What is the meaning of life?
Notes from a loony - some blogs on depression, anxiety, and OCD
Articles from the blog are easily accessible , but here are somere are some relevant posts.
Withdrawal: Duloxetine discontinuation syndrome (June 2021)
I am not sure how long I had been taking Duloxetine (Cymbalta). I think about it was about ten years at a daily dose of 120 mg.
I thought I wasn’t getting the benefit I used to. Now I know it’s complicated, many things can change, and so on, but one hypothesis was that the antidepressant had stopped working, or was no longer as effective as it had been. Others have noted a decline in the efficacy of anti-depressants with time: antidepressant treatment tachyphylaxis is the name given to the problem. (It’s been reported with at least SSRIs and MAO anti-depressants, and doesn’t appear to affect everybody.) There’s a limit to how much you can increase the dose to overcome this tolerance, so the main method of dealing with it is switching to a different drug. With my psychiatrist I decided to move to Venlafaxine. You can’t just stop taking one and start the other; you need to stop taking the Duloxetine gradually, wait a bit, and then start Venlafaxine on a relatively low dose. We agreed on a programme of a relatively slow taper, as this method is called. Things were then delayed by my being hospitalised with pneumonia. I knew that stopping anti-depressants is not something to be suddenly or lightly, and I knew that Duloxetine is widely regarded as one of the more problematic, so didn’t think it was wise to start in a period of serious ill-health.
Eventually I started, and went down from 120 mg to 90 mg for a week, and then 60 mg. Things were OK. I don’t remember any obvious symptoms, and my mood held up well. And then I went down to 30, and the withdrawal side-effects began, first when the famous brain zaps kicked in. It’s difficult to describe these to someone who hasn’t experienced them. It is as though you’re brain is sneezing, or you experience a big mental shiver - it’s most unpleasant. Sometimes you feel as though you’ve been moved against your will. I also had an upset gut, but still I didn’t feel any different, mentally: I wasn’t depressed, or at least I wasn’t noticeably more depressed. So after anger two weeks or so I went down to 15 mg. (This point is where cutting tablets up and slicing capsules open comes into play). After two weeks, maybe a bit more, or I went down to 0 mg.
My records show that withdrawal was worst after going down to a quarter of my original dose and lower for about eight to ten weeks. It was really bad: brain zaps, upset stomach, frequent migraines, extremely vivid dreams starting early in the night, a feeling that I was still dreaming when awake. Even after three months or more I didn’t feel right. My gut hadn’t returned to anywhere normal. Most noticeably after a couple of weeks at zero my mood started plummeting. Low mood, anhedonia, no energy, recurring thoughts of suicide - all of course classic symptoms of depression. It’s interesting my mood took so long to fall, and that the lowering of mood correlated with the discontinuation side-effects starting to fade. The half-life of duloxetine (the time if takes for the body to process half the dose) is about 12 hours, but it must cause longer lasting changes to the brain’s neurochemistry (or perhaps the brain itself). Looking at the research literature I don’t think these things are very well understood.
I know there was a class action started against Eli Lilly in the States about what is called duloxetine discontinuation syndrome (DCS), but it was dropped because there was no evidence that Eli Lilly knew about the possible problem before they marketed the drug. I don’t blame anyone. I started taking it on consultation with my psychiatrist and I was aware that there might be withdrawal problems, as there are with many medications. I suppose I thought it wouldn’t be that bad, having come off other anti-depressants before. Even now I think there must have been many people worse off than me.
Fear of death (April 2021)
When I was three or four I was afraid of television aerials, dogs (particularly black ones), electrical plugs, outdoors painters, thunder, and pneumatic drills. As I grew up these specific fears resolved into more general anxiety disorders, but I still have mild arachnophobia (I bear spiders no ill will, but they have far too many legs and move much too quickly for their size) and thanatophobia, a profound fear of death.
