Thursday, August 10, 2006

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Well.

Obviously things are not right here. It is a matter of frequency, intensity, duration and content of thoughts - all are bad and getting worserer.

Things are, I will venture to say, bad. As usual, they are worst when I am alone. They are remaining so despite the various prophylactic measures. I am reading, going to the gym, doing stuff, taking tablets.

Still, many many times a day, I wish I was dead.

By the way - I am going to write about this as reassuringly as possible. I am writing more so people can get an idea what it's like to have these thoughts, and also in the hope that by writing this stuff down I can get some decent sleep tonight - but it's not as a plea for emotional support (I don't know that works) and definitely not as a "oh God, look how close I am to suicide" thing. I'm not close to it at all, as I am taking some pains to express here, and long before that happened I, or several of the excellent people around me, would have got me into hospital).

So, morbid thoughts. What I am talking about is "intrusive thoughts", thoughts that come into your head 'against your will' - thoughts that keep coming and saying the same old stuff, like an unwelcome and possibly unbalanced actor who, regardless of the play being performed, enters stage right and launches into a soliloquy.

The same thing, several hundred times a day (only a slight exaggeration - driving or lying in bed at night it's every few seconds sometimes). And against the will - I'm bored with thinking these thoughts, I'm bloody bored with hearing them... and still they come.

It's so futile. If I spent all of my time and effort looking for ways to square the circle, or make pi equal to twenty two on seven, that'd be widely recognised as folly. But this kind of stuff - it's different.

The majority of the morbid thoughts are probably suicidal thoughts, although a fair proportion involve horrible things happening to those close to me - if Sarah is ten minutes late home, I know that the only possible explanations involve trucks carrying nuclear waste and firemen with the jaws of life.

In the general population, I suspect fleeting suicidal thoughts are very common - they may even be universal. Recurrent, intrusive ones are less common. The making of plans I suspect is less common again - when I get that bad I go into hospital, and there's no need to do that yet. True preparation for suicide rare, actual attempts are more so, the completed act rarer still. I am a long way from the bad end of the scale.

And every time the thoughts come I come up with utterly concrete, irrefutable evidence why it maust not be done. My wife, my niece, my children, my family, my patients. That plus the sheer ingratitude it would imply to the Cosmic Whoever, the appalling selfishness of the statement that being rich and white and male and literate and tertiary educated and having all my limbs isn't apparently good enough for me, that the respect and affection of the many fine people around me somehow still isn't sufficient.

So it's not at all likely. Plus I have seen the side effects of suicide, seen the people who were caught in the shockwave, the mothers and the children and the sons who were standing near ground zero, couldn't take cover. I am utterly unable to convince myself for a microsecond that things for those left behind would be okay.

So, all of me knows it's not an option. But still the thoughts go on. This is what I mean by squaring of the circle, your mind coming back and back and back to something, an endless successsion of futile attempts to do something that you know is impossible. My mind - see how I distance myself from this, say "my mind" rather than "I" - keeps coming up with this shit.

All the time at night. Any time I am alone - I've been writing fiction like a mad thing, I am trying to study, anything rather than be alone in my head - and these thoughts come into my head. Any time I am not actively doing something that requires me to think specifically and in detail about something else.

Working in the ED, running a resus, would be down-time after this.

The stupidity and futility of these trains of thought enrage me. Why can't I just say "well, a 'painless for all concerned' death is not an option, we've worked that out. Now, rather than think about it, how about we try actually doing something useful or enjoyable in the next few hours?".

Anyway. I suspect things today crossed that threshold between "Well, could be worse, I could have to take antipsychotics" to "Well, I'm starting to take the antipsychotics so it doesn't get worse".

In psych we call this "insight". Insight is closely related to compliance: "Insight" is when a patient sees things the way we want them to, "compliance" is when they do what we want them to. Insight and compliance are two of the three cardinal virtues of the psychiatirc patient, the third being "private insurance". If you have three of these virtues you are assured of entry into the Kingdom of decent psychiatric treatment, if not, you are cast into the Pugatory of the Open Bed System (sleeping in the parklands) or the Hell of the closed Public wards.

