Friday, February 24, 2006

Our true selves

You know, when I started working almost exclusively at SMACHEAD I thought that I would see "less medicine": that I would see only a fraction of the active medical problems that I was accustomed to seeing at Florey, and that my clinical skills, like unused muscles, would rapidly whither away.

But this has not actually been the case. I spoke last week with a muscular-looking man: stocky, red-headed, swollen calves and forearms like popeye... who was until recently a brickies labourer. He has a mild form of muscular dystrophy. By all accounts he should be in a wheelchair by now, and most people with what he has would be dead before his chidren (both girls, and therefore safe) grow up.

"I don't look like I've got muscular dystrophy, do I?" he grinned, flexing a fist, and I sort-of nodded. Weakness in the muscles closer to the trunk means that forearms and calves are often hypertrophied, excessively large. Like the elevated mood of a bipolar patient, or the absence of wheezing in an asthmatic who is about to die, these are not true signs of health but symptoms of a terrible disease. Once you knew what to look for, he looked sick. But he didn't want to hear that he looked like a sick man.

He smokes twenty cigarettes a day. He's not going to die of a heart attack or lung cancer. We are meant to be handing out cheap nicotine patches to our clients, I haven't pressed him on this.

And another patient. A very unfortunate man with, again, bipolar disorder (seems to be a lot of it about...) who came to us for methadone treatment. His problems are twofold - the way his mania manifests and the way his blood responds to the treatment.

Mania affects different people in different ways. Poor sleep, feelings of limitless energy, disinhibition in various ways, that kind of thing.

I get this weird ego thing - I talk all the time, fast and loose, I exercise lots, and form the conviction that I am sexually irresistable, remarkably artistically talented and full of untapped physical and intellectual potential.

A friend of mine buys expensive but useless stuff. In small amounts none of these are problems, and a mild hypomania is actually a damn fine thing: it's glorious. When you have to deal with the consequences of some of the embarrassingly stupid decisions you've made, then the problem arises.

Anyway - this guy tended to get more of the irritability and impaired judgement side of things, and I suspect this had been partly to blame for the crimes which had put him in prison. Stealing cars, robbing video shops, that kind of thing. Since getting diagnosed in prison and then getting out a few months ago he had been a model citizen - one big purple tablet in the morning, two at night, and for the first time in his life he felt calm.

Until the next GP visit. Blood tests showed that the valproate was affecting his body, causing his bone marrow to stop producing white blood cells. If he didn't stop taking it he would die.

"My arse" he said to the doctor. "I've never felt better."

"This is serious" she said. "You could get very sick. I can't prescribe this any more."

Things deteriorated and she sent him to our service. By this time he had resumed taking his valproate (he had quite a few weeks worth in stock) and felt much better. I tried the same thing.

"If I get sick, I can go to hospital. That's what they're for" he said.

"Mate, they will be able to do piss all for you." I said. "Trust me, I work there. You need white blood cells, you'll die without them. First time you get a cold or something you'll crash. If you get sick, nothing works - no antibiotics, no transfusion. They'll have to put you in intensive care if you get a bloody cold."

He shook his head. "Gotta go sometime."

"If you don't stop taking the valproate" I said, "I reckon you'll be dead within the year."

The preceding was a bit dramatic, but not grossly inaccurate. No white blood cells means essentially no immune response - like AIDS but quicker. He was the kind of man who responded to difficulty with anger, and he was looking pretty angy now.

"There are alternatives" I said. "Lithium, topiramate... look, I'll write them down. Work just as well, better in some cases. As long as you don't get pregnant." And I sent him urgently off to a specialist, because this wasn't one I was going to deal with alone.

Anyway. Apparently Diderot said poverty and disease were the "two great exorcists": they drove out what else inhabited the body and left only the true person, the "true self". We do not see a person's true worth, says Diderot, when they are lying on a bed eating mussels and drinking merlot, we see their true worth when they are weakened, sick or poor.

I don't know about that. Leaving aside the possiblity that you can tell quite a lot about people from looking at what makes them comfortable, from watching what they do with the wealth and health they have, the idea that we see people truly in sickness does not automatically convince me.