Most people don’t want to die, but I am surprised how casual most people are about their eventual demise. Why isn’t everyone raging against the dying of the light from the moment they first realise that the light will some day die? I think that in twenty-five years or so I could well be dead, and I think back twenty-five years from now and that doesn’t seem to be any time at all. Even if I die peacefully in my sleep, which seems to be most people’s goal, I won’t be happy. When I reflect on my fear I’m particularly afraid of not being conscious ever again. The universe will roll on perfectly well without me. A few people will grieve, but that will fade, and the ripples of the effects of my life will soon die down and I will be forgotten. Just writing that makes me very, very miserable. And angry, as does thinking about the unfairness of having to get old.
Mental illness requires consciousness. Your computer can’t be depressed, but a dog can be; we know from that dogs can show symptoms akin to depression, and of course other animals can suffer mentally too. Social outcasts in groups of social primates also give the appearance of being depressed. But can a wasp be depressed? We can’t know for sure, but it doesn’t seem likely. A wasp has very little consciousness, not enough to feel depressed. I explore animal consciousness in my new book, .
Some forms of mental illness require more than consciousness: they require self-consciousness: thanatophobia is one example, and illnesses to do with the meaning of life are another. I am pretty certain Beau, my poodle, is not afraid of his death. Of course (non-human) animals are capable of fear and other negative emotions, but not of concepts that require self-reflection. I don’t think he has any concept of death, so he can’t be afraid of it. I’m not saying that if something happened to me he wouldn’t be very upset, but that he can no more appreciate the meaning of mortality than he can understand quantum mechanics. These concepts are utterly beyond his comprehension because he doesn’t have the mental capacity for them. It isn’t simply that the concepts are too complicated for him, it’s that reflecting on the death of his self requires a complex concept of his self, and for that he requires self-awareness. Awareness and self-awareness are very different things. Many animals are (probably) aware, but few are self-aware. I’m not sure it’s right to talk about awareness and self-awareness as if they are a dichotomy – he might possess a bit of self-awareness, but not enough to worry about his death.
Can we learn anything useful from all this? On the whole I’d say Beau is much happier than me, and he doesn’t spend his life reflecting on canine existential concerns. I think his happiness and restricted self-obsession are related; sometimes humans reflect too much. Of course some thinking is good: it’s good to be aware of our situation; it’s important to prepare for our deaths and leave our affairs in order, and I wouldn’t want to put existential philosophers out of a job, but for many of us too much reflection can be a bad thing. We should look at Beau and realise that it is good to live in the moment, which is essentially what studies of mindfulness and mental illness tell us to do. This obsession with death is also utterly futile because there is nothing I can do to prevent my impending obliteration. And maybe that’s true of much mental illness: we need to learn to stop thinking. Easier said than done of course.
Psychologists occasionally reflect on what makes humans unique. To the list of language, a highly convoluted cortex, and opposable thumbs, I think we should add the ability to suffer mentally in particular ways. Our uniqueness has given us unique ways of being tormented.
Pure O: Obsessing about obsessions
Do you just find yourself sometimes obsessed, thinking about the same thing and can’t stop? There was an interesting article in the (UK) Times on 2 September 2020 about George Ezra’s struggle with his “pure obsessional” thought disorder. The article then covered the debate about whether it is a distinct category of mental illness from OCD. As you might know, my view is that diagnostic criteria for mental illness are pretty messed up, and we don’t have much idea about what is going on in terms of brain dysfunction, genetics, and the effects of experience, and one of the best things about psychiatrists is that they can prescribe drugs (although even then some claim some drugs may do more harm than good). I think it’s very hard to disentangle different types of mental illness, and depression and anxiety disorders are one big blob of unwellness that manifests itself in different ways in different people at different times.
I am definitely inclined to “Pure O”, but I still have some compulsions, albeit currently weak ones that are not too dysfunctional (such as checking the door is locked in multiples of three). The key thing is that the compulsions don’t trouble me, but the obsessive thinking is horrible. When I was younger though my compulsions were much worse – going downstairs in the middle of the night when I was 12 or so checking that the front door was locked maybe a hundred times (although it would have been 99, a multiple of 3, or 81, a nice power of 3, and once or twice 243 times). I was also obsessed with the idea that other people could read my thoughts, even though I knew they couldn’t. I sat in the back of my uncles’ cars and worried that a passing driver would misinterpret my hand posture as a V-sign, and would then track me down, so I would mentally say “sorry sorry sorry” (again some power of 3 times). It was the different world then. I’d never heard of mental illness and had no idea what a clinical psychologist or psychiatrist was. There was nothing like a counsellor at school (I think i might be wrong here: there might have been a nurse in case we broke our leg in break – might).