I am assuming I don't have to renegotiate those terms "we" and "they" any time soon.

So. I'll start the quetiapine tonight. As the molecular biologists amongst us know, quetiapine occupies D2 receptors in the brain, where the D stands for dumb, and the 2 refers to how it makes you twice as dumb as you were before. So, before that kicks in, what to say?

Well, firstly - Foilwoman has written something smart and insightful about the Human Condition. This kind of event is too commonplace to actually be news, but what she said resonated with me so much that I have now started (as writers say) pimping for her. Go you and read what she has said. Women, read and nod. Men, read and weep.

What else? My workplace has descended into a soap opera. I turned up at quarter to nine yesterday and by ten past I expected swelling music in the background and credits to start rolling down the screen. I was going to write it up with a cast of characters (we have our beauteous and wronged heroine, we have a devious plotter with a shady boyfriend, a no-nonsense matron with a heart of gold, a large collection of misfits, psychopaths and wayward teens, and a plot involving drug dealing, deceit, desperation and dashing off with the rent unpaid) - but instead I had to see patients and police officers.

The police have been seeing me about those three patients of mine who died - the asthma woman (killed by Shipton), the blood on his hands man (killed by insight and a ten metre fall) and the suicide man (who tried to commit suicide, was saved by Florey, and then died from a completely unrelated event a few days later). In each of these cases I have had a minor role, almost always sandwiched between the thoughts and deeds of those higher up the food chain than myself, but I am still required to explain what we did and what we did not do.

Going over the deaths is bad enough. Any death, particularly a death in which you have been involved, and more so a death wherein your involvement constituted at some level a fundamental failure of your duty to protect someone - these are hard. The woman who had asthma, herein referred to as Mrs Cesious, the one who came in and died a few minutes after I had listened to her chest and for a second been reassured by the silence - that death frightened me and everyone around me. For the next few days Shipman was silent, people standing around whispering to each other, and three months later a kid came in with asthma and we all moved like we had been scalded.

And the man who took the overdose, and was treated, and then died in his sleep, and the man who killed however many he killed and then threw himself to his death - they all hurt. But the thing that gets to me while going over these deaths at this point, two or three or four years on, is the glimpses you see through the curtain of legal and forensic text of the survivors.

One of our suicides asked hospital staff to transfer his son to another hospital - his older brother had hanged himself in Florey five years ago.

In another case, the father of the doomed woman said his daughter had rung the hospital an hour before and said she was leaving her husband - an hour later she was dead. Could this have been more than co-incidence?

Anyway. Once you're gone you are not immediately forgotten. Your absence pains those who loved you. Let's leave this as the text for today.

Thanks for listening,
John

10 Comments:

Blogger Prom said...

BJ, would it help or hurt to think of these intrusive thoughts as coming from an external source? I don't mean decend into delusional thinking exactly but just take the attitude that they are like an annoying neighbor who bangs on the wall and yells at you to kill yourself on occasion. I mean, what the heck does he know? He's just an outside, ill informed idiot who doesn't know enough about you to have any real impact on your self valuation.

I guess what I'm suggesting is an interum peace with the voice as a coping strategy that lessens its power over you until it gets tired of poking you and goes away.

1:58 AM  
Anonymous John said...

A technique that sometimes works well is to create a 'Brain Ecology'. That is, assignation of character parts to particular idiosyncratic animations. For example, perhaps your chosen 'ecology' is a tropical reef scene out of Finding Nemo. Each 'voice' is then assigned to a particular character within the reef scene. The appearance of that tonal voice is represented by the appearance of the associated character. The characters may also interact with each other through internal dialogue. The reef scene is only an example. It can be anything, anywhere, natural or man-made. Another example may be the multitude of personalities which live in the average apartment building or block of flats. The point being to exaggerate the 'voice' and turn each one into a slightly absurd caricature. Like the cartoon version of the reef or the TV soap opera version of the block of flats.

