Shaky

THE FOLLOWING is a mess. To be frank I don't feel like posting it but am doing so as I'm too tired about it to care. This is not my hypochondria: it's the result of my consultation of the mental health Operative in 4 hours of interviews. I don't care whether I do or do not have bipolar, it's not going to make any difference to me what label I get. A diagnosis is not a medal of honour to sport with pride, though more than one nutter I've met seemed to see their personal labelling this way. The following issues all came up during my recent mental health assessment with the Operative, who will pass on the details to the Psychiatrist so for once I get a proper evaluation instead of someone judging me as an apathetic junkie and ignoring 15 years of prior psychiatric history. So here's how the post started:

YESTERDAY'S non-post wasn't meant to be quite as childish as it might have looked. It was just that my brain was overloaded with things I had read/seen/might say/couldn't summon so I just gave up.

Presently as well as not feeling particularly fine due to no heroin and only 100mg methadone (I still don't feel right) though I have to say I don't particularly feel the "need" for a hit right at this moment.

What's bothering me is that I busted myself for having had what the Operative seems to see as some kind of "manic" episode when I was attemtpedly detoxing cold turkey some years ago. I could kick myself: I had assumed we were on safe ground and that what happened to me happened to everyone. Though one point that forever confounded me were the tales and representations of sick junkies lying in bed for a week. There is no way I could have done that. I suppose I did realize there was something wrong some time back when, leafing through an old depression book, I chanced upon an appendix listing DSMIV criteria for a "mixed bipolar episode" and realized with horror that's what (perhaps) had happened to me. Then I read at the very bottom some wording like: not caused or sustained by any underlying organic factors and I thought A-ha! That can't be it then as drug withdrawal is surely an "organic factor". Here are the DSM criteria for mania with my comments see what you think. "Mixed episode" means mania and depression simultaneously.

Put in druggie terms, my experience was like "bad speed". I.e. speeding out of my head and yet suicidal. Though I have to say I was going way WAY faster than I've ever gone on speed... The experience went on day and night for eight days until basically I used heroin. All agitation and a worsening constant anxiety ceased; then I felt depressed for weeks on end.

Manic Episode

DSM IV Criteria


A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
(Elevated for brief periods. Most of the time I was depressed, suicidal, anxious, terrified etc.) But unlike any ordinary depression my mood was EXTREMELY volatile. Swinging all over the place very rapidly...

B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) inflated self-esteem or grandiosity no way ~ depression
2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) managed 4 hours flat on massive doses of sleeping pills, woke with a jolt feeling horrible
3) more talkative than usual or pressure to keep talking my mind was full of such negative ideas I didn't want to express them
4) flight of ideas or subjective experience that thoughts are racing yes: racing so fast I felt like I was flying/lost track repeatedly of my thought process
5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) definitely: could barely focus for 30 seconds on anything
6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation pretty extreme agitation: couldn't stop pacing the entire time; walked five miles right in middle of full detox
7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) no because depressed out of my head

OK so four symptoms: racing thoughts, severe insomnia, distractability and extreme agitation (totally unable to keep still almost the entire time for eight days)

C) The symptoms do not meet criteria for a Mixed Episode

D) The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. wasn't working; social functioning yes: this was one of very few times I felt bad enough to loose my ability to keep up even a veneer of social nicety

E) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism) I would say yeah they are (so this wasn't it) but you could argue withdrawal is indirect as the drug's NOT THERE

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I disorder.

OK here's the criteria for depression:

Major Depressive Episode

DSM IV Criteria


A) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations

1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. very much so
2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) no interest in anything, except pacing back and forth and glimpsing horrific passages in Revelation with my shot attention span
3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. barely any appetite at all but didn't weigh self
4) insomnia or hypersomnia nearly every day max 4 hours' sleep even on sleeping pills
5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) extreme agitation of mind and body all the time; unable to keep still or focus on anything
6) fatigue or loss of energy nearly every day yes despite feeling so hyper I was utterly exhausted
7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) very low self-esteem
8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) extremely
9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide suicidal thoughts x100s per day ~ with specific plan

B) The symptoms do not meet criteria for a Mixed Episode they might

C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. yes

D) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism) I assumed this proviso got me off the hook, but I'm not 100% sure

E) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. no bereavement

And finally: criteria for mixed bipolar episode

Mixed Episode

DSM IV Criteria

(Note: this is often referred to as "rapidly cycling bipolar" - but technically Rapid Cycling refers to at least 4 episodes in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed or Hypomanic Episode, and the Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity - e.g., Major Depressive Episode to Manic Episode)

A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period. yes for manic, definitely for depressed

B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. yes impairment

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment), or a general medical condition (e.g., hyperthyroidism) again not really sure, the Operative didn't seem to think this criterion counted as my experience was markedly different from the normal writhing in bed of heroin detox

Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication,, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder

These are the ordinary withdrawal symptoms from heroin/methadone, as listed on the drug abuse info cards dished out by Havard Medical School in the States:

