Hello insomnia, my old friend...

I know I am becoming unwell. Maybe “becoming” is an overstatement. It implies a kind of inevitability that I will descend into madness. That is not inevitable, but I have symptoms. Items on my carefully constructed “symptom list” have started to flag up.

The whole point of the list was to catch my mood disturbance before it spiralled out of control. To find a way to surf the waves rather than have them drag me under. So why am I not doing anything about it? I had a couple of weeks where anxious/low type symptoms were present. Nothing pathological, and nothing I couldn't do something about. In fact, I'd say my mood has pretty much been “normal” for a good month until now.

Now I am restless. Now I am avoiding sleep. There is so much to do with the day, oh how I wish a day had more hours than it did. I want to do everything: to learn, to teach, to sit exams, to practice medicine – oh, how I love being with patients! - to drive, to drink, to cook and eat, see friends, go to the beach, go to the gym, shop (especially for expensive dresses), to charm, to smile, to feel happy - why can I not be happy? Why do they (mental health professionals) want to curtail my excitement? I hate them. I loathe them, no, not just them, I loathe everyone. They're liars. This isn't a diagnosis, this is me and I am happy. I don't need to sleep – they're wrong.

Why am I so fixated about what they would think if they saw me now? Because in my heart I know something is wrong. I know they would worry about me sleeping less, about the times my thoughts rush, about me dropping almost £200 on a dress I really didn't need on Saturday because I felt like it (“I'm a doctor, I'm rich! I can have anything I want!”).

It's not all fun and games. A part of my heart is intermittently sinking. I am hearing those niggling voices say, “she hung herself”, “she hung herself”, “she locked herself in her room and hung herself”. Not one suicidal thought for two months and now they're back again. Damn those pesky voices...

What to do? My action plan involves stopping drinking and going to bed on time. Well, it's way past midnight already, and I resent trying to sleep when I don't want to. I didn't have a drink tonight, but it's a school night. Come the weekend I'll have forgotten this pledge to myself.

Who to tell? I've told my boyfriend, but he's gone abroad for a fortnight. I have a new GP I'm seeing on Friday. New. Can I trust him? Can I trust him to understand this, to understand me? I have one more session of CBT pending. Let's hope I can use it to turn myself around again. Because I am lost for ideas and lacking motivation.

It's hard to want to change when you're enjoying yourself.   

Coping with change... Again

It's been so long since I've written anything. Except drug charts and stuff.

Normally that's a good sign – the amount I write seems to be inversely correlated to my mood. The lower I go the more words pour out of me.

My mental stability is undergoing serious challenges this week: I'm moving house (which will involve negotiating my way through London during the Olympics); and I'm starting a new job. I'm having to say goodbye to all of my friends in London and, perhaps more importantly, people involved in my mental health care.

There is no way out of this chopping and changing as a junior doctor. I'll have another job in four months time and again four months after that. I will no doubt be having to move to a different part of the country next summer depending on the location of whatever training programme is mad enough to accept me.

I think it's hard enough for a healthy person, but when you have an underlying mental illness such as bipolar disorder moving so frequently can be very de-stabilising. I'm having to make sure I have a good GP to access and that Occupational Health at my new hospital are aware of my condition. I have to weigh up the pros and cons of letting my next supervisor know. And I guess in the short-term I need to be very vigilant about monitoring my mood and intervening early if things start to slip. So far there's no evidence of that that's happening. Not in a serious way. I felt really down this afternoon after a seagull shat on me (this isn't a joke), but come on... Isn't that a healthy emotional response?

I do wonder sometimes whether the UK medical training system couldn't be better at helping some doctors stay within a smaller geographical area. There are special circumstances that can allow a trainee to request to stay in a certain area, such as having children or requiring regular medical treatment that couldn't be accessed elsewhere. However I think it would be hard for me to make such a request on the grounds that moving house “may” destabilise my mood, especially as staying sane could well be seen as my responsibility, nor theirs. I don't begrudge them this particularly. I suspect such requests are rarely made on the grounds of embarrassment. But it's something to think about in future I suppose...   

Perfectionism

I've been going for CBT for three weeks now, and I have to say that day by day I am getting better at challenging my negative thoughts. Whether that is due to the CBT, medication or other factors such as being back at work I will never know.

Keeping my little thought diary has shown me how desperate I am to please others and how much I fear criticism or punishment. Yesterday my therapist pointed out that this tendency has its benefits. It drove me to succeed through A-levels and medical school. I have managed to command a lot of respect over the years from people around me. I've won prizes. I have a great CV. But then there's the flip side. The moment when failing to achieve my goals becomes intolerable to me and I give up altogether. Many people with depression and bipolar disorder are very talented and successful when well. Is this why? Are talented people prone to depression when the praise dries up?

I've received so much praise in my life. From the age of five I was reading and writing better than anyone in my class. I was way ahead when it came to maths and languages. OK, so sport was never my strong point, but you can't have everything. The point is – I was constantly told I was clever by both teachers and a pair of loving parents. So when I moved to a bigger school with pupils as clever as me it was a shock. I managed to get over it and climb my way back up the academic ladder. Yet by the time I hit medical school I was definitely mediocre. Indeed, in my current friendship circles I still am mediocre.