The muscular dystrophy guy - the guy living a relatively normal life, until recently hosting bricks, watching the telly and smoking ciggies down the pub. He has a weak form of muscular dystrophy - a protein that is subtly malformed, not enough to be completely useless, but not good enough to be strong.

He is in between the sick and the well, someone who has a foot in both camps. You can close your eyes and imagine the person he would have been had one codon been different, one gene subtly altered - as if he stands before you flanked on the right by a strong and vigorous man who will die in his seventies, on the left by a withered figure in a wheelchair, wearing an oxygen mask, maybe days away from death.

I don't know that the sick man is any more true, that the sick man's life shows any more of what this man was really like than does the well man. It makes just as much sense to say that this man's true nature was as we saw it - checked shirt, packet of White Ox tobacco in the breast pocket, suntanned and grinning - and that it was the unhealthy man who was the illusion.

And the man on valproate. Was he any more himself when unmedicated, when his blood was vigorous and healthy but his mind was full of racing thoughts, plans and ideas and scams that almost seemed too good to be true, holding up a service station, shaking with wild ideas? Or was he "really" the quiet man with the thin blood and the intelligent, calm look?

I don't know. I don't know that I believe in "true selves". A field grows a flower, that kind of thing. There isn't a true self, any more than there is a "true path" that a leaf can take as it falls to earth: things happen to you, you ride them out, you do the best you can. Diderot died at seventy one of emphysema and the beautifully named dropsy - I don't know that he was any more his true self as he breathed his uncomfortable last.

Anyway, this is starting to sound like something that should have a moral at the end of it, and I've never been particularly good at morals. I suppose in the end I'm just grateful: grateful that I can load bricks and make plans, that I can look at but not leap upon dark-haired and dark-eyed girls I see, and that my proteins were twisted just enough, but no further, than necessary.

Thanks for listening,



Anonymous Contemplamilla said...

Nicely put. I think you're right, too. Sort of like, "wherever you go, there you are" - that kind of thing.

It's a paradox I suppose - if we follow all the spiritual directives, we're meant to be trying to become more of ourselves every day. But if we aren't already ourselves just as we are, including all of our "faults", then what are we?

Not that this means we shouldn't continue to strive towards whatever meaningful end we find for ourselves. Maybe just that we should stop agonising about not being "there" yet, because "there" isn't only the destination, it's all the places along the way as well.

Here endeth the lesson. Thanks for the insight!

8:02 PM  
Blogger Foilwoman said...

I think everyone who takes psychotropic drugs (in which I include antidepressant, anti-anxiety,antipsychotic and all other psychoactive drugs) worries about whether they are their true self with or without the medicines. I accept that I'm me on Zoloft, Adderal, and a smidgeon of Lunesta every now and then. But I used to worry a lot that I was just hiding realistic depression, or lack of concentration, or worry and wasn't really addressing the underlying problems. But it is much better to face troubles with a smile than to be overwhelmed and take to one's bed.

I hope ValproateGuy finds another medicine that treats him well. Isn't there something they could give him that would help the white cell count?

3:11 AM  
Anonymous Danny said...

I found myself on Venlafaxine a few years back to control my very manic mood swings. After being totally erratic, doing the most insane, self-destructive things I was convinced by many that this was the way to go. Sure, it calmed me down, it also robbed me of the will to live. It made me physically ill, made me drop so much weight that people who saw me thought I had some disease such as AIDS and, worst of all, sapped me to the point where each day was like the last. I spent eight months on the stuff and I can't remember any individual days at all - it's all one big blur. I felt calm, but I also wanted to lay down and die.

Remember the Stranglers Golden Brown? Essentially a song about heroin addiction, it can be applied to anti-despressants:
"Every day, just like the last,
On the ship, tied to the mast
Never a frown, with Golden Brown"

I'm not for the anti-depressants. You have to strike a balance, in my case it was learning that when the Black Dog enters the room and demands that I do something that I know is wrong, I have to resist it. And resist I do, even when I want to obey and just run wild, have a fight, commit a crime, take what I want and whom I want. I fight the Black Dog and tell it that I have a good life, I'm succeeding in what I do, have wonderful kids and a good woman, and great chums that I can call upon if I need to.

That's my battle, and that's how I win. Sometimes the Black Dog gets a small victory, but he doesn't get the big wins anymore. Doesn't stop him from coming around, doesn't stop me from being manic, but I cannot, and will not, go back to swapping one problem for an addiction.