I’m not so bad now, but I am still pretty obsessive, and occasionally something comes along that I just can’t stop thinking about. I know everyone has their worries but talking to other people about worry, obsessional thinking is completely different. It’s all consuming. It can be dangerous. It can be a form of self-harm. Mostly now I just have a “completeness obsession” – the idea that if a read a certain book or hear a particular piece of music I will be a better person. That isn’t unnatural, but then comes the idea that just owning a certain book, or worse all books in a series, or all pieces of music, will do the job. Or having every track on a music programme. That can work out to be quite expensive, and it takes a bit of time, but it doesn’t make me very unhappy. When I was 12-13 I was very, very unhappy about it all.
My experience is that obsessional thought goes with compulsive behaviour, and therefore it does make sense to talk about OCD, and the relative amount of obsession and compulsion is on a continuum. When I was young I was more compulsive; now I am more obsessional.
I wish I could be optimistic about treatment. There are no specific drugs; SSRIs and anxiolytics are usually prescribed, but they don’t seem to do much for me, and neither has CBT (although of course you might argue I’d be even worse without these).
You might also be interested in Rose Cartwright’s book . Personally it didn’t tell me much new, but you might have a different view.
If anyone has come across a reliable way to stop obsessing about something, please let me know. It might be extreme, but sometimes I wonder if giving myself an electric shock every time I had a bad thought would work.
Anxious about anxiety (August 2019)
It’s getting to be almost acceptable to be depressed. Public awareness has improved immensely over the last few years, and while people with depression still face a great deal of ignorance and discrimination, I think the corner has been turned. Every day sees some celebrity coming out as mad; even famous footballers are admitting to being depressed, even suicidal.
I can’t say the same about anxiety, particularly generalised anxiety disorder. Severe anxiety is just as crippling as severe depression. Depression and anxiety aren’t in opposition: they’re comorbid, with a person who suffers from one being much more likely to suffer from both.
And as I sit here writing I am really suffering. Anxiety is more difficult to describe than depression. Everyone is occasionally a little down, and can at least begin to imagine depression by magnifying the feeling. I don’t think there’s a healthy equivalent of anxiety. Perhaps the flutters you feel when you’re late for a train or plane or having to give an important talk or public speech. But for me anxiety and nerves are very different.
Severe anxiety is just as crippling as severe deoression. You don’t want to do anything because you can’t. You don’t want to travel. You don’t want to talk to people. You don’t want to catch a train. You don’t want to go into town. You don’t think you can give the talk you’re just supposed to be giving. You don’t want to go outside. I hate the outside. I can just about manage the garden, but the village shop? It might as well be Antartica.
The Wikipedia entry talks about excessive worry, and worry is part of the problem, but there is also a huge physical element: sweating, racing heart, breathing shallowly, and shaking. But the bit I hate most is the shrinking of consciousness, the narrowing of the mind, so that you can’t concentrate on anything. Oh, and the irritability. I am not a nice person to be around around at the best of times, but when I am anxious – avoid me.
I know there are things you should do, including mindfulness, relaxation, and deep breathing, but these activities all presuppose that you have enough focus to be able to begin to focus. There are drugs, but they make you feel sleepy and brain dead
Loneliness (April 2017)
Lonely people tend to die younger. They have more health problems when they’re still alive, and tend to be more anxious than average. They tend to suffer more from high blood pressure. They have weaker imune systems. Bummer.
Of course as with all findings about mental health, you must be careful talking about causes when all you have are correlations (feeling unwell might prevent you going to social events, for example), but it does seem likely that being lonely is bad news. The findings on the positive effect of social support – people with plenty of good friends and a strong social network tend to be happier and healthier – are after all just the other side of the coin.