My default mindset seems to be that I am a) stupid, b) fat, and c) unpopular. Luckily this mindset tends to be challenged on a daily basis unknowingly by others. I might get good feedback from a senior doctor; I might squeeze in to a small dress and note the fact that my BMI is only 21; I might find myself surrounded by friends and having a good time. When I am well I can get away with the odd reminder that I'm not as bad as I think I am. But when I am unwell I need constant praise and signals from others to stop me from sinking... And life's just not like that is it?  

Weight problems...

I've gained 2kg.

Okay, so that doesn't sound like that much. But in reality I've noticed my underwear is a little on the tight side. When I moan about my weight my boyfriend just roles his eyes and says he can't see any change in my appearance. We went on holiday last week, and looking back at the photos all I can see is how flabby my arms are starting to look (again, my boyfriend supposedly can't see this the way I can).

What bothers me isn't the weight gain itself, it's the question of why this has happened. Whatever it is has to be nipped in the bud or I'll risk gaining another 2kg next month. Deep down I know it's related to my mood. I'm not one of those depressives who draws attention to themselves by wasting away. I find myself slipping from a relatively active lifestyle to dividing time between my bed and my sofa. Pretty much all that gets me out of bed is food, as I suspect my writing has revealed. Is that such a bad thing though? When all is dark around you to hold on tight to any remaining source of pleasure in your life?

I've decided to avoid the temptation to respond to this with starvation. I've been through too many periods of self-starvation and subsequent overeating to entertain the notion that it would actually work. The plan is to gently increase my exercise levels and maybe ease off cake for a bit. I'm not an idiot, I know what my body needs to stay healthy. So why is it so damn difficult? I guess that long-term lifestyle changes require a degree of mental stability. I'm much better than I was a month ago, but in general I am an impulsive person. It's so tempting to hugely restrict my eating for a few days just to become giddy with excitement as the numbers on the scales drop slightly. Alas, the excitement never lasts. And when you enjoy food like I do starvation's a real mood killer.

Besides, I don't actually need to lose weight. I calculated my BMI and technically I'm still "healthy". I'd have to gain well over a stone before I'd be classed as overweight. But that doesn't take away my distress at the knowledge that I'm now (almost) the highest weight I've ever been. I've decided to bite the bullet and discuss the issue with my GP tomorrow, but I'm scared he'll just point out that I'm a healthy weight and leave it at that. We'll see.

I read a great blog post on the subject (here) the other day. Turns out it's not just me struggling with my body as well as my mind. If anyone has any other tips for managing to keep your body healthy in the face of a mood disorder I'd be glad to hear it.

Bad news for patients...

So my union has decided to go on strike...

Two weeks ago when the BMA asked if I would be willing to take part in industrial action over threats to my pension I firmly said “no”. Today I found out I am in a minority. An overwhelming 92% of the junior doctors who responded to the ballot favoured taking part in a strike over this issue.

Now all routine GP appointments, hospital clinics and operations will be cancelled on 21st June. Supposedly this won't harm patients. What the hell? What about the elderly woman living off a state pension – a fraction of the pension her consultant will eventually live off – who has to endure another week or so of pain because her hip replacement is cancelled? Or the patient with worsening COPD whose chest clinic appointment (and subsequent clinical intervention) is postponed? Will their lungs appreciate that? Not to mention hundreds of psychiatric patients who won't get to see their psychiatrists that day...

There's no way around it – this strike will affect patients. 

My view remains that if doctors are so unhappy about their NHS pension they don't have to take up the offer of one; they can pay in to a private pension instead. But they know that private pensions are crap by comparison. Most of my friends outside of medicine work in the private sector. I currently have a fairer salary and fairer pension than any of them, even if proposed public sector pension reforms go ahead. Sure, unlike them my job involves sticking fingers up peoples arses, but we all have to make sacrifices in life...

On an entirely different note, it's my birthday this week. I have already opened my presents from my mother – a cheque for £125 (much appreciated) and two books on bipolar disorder, one entitled “The Bipolar Disorder Survival Guide”... Gee mum, thanks. Thanks for rubbing it in.

Having got over my initial annoyance I reflected on the fact that she's only buying these books out of love (and perhaps a little desperation). Both books look fairly good. I just wish my illness weren't the main topic of conversation between myself and my family members at the moment.

Depressingly I didn't have time to make carrot cake last weekend (the heat made it unbearable to turn the oven on), so I bought one from M&S instead. Not a patch on what mine would have been. But then I didn't exactly get a birthday cake this year, so it was nice to have something sweet and manufactured in the fridge to comfort myself with.  

Is this really hypomania?

My mood's bounced back up in style since yesterday.

Once again I'm up good and early and being "productive" (i.e. trying to take on two many activities and getting distracted every ten minutes). The same thing happened three days ago. On that occasion I woke a couple of hours early, made a cup of coffee but forgot to drink it, started cleaning the fridge but couldn't be bothered to finish the job, went online to check out the news, look at pretty dresses, and checked out flights to various European cities. I almost bought a £300 return ticket to Austria on the spur of the moment, but thankfully had the insight to remember I'd have to check with my employer if I could take time off for this trip.