Doc, we're gonna sit down one night and have a long talk. In the meantime let's sink some wine!

9:02 AM  
Blogger Chade said...

As much as sometimes you wish you weren't, you're always there in your own skin.

Doc, thanks for returning with these tales for us to partake of. When you tell tales of the human condition, there are no need of morals. To be human is to be imperfect and for the most part, few happy endings. It's like Danny said, it's a battle to be the human you want to be, but it's a battle worth fighting. Personally I'm partial to the: Whatever it takes to get it right, in regard to enjoying this little globe upon which we live. If you need a chemical here and there to do the job because The Intelligent Designer was just a little bit unintelligent with the design then so be it.
Until next we pop the cork to partake of the chemicals I find ease the world...

12:23 PM  
Anonymous Camilla said...

Danny, I was faced with the same choice at one point - take anti-depressants for a while, or struggle on somehow without them. I chose the latter, and I'm glad I did now. I was lucky though because I had a great therapist who helped me through the worst of it. Looking back now it frightens me to see how close to the edge I strayed, but I wouldn't change anything because (trite though it sounds) I needed to go through that darkness in order to be able to pick my life up again. What is it the song says, "it's only after you've lost everything that you are free to do anything".

I agree with Chade too though - sometimes you have to partake of the chemical assistance in order to be able to get on with living. I feel quite lucky that when it came down to it, I actually had a choice. Lots of people don't.

7:34 PM  
Blogger Chade said...

I completely agree with the 'choice'. It's a good thing when you've got it and are able to struggle through with the support of friends or a good therapist. Support makes all the difference in the world.

8:41 AM  
Blogger Bronze John said...

Lots of thought-provoking stuff here, probably too much to fit into comments. But:

From what I can work out, and assuming the medications do what they say (antidepressants stop you getting terribly depressed, anti-psychotics stop you going "too" psychotic...) I think the thing is to do more than treat every patient individually, you have to treat each symptom and each episode individually.

For example - depression can be a sign of something wrong. Depression and distress, even to the extent of psychosis, can be a motivator to get you out of an untenable situation. Same thing with anxiety.

Psychosis, I've always believed, is rather different. Not that the cause is unimportant, but the neuroanatomy/biochemistry almost always has to be fixed first.

Obviously I'm positing this dichotomy between medicating and listening, and that's not the case at all.

But the thing is there are people and situations where medication-free treatment is much less successful than medicated. People get sicker faster, get sicker for longer, tear up their lives, kill themselves or others more often. No-one with any compassion is going to withold medication in that case.

I think I'm trying to say you have to be really careful about medicating things away because they are unpleasant. Emotional pain, like physical pain, is a sign that something is wrong. At one extreme you can say if you fracture your ankle you can take a big whack of morphine and amphetamines and keep on walking, but you will stay sicker longer than if you listened. At the other extreme you can say if you have a joint infection you'd better get onto the best antibiotics before you finish reading this sentence and there is absolutely no point soldiering on.

At any one time, any symptom of any disease in any person will fall somewhere on this continuum.

Anyhow - longer than some blog entreis and I still haven't managed to say what I mean. And evidently I haven't managed to convince myself about some of this, so why should anyone else listen?

9:01 PM  
Anonymous said...


Healthline just launched a video campaign for bipolar disorder called "You've Got This" where bipolar patients can record a short video to give hope and inspiration to those recently diagnosed with bipolar disorder.

You can visit the homepage and check out videos from the campaign here:

We will be donating $10 for every submitted campaign to To Write Love On Her Arms, so the more exposure the campaign gets the more the videos we'll receive and the more Healthline can donate to research, support, and treatment programs for mental health disorders.

We would appreciate if you could help spread the word about this by sharing the You've Got This with friends and followers or include the campaign as a resource on your page:

Please let me know if this is possible and if you have any questions. And, if you know anyone that would be interested in submitting a video, please encourage them to do so.

Maggie Danhakl • Assistant Marketing Manager
p: 415-281-3124 f: 415-281-3199

Healthline • The Power of Intelligent Health
660 Third Street, San Francisco, CA 94107 | @Healthline | @HealthlineCorp

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7:55 PM  

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