We can distinguish acute loneliness (loneliness that persists for a relatively short period of time and that arises as a result of loss or transition, such as the death of a partner, change of job, or a geographical move) from chronic loneliness (loneliness that goes on and on and is part of a person’s life over some years). I’m currently reading Emily White’s book about her chronic loneliness, and enjoying (or identifying with it perhaps) very much.
I think there is now more of a stigma attached to being lonely than there is to being mentally ill. Most people now accept that mental illness is a result of many factors, and that the ill person is not to blame. However, many people appear to believe that if you’re lonely, it’s your fault. You should just try a bit harder: join a club, do volunteering work, or take a dancing lesson. Or perhaps, they think, you’ve got no friends because you’re not a very nice person.
I admit it: I am chronically lonely – and I’m a very nice person.
Being chronically lonely (just lonely from now on) is related to many other things. White clearly thinks that being lonely and being depressed are very different; the main evidence for this claim is that many people report average levels of depression. I’m a bit sceptical that people have good insight into their mental states (we know from cognitive psychology that our insight is limited), but loneliness does seem to be related to social anxiety and personality factors independently of depression. I can feel lonely at a crazy party. In fact I sometime feel loneliest at a crazy party, where everyone else is obviously enjoying themselves, playing party games and singing songs. I have been in a packed football stadium where everyone else is singing and chanting and cheering and I just can’t join in; it feels false, wrong. I’m not looking down on the people who join in – although it must often look that way to other people – I just can’t make myself feel like other people. I’m an outsider (or as my mother used to say, “weird”, the irony being that she also is a lonely outsider).
I do wonder if people who think of themselves as very lonely mean “lonely” in the same way as others do. I think most people have acute loneliness in mind, whereas I think people like White and me are struggling for a word to capture a sense of alienation and otherness that pervades our lives even when others are present. A lot of what White talks about in Lonely makes me wonder if she just means “single”: a lack of intimacy, having somewhere there, the sound of voices and feet padding on the carpet at home, havint someone to touch, having someone with whom to share everything. But then I have felt lonely when with other people, including partners. Perhaps some of us are just destined to feel different. And for me it is entwined with depression.
But these are simple labels for complex experiences. I have no advice for others in the same party. I don’t want to go to a party or start dancing. Perhaps that’s why I enjoy the gym so much: I can be with other people, who vaguely share the same aim, but who don’t expect anything of me.
Big baby: Taking responsibility for our lives (September 2016)
t’s not my fault my blood pressure is too high, manufacturers put too much salt in processed food. Let’s sue the food multinationals! It’s not my fault I tripped up, the council should have put more effort into levelling the pavement. Let’s sue the council! It’s not my fault that I’m fat because I stuff my face with chips, it’s the shops for selling them. Let’s sue the shops! Let’s appoint a government chip tsar to tell me to eat fewer chips! And a salt tsar, and a council tsar, and chip tsar, and a tsar tsar to look after them! And when anything goes wrong, let’s sue the tsar tsar!
I’ve read a lot of life coaching sites and books, and there’s a strong belief that taking responsibility for your life, mistakes, and happiness is essential for personal growth and mental health. It certainly sounds plausible, and there’s plenty of anecdotal evidence, but I’ve found experimental data hard to come by. It’s the sort of idea that would be very difficult to test in practice. We do know from the work of hat the people who found purpose and meaning in their lives, who accepted their situation and who took responsibility for their lives, were those who were most likely to survive in concentration camps. So taking responsibility and accepting the situation can save our lives.
Then there is the well-known related result that when we are successful, we think that it is due to our efforts, and when we fail in some way, we have been unlucky; but when other people are successful, they’re lucky, and when they fail, it’s because they didn’t try hard enough. [If you want to find out more, the original source is Jones and Nisbett’s (1971) work on the actor-observer bias. In terms of attribution theory we generally prefer external attribution to facing the possibility that we are at fault (that is, internal attribution); this work dates back to Fritz Heider in the late fifties. The fundamental attribution error is the name given to the cognitive bias that we overestimate internal factors in explaining the behaviour of others, while underestimating their role in our own behaviour.]