I never know whether to class these kind of episodes as hypomania or not. The only reason I have a diagnosis of bipolar disorder is because of the times I have been supposedly "high". I say supposedly because I still can't make up my mind whether my intermittent bouts of over-activity are pathological or not. My psychiatrists have thought they are - but then it's their business to spot these kind of things. Certainly when I've looked at information leaflets or online about bipolar disorder, I end up thinking Shit, that Sounds Like Me. But then a part of me questions whether perhaps I am just an intrinsically more intelligent, creative and energetic person when healthy and my diagnosis is all wrong. Or whether all of these psychiatric diagnoses are a product of the pharmaceutical industry wanting us to believe we're all sick and need pills to make us better.

DSM-IV states that true hypomanic episodes should last four days or more. I've had a couple of periods in my life when I have been symptomatic for well over four days (once in adolescence and once in my third year of medical school when I went fucking nuts). Each of these episodes were followed by acute crashes into the world of depression. But apart from that I tend to be symptomatic for less than 24 hours, and in all honesty I'm not sure how apparent these episodes are to other people, perhaps because no one tends to be around at 4am, but also because my sensation that my thoughts are racing aren't really visible to the outside world.

My current psychiatrist says that hypomania can last just a few hours at a time and that what I describe to her fits the bill. Which brings me around to the question - should I be concerned when I start to feel this way? Sometimes the sensation that my thoughts are rushing can be very distressing. But at other times I feel great. It's certainly nice to need less sleep. And booking last minute holidays or being extremely sociable and chatty is fun. Then again I don't really achieve much when I'm like this. Sure I can write, but I can't read or study because I get distracted. I don't finish cleaning whatever it is I've started cleaning. And so on.

So lets say I decide when I feel like this it is a bad thing, what am I meant to do about it? For a while I thought you couldn't do anything because I put it down to brain processes that could only be altered through medication (which clearly my medication ain't quite achieving). But then I found this website they other day that has some really sage advice about the importance of nipping hypomanic episodes in the bud and the best ways to do this. The author advises you to Stop, Isolate and Relax. I won't go into the details - check out the site if you want to know more.

That's about all I have to reflect on this morning. But before I stop writing, I just wanted to brag about the fact that my salary is 133% of the UK national average - check out this new BBC tool to see how you fare: http://www.bbc.co.uk/news/magazine-17543356

So much for the European Working Time Directive...

I'm now back at work, albeit without any on-call duties. My main worry about going back was how my friends and colleagues would respond to my absence. Fortunately that hasn't been too bad. My own team are quite understanding and don't ask too many questions. When other people have asked where I've been I've just said I've been unwell and they haven't probed any further. I can't say I'm quite back to my normal social self. I used to enjoy having lunch and chatting to my friends in the doctors' mess. Now it feels noisy to me. I want to escape to the hospital chapel instead.

The thing I am struggling with most is tiredness. Although Occupational Health stipulated that I am not to do any out-of-hours work, the reality is that in medicine or surgery there are no fixed hours. I am supposed to work 8-5pm (which trust me, after a month doing nothing is exhausting enough), but on Monday we finished at 6pm, Tuesday at 6.30pm and yesterday I wasn't done until 7.15pm. That's 4 hours and 45 minutes I've already worked for free this week. I used to joke that I was a full-time doctor, part-time NHS volunteer. I would guess that the extra hours I have worked this year amount to days. So much for the European Working Time Directive!

The long and short of it is that yesterday afternoon I became quite distressed again mentally. I had worked largely on my own in the morning and hadn't had much in terms of a lunch break. My mind drifted to suicidal ideation, as it frequently does when I am unwell and under pressure. I could hear voices telling each other I had jumped under a train. I saw vivid images of myself jumping under a train. I had a strange sensation of being knocked over by a train. Obviously I didn't fall, but the sensation of being hit was there. I rested against the wall, took a few deep breaths and got on with the day with my friends. When I got home I cried. I cried before dinner. After dinner I cried for an hour before bed. I woke up twice in the night, crying. The bedroom is now littered with the toilet paper I was using to mop up my tears.

I loathed myself for doing so, but I decided to text one of my colleagues and say that I wouldn't be in until mid-morning today, rather than 8am. I needed a few hours rest in the morning to collect my thoughts and do some writing. I figured this is the only way I can continue to work – by admitting that I am still unwell and taking small breaks here and there.

That is such a hard admission. I feel weak and pathetic – pathetic because I can see everyone around me “coping” with the hard work and hours, able to come back to work early in the morning after a tough day. But to my knowledge they are not plagued by suicidal thoughts, persistent crying, sleep disturbance or crashing mood swings. Yes I am at work, yes I am now able to work. But my illness is still very much present, and I'll just have to keep judging my ability to function on a daily basis.

On a more positive note, I'm planning to try a new carrot cake recipe on Saturday. Just a day and a half to go...