modifications to my treatment, but I do so with much trepidation.  I don't have a lot of overhead for dosage increase of Zoloft, and it seems awfully soon to go up from 100mg/day, when the absolute ceiling allowed is 200mg/day. 

Hopefully, my psychiatrist kept notes on my effects and side-effects of the other medications I had tried and abandoned, as some may be worth re-visiting.  Considering that some of the side-effects that had led to cessation of some medications have become permanent conditions of uncertain cause.  I have so many things wrong with me, and I take so many medications, not just psychoactive ones, the cause of my "side-effects" would be a very difficult and hazardous thing to sort out.

Hey look, I just ran out of motivation to ramble into the void.

A Gratitude Experiment

It took me a long time to arrive at the title for this experiment.  I started with "Optimism" but that didn't feel right.  I had noticed that when I write, even when I start out with intentions of reporting positive outcomes, I have a habit of making sure I thoroughly cover all of the negatives as well.  The idea here is to write something in which I focus on the good over the bad of my experiences and feelings.  I searched my psyche for positive adjectives I could apply to myself that didn't instantly inspire a sarcastic counterpoint, and I finally settled on "grateful".  I can honestly say that there are a great many things in life for which I am grateful, but don't worry, this isn't turning into some kind of sappy list of puppies and sunsets.

This is part of a continuing series reporting to myself about the efficacy of pharmaceutical interventions of my various psychological and/or neurological defects.

After extensive trials over the course of years, the following medications have a net positive effect on my behavior and feelings:

Clonazepam (AKA Klonopin), a benzodiazepine class of tranquilizer
1mg every 6 hours.
This has been very effective in preventing a number of the worst of my traditional panic symptoms, as well as preventing a difficult to describe sort of obsessive circular thinking about unsolvable existential dilemmas, which had begun back when I was 3 years old (not kidding).

Atenolol, a Beta Blocker
25mg twice a day, six hours apart
While not technically a psychiatric medication, in addition to its application to hypertension,  it suppresses the physical symptoms of panic attacks (increased heart rate, shortness of breath), and I believe it breaks a feedback loop that causes panic attacks to escalate.  Without it, I often experienced subjectively realistic, yet false, symptoms of cardiac distress.

Sertraline (AKA Zoloft), an SSRI (selective serotonin reuptake inhibitor)
100mg per day
This was the gold at the end of the rainbow for me.  When I began Zoloft a few months ago, it had been literally years since I had last tried an SSRI.  All previous trials with other drugs produced dramatic negative effects, both in terms of known possible side effects, and zero or inverse results for the intended primary effect.  It isn't a "happy pill", but it is a surprisingly effective at making me feel significantly less terrible.  I suspect this medication is what allows me to write this "Gratitude Experiment".    Here's an unexpected and welcome side-effect: I am slowly but steadily losing weight since starting Sertraline, and I have no idea how or why.  I could make some guesses, but I am pretty much unaware of the changes in my behavior that have led to this weight loss.  I think I've been on it for a little more than two months, and I have lost 25lbs.  Not to worry, I could lose another 25 and still be overweight.

So, those are the drugs for which I am grateful in terms of my psychological well being.  For my purely physical conditions, there is a whole other list which I can't even remember off the top of my head, but I'm grateful for those as well.

I must emphasize strongly, as I have before, that I am not advocating the use of any of these specific substances.  Every person is different, and responds differently to the same substances.  If you don't feel overwhelmed by or hopeless about your life, you probably don't need any of these, or anything like them.  If you would benefit from pharmaceutical intervention, that must be a cautious process undertaken at the direction of a qualified psychiatrist.

This satisfies the primary intent for this post.  The lack of a list of the many people and things for which I am grateful should not be interpreted as a lack of appreciation for the same.

Ungrateful and ungracious complaints aplenty in future posts, I promise!

I Lied

 To my one possible reader: you probably shouldn't read this.  I don't think it will be in any way helpful, and could be harmful.  You know who you are.

We are now apparently beyond what had been the foreseeable future of my previous blog entry. I have an appointment with my psychiatrist within the next couple of weeks.  My pretense here is to practice talking to myself about what I need to talk about with my psychiatrist.

My experience with Zoloft has been a net improvement over my state before I began taking it, yet it is not an improvement over my state when I first, years ago, became desperate enough to submit myself to pharmaceutical treatment.   That is actually saying a lot, because before the Zoloft I was, as I had put it, "done".  I can't think of any better way to put it.  I think that may be how some people feel before they turn to suicide.  My other way of describing my experience was the conviction that I had turned some kind of corner and was living a "post hope" existence.

The truth of my existence as I see it has not changed due to Zoloft.  What has changed is that I spend less time thinking about it, less often, and with less severity.  Before, I could not break out of almost constantly obsessing about hopelessness, failure, regret and shame. Now, those feelings are more like familiar companions, rather than a violent insurgency.  They are always there, but they don't make as much noise.

In considering a Zoloft dosage increase, I am very concerned about maintaining realistic expectations of what good or harm could come of it.  The good news is that I am presently at pretty much the minimum common dosage, and there is a lot of headroom between that and the maximum safe dosage allowed.  This is pretty much the opposite of my situation with Clonazepam, which I have been taking at the maximum recommended dosage for several years.

What do I hope to accomplish with this, or any other, treatment?  That's a tricky question.  To my mind, hope is a dangerous idea.  Hope is just self pity holding hands with self delusion and skipping down the path to disillusionment. (That image courtesy of watching The Wizard of OZ twice while babysitting last Sunday.)  For someone such as myself in possession of  all of the fundamental requirements for survival, and then some, hope is simply greed.

I guess, however shamefully, I hope for hope.  I wish for the courage to be foolish, to want to do things and to do them with little concern about whether I am even good at doing things.   Most of all, I want to sing, and I want to feel that transcendent feeling that music, and especially singing, had once given me.

This is absurd and selfish and wrong.  Can a drug change that?  Can anything? Should it?

I won't manage to say a fraction of this when I speak with my psychiatrist, and I have yet to meet one who likes written communication, but that's probably a HIPAA thing.

Honk If You Love Retro-Blogs.

I don't hear any honking.

All blogging by Michael "Mookie" Kepler (born James Milton Wood [Jr.]), is suspended for the foreseeable future.  Brief reports on family events and such will continue to be posted on Facebook, probably.

Thanks to Zoloft I no longer feel a frequent urgent desire to die, nor do I spend extended periods of time obsessing about how worthless and meaningless my existence is.  I had not addressed these states of mind in previous writing, or speaking, because I felt it was somehow inappropriate.  I'm not sure why I think it is OK now.

For some years now, Clonazepam has kept my mind out of truly horrifying places which had haunted me, often to the point of intolerable anguish, since I was three years old.  So, that's old news, but it seemed related.

I guess the message is "Better tolerance of living through chemicals, hooray!"

Your results will almost certainly vary, and finding the right chemicals to tolerate your life, if needed, is a matter between you and your Psychiatrist, if any.  Finding what seem to be the right chemicals for me took literally years of very unpleasant, and possibly dangerous at times, trial and error.

I suspect the ideal dosage of Zoloft for me is yet to be found.  The darkness no longer overtakes me, but I feel it trying.  I do not feel safe yet, but I am grateful for the improvements that have come.

Just so you know, I know that "tolerance" and "safe" are pretty much meaningless ideas, if you really apply any amount of critical logic to them.

This adequately demonstrates why I will no longer be writing into the void.

Goodbye, Imaginary Audience.