The other side of responsibility is blame. It is YOUR fault that I didn’t succeed at doing this or never even tried doing that in the first place. The UK is now starting to resemble the USA in being a blame culture, full of lawyers and ambulance chasers and people taking out insurance without reading the small print and then blaming the banks, and people eating too much and blaming the food manufacturers and supermarkets and advertisers. In researching this blog I came across the following, unattributed, quotation: “When you blame others, you give up your power to change”. That rings very true to me.
It’s not a healthy situation, either for society or for ourselves.
Self-employed creatives have it harder than most. Although being self-employed as a writer (or retired, depending on your perspective) is liberating, it is also frightening. Writers are wholly responsible for their own work. If anything goes wrong, they only have themselves to blame. Employees do as they’re told, however high-level their job: in the end they have tasks they have to do, and places they have to be – and if they don’t do them, or if they’re not there, ultimately they get fired. But if I don’t write my two thousand words today I can’t fire myself or sue the council. Being responsible for your own time is also dangerous because it’s so easy to misuse it. Procrastination must surely be the writer’s biggest enemy – why do today what can be put off until tomorrow? Writers must take responsibility for their time.
When however we apply the idea of responsibility to mental illness the issues are less clear. I’m not saying we should blame ourselves for our illness. Why am I mad? The reasons are complex; it’s not one’s person’s fault, it’s just the way it is. But there’s no point feeling sorry for ourselves either – in fact wallowing will just make things worse. If we can’t blame others for our predicament, we can at least take responsibility for our mental health and trying to get better. Yes, I know there are times when you’re unable to get out of bed, or move from the chair – I’ve been there. But most of us have some better days, and then we can make a plan to live by.
The first step, which surprisingly many don’t take, is to acknowledge to yourself that you’re ill. Or, if you’d rather, that you have a particular set of problems. Life isn’t going to be as easy for you as the cheery soul at the next desk who is never faced by self doubt, never wants to spend a week in bed in tears, and who has never thought about suicide. We are, I’m afraid, different. We have it harder.
The second step is to implement the plan. I’ve talked in another blog about what we can do to improve our mental health, and how physical health is an important part of mental health.
The final step, which even fewer take, is to come out; perhaps we don’t quite have to go so dare as to say we’re glad to be mad, but we can at least announce that we’re mad.
How are we ever going to remove the stigma of mental illness if we ourselves are embarrassed about it, or if we try to hide our problems from others? Would you hide cancer or a heart attack? Are people ashamed about having arthritis? Of course not. Unless we decide there is no shame in being depressed, or obsessive-compulsive, or schizophrenic, how can we expect other people to think anydifferently?
Obsession (July 2016)
Depression alone is bad enough, but unfortunately it is rarely a pure affliction: people with mental health issues are usually doomed to suffer many versions of misery. Depression and anxiety go together, so much so that many researchers believe that there is a deep relationship between the two. Unsurprisingly then, both benefit from the same sorts of pharmaceutical treatment (SSRIs).
Anxiety comes in many forms, and many of us suffer from more than one. At different times I’ve had my share of social anxiety, generalised anxiety, panic attacks, agoraphobia, and other phobias. I have found that one of the most striking – I want to avoid the word distressing because all forms of anxiety are distressing to those who suffer from them – is obsessive compulsive disorder (OCD). When I was a young teenager my life was blighted by OCD, often in florid forms. In the night I would go down the stairs dozens of times to check that the front door was shut; I would get up multiple times throughout the night to check that my bus pass was still in my school jacket pocket; I would repeat things in multiples of three. I was afraid of contamination, the idea that germs and disease could spread by touching something that touched something that touched something, or even by having seen someone with a disease. I would then wash my hands several times (in multiples of three of course). I was afraid other people could read my thoughts, or would misinterpret an innocent gesture as an offensive one, so would apologise inwardly to them (in powers of three; twenty seven sorries is bad enough, but just try eighty one).