OPIATE WITHDRAWAL
Early Signs (8-12 hrs): Diaphoresis, nausea, yawning, lacrimation,
tremor, rhinorrhea, irritability, dilated pupils, resp. rate, pulse>90
Severe Signs (12-48 hrs): Insomnia, elevated T,P,R,& BP, nausea,
vomiting, abdominal cramps, chills, diarrhea, muscle twitching,
dilated pupils
Course: (1) Heroin: onset in 8-12 hrs, lasting 5-10 d, untreated.
(2) Methadone: onset in 24-48 hrs., lasting 2-4 wks.
Methadone:
• Methadone-maintained pt - confirm dose w/methadone clinic.
• Analgesics: pt is tolerant to opioids - analgesic Rx required for pain
management. Methadone maintenance pts. may require higher
than conventional doses or increased frequency to attain analgesia.
• Expect coping problems: Don’t dwell on dosage with pt.
• Monitor pulse, respiration, pupil size.
Acute Medical Adm:
Dose (inpt.)
• Untreated street addict: @ signs of w/drawal. Rx 20 mg po.
• Known heavy use: 30 mg po: Increase 5-10 mg q 2-4 hrs. to
stabilize. No more than 40 mg in 1st 24 hrs.
• Avoid doses >40 mg qd. unless enrolled in a licensed methadone
program or inpt. > 4 days.
• May use Clonidine 0.1mg. po tid with methadone or alone for
short stay patients.
• If NPO: ½ daily dose IM, divided q 12 hrs & restart prior full po
dose as tolerated.
Course: Onset 30-60 m: peak levels 2-6 hrs: duration 24-36 hrs.
Side Effects: Reduce 5-10 mg prn lethargy:
• Taper: If 1-14 d s/p admission, 10-20% qd. Expect distress.
Discharge planning: initiate as quickly as possible.

Bear in mind I was coming off "cold" ~ ie total cold turkey with no methadone help at all. In fact I flushed my methadone down the toilet in order to get on with detoxing as quickly as poss.

Severe insomnia, depression, anxiety and agitation are all normal in opiate detoxification and to be expected.

What happened to me, however, appears to have been far more extreme than the average experience.

As for the severity markers, by day 5 I was well enough physically to go visiting relatives. Just had a bit of chills left. But without going into protracted detail, mentally totally unable to cope.

I had taken antidiarrohea meds, anti-emetics and anti-cramp meds and I did have sleeping pills.

My main physical withdrawal symptoms were: extreme sweats, especially night sweats, hot and cold flashes. I was lucky to get no cramps, no diarrhoea, no running eyes and nose (which I'm not prone to anyhow). Which may all sound a bit weird but bear in mind I'd been using only 0.3g daily by skinpopping. Average British street purity is around 40% so that would be up to 120mg diamorphine a day daily for 6 months, with broken history of regular heroin use extending back eighteen months before adn irregular use 2 or 3 years behind that.

The most farcical thing was, all this happened in front of my family. It wasn't "flu-type symptoms" that busted me, or sweating (that only happened ultra-heavily at night) but my extreme restless agitation and highly "labile" (variable) mood and shot to pieces attention span. I was behaving in a totally out of character way. What happened to me went FAR beyond ordinary anxiety/depression (which I was more than familiar with by this time) ~ as I say, this felt like "bad speed" but far more extreme than anything speed or coke's done to me. I was going extremely fast ~ felt more than anything like I was on bad acid. Difference being bad acid wears off within 24 hours tops. This went on and on for eight days, day and night, ceaselessly. And stopped when I used heroin again. Even then my mood failed properly to improve. Though the agitation and "mania" ceased, i was left depressed out of my head, even when high on heroin ~ and of course my tolerance had reset to zero so heroin back then was full-on strong.

OK I do apologize for the scattershot nature of this post. I didn't really want to tell the story of this nasty episode from beginning to end. It was one of the handful of all time WORST experiences of my life. By any normal standards what happened to my head was EXTREME. Basically I felt like I was having a breakdown; there were times in that week when I really did lose it.

Now I'm wondering whether anyone reading this who knows anything about bipolar/psychiatry/etc can comment or remark on anything the above brings up for then..? I've not yet had the chance to be grilled on this by the psychiatrist and feel a lot of apprehension on what label I might get. Bear in mind I've also overreacted to antidepressants on several occasions ~ gone into "hypomanic" type states. And in the year before my addiction really kicked in was getting regular mood swings from frequent depression to mild bouyand sustained euphoria with overconfidence and a mild version of those mania symptoms I lacked during the detox episode because of feeling so mentally lousy. Those swings were short ~ only a couple of weeks usually ~ but long enough to "fulfill" the lovely DSM's criteria, which again fills me with stress: what does this really mean..?? My detox episode is by far from my only "bipolar" type experience. The Operative focused on it because it was the most extreme. I'd be most grateful for anything anyone's got to say.

Right I've got to go this is tangled enough. Sorry for the mess. I really have not the energy to hack this around so please make sure if you're answering you've read through thoroughly.

Cheerio, everybody. Back tomorrow!


M U S I C


Maybe this should be my new anthum: "I want to live, not merely survive; and I won't give up this dream of life that keeps me alive..."

Duffy: Diet Coke Ad



Robbie Williams ~ Feel

This one made me cry during one of my far too infrequent sobriety attempts.
I got too much life, running through my veins, going to waste...