The idea behind this approach is as follows: One of the problems dealing with intrusive voices and the like is the difficulty in 'handling' them. We have very poorly developed internal vocabulary for dealing with 'brain business'. It is also hard to separate out and distinguish the different 'tonal qualities' of internal dialogue. So it can be difficult to separate these tonal characters from the core identity. The assignation of bit character parts helps to achieve a degree of separation and thus internal perspective while at the same time, acknowledging the voice. Simply drowning them out with medication seldom works for long. When a particular 'voice' comes on to the mental stage, it can be greeted by its character name, acknowledged and managed. Each voice probably has a degree of relevance within a very specific context or circumstances. Part of the process is to work out when the message of that 'voice' may indeed be relevant. Then to get it to realise that now is not that time. The problem develops when the prima donna 'voice' takes over the whole show and tries to be operant in all possible contexts. The game is to try to get these minor characters and stage extras back into their perspective and to wait for their cue to perform. That can take time. If nothing else it can be mildly entertaining as one wrestles with the various 'voices' retraining them to their appropriate cues. It certainly helps pass the time. The tonality of voices is a natural phenomena which all people experience to a greater or lesser extent. The problems arise when control and timing issues get out of alignment and balance.

7:19 AM  
Anonymous Anonymous said...

Oh boy, John! I can relate to those intrusive, disturbing thoughts! Right after my first child was born, I had repeated thoughts about hurting her, killing her...and all the various and imaginative ways I could do it. Each time I came into contact with a kitchen implement, an appliance, a microwave, etc., these thoughts would come out of nowhere. It was horrible, and completely outside of my control. Worse, it made me wonder what kind of mother I was, and I really believed I was the only one to whom that had ever happened. Imagine my relief when I read somewhere that it was actually fairly common and probably caused by hormones. Anyway, good luck with eradicating them, I feel for you.

5:18 AM  
Blogger Champurrado said...

Doctor:

A neutron walks into a bar and orders a beer. The barkeep sets down the beer and says, "for you, no charge."

5:33 AM  
Blogger Benedict 16th said...

Happy Sinister day - and go those mighty dockers...

Benedict

2:37 PM  
Blogger Bronze John said...

Hail Ben',
Benedict is referring to International Left Handers Day, which occured August 13th. Traditionally (i.e.: I am making it up as we speak) recipients receive cards and small gifts. However, the cards have to open the other way.

As for the fortunes of said Mighty Dockers, we have entered uncharted waters. After twelve years of successive failure, including seasons where we won two out of twenty two games and regularly got thumped by over a hundred points, we have now begun to win. We are fourth on the ladder and have beaten the three teams above us.

We used to be everyone's second favourite team. Now we are actually feared.

I can no longer sit and watch the football prepared to be satisfied if lose because we never really were a chance. This is a truly weird feeling.

Thanks,
John

10:12 PM  
Blogger Bronze John said...

Hail Prom,
I don't know. People are different. For me it was a great relief to realise that the thoughts were things that I was coming up with, because that meant that at some level I could work out why, could dign in, find out which part of me was so miserable and alienated and that it was doing this, and see if I could get us talking again.

Which eventually happened. And we did get a sort of peace going.

Thanks for asking,
John

10:14 PM  
Blogger Bronze John said...

John,
Intersting ideas there, particularly the greeting/acknowledging/managing, which is eventually what happened. I will try and read up on this.

John

10:16 PM  
Blogger Bronze John said...

Anonymous,
That sounds horrible. Like you said, you aren't alone, a lot of good, decent mothers (and some fathers) feel similar things. Good you were able to get this sorted out.

I wonder sometiems about how this kind of stuff worked out in the old days - a few hundred years ago, a few thousand. Was there less of this kind of stuff because there were fewer singles or couples raising children in isolation? Was it treated with prayer or alcohol, or not at all?

Anyway, thanks for sharing with us.

John

10:20 PM  
Blogger Bronze John said...

Champurrado,

My kids will hate you when I tell them that joke. Thanks

John

10:23 PM  

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