All classic stuff. I didn’t know what OCD was then, and I just suffered, alone, in misery. OCD is, to use a cliché, living hell, and it’s even worse if you think you are alone and have no idea what’s going on. In retrospect something should have been done about it, but I just grew out of it. Mostly – I still have a tendency to overcheck things, usually three times, but no more, and only occasionally, so it doesn’t bother me. We can live with some pathology. Being obsessive even has its advantages as an academic; there’s nothing wrong with checking your data a few times, or being careful about proof reading and checking your facts are right. Being a writer is sometimes obsessive; we often feel a pressure to write. I think you need to be a bit obsessive just to overcome all the negative feedback writers get. The boundary between OCD and having an obsessive personality isn’t always clear – as ever the problems start when what we do makes us unhappy, or interferes with our lives. We also have a problem if our behaviour doesn’t make us unhappy, but affects those around us.
As with all mental illness, the precise causes are unknown, but as with depression there is almost certainly there’s both a genetic and environmental component. The brains of people with OCD look different, but again whether that’s a result or cause of the illness, or whether both result from something else, is not know.
But not all obsessions involve an obvious compulsion other than one to keep the obsession going. We all have things we worry about from time to time. Most of us are familiar with “ear worms”, tunes that get stuck in your head. I suffer very badly from these (I speculate it’s to do with my psychopathology). It can drive me mad – or more precisely even madder than I already am. They’re the strangest tunes too – I once endured a week of John Denver singing “Annie’s song” non-stop. Worst of all though are obsessive thoughts, the rumination on particular events, ideas, or people that takes over our minds. It is horrible. The compulsion, in as much as there is one, is to continue the obsession. The thoughts – bad thoughts – involve regret, guilt, and fear. When I was in my OCD phase as a teenager at the end of every school term I would struck by the idea that I had done something wrong, and the school holiday would then be ruined by the fear of punishment that would await me on my return at the start of the next term. Of course I never had done anything, and was never punished; it was all in my head. It’s impossible to reason yourself out of OCD.
I think obsessive thinking is verging on psychosis, because things really are out of control. We might refuse to accept that the obsession is irrational, and some people might even act upon their obsessions – I assume that is how people become stalkers. I just suffer though.
Obsessions without compulsion is called “primarily obsessional OCD”. I was encouraged to see that the Wikipedia entry on OCD says that “Primarily obsessional OCD has been called one of the most distressing and challenging forms of OCD”; it’s more than distressing, it’s mental agony. I almost envy people with OCD because at least enacting the compulsion provides a little relief, no matter how short.
However illogical and crazy the behaviour might seem to someone who has never experience OCD, it is impossible to reason your way out of the illness. You can’t tell yourself that it’s irrational to wash your hands so many times. First, the compulsion is stronger than our belief system. And second, there is always a grain of truth we can cling to – it is just possible that a disease might be passed on by touching something that was touched by someone who touched someone with a disease, for example. There is though a clear treatment plan for OCD that involves breaking the link between obsession and compulsion. One of the best books I have read on OCD is by Jeffrey M. Schwartz. He identifies four stages in treatment: relabel (you must recognise what is obsessive and clearly label it as such); reattribute (this thought is not me – it’s my OCD); refocus (the really hard bit, where you have to shift attention, at least for a while); and revalue (to take the whole cycle as something not to be taken as face value, and to adapt the view of a more impartial observer – being mindful). He suggests gradually building up a delay between having the compulsion and having to do it – you might only be able to manage a few seconds at first, but you increase it, perhaps very slowly.
Such treatments, while effective for dealing with the compulsive actions, don’t immediately help us in being able to stop the bad thoughts coming in the first place. In a recent bout, ruminating on a mistake I had made, I tried saying internal loudly and firmly, “It was my choice”, which I eventually simplified to a loud “STOP!” in my inner speech. This approach eventually worked – or the bout blew itself out. A friend told me that a common technique is to visualise a STOP road sign, and I have since tried combining visualising the sign with thinking STOP! It is exhausting work though; bloody exhausting. At least my obsessions appear to have a natural life span, and eventually, after much pain, they eventually peter out.
The intrusiveness of thoughts is one reason why I find meditation so difficult. My thoughts just won’t go away. Even when counting breaths the thoughts overwhelm my inner voice counting. There is a paradox here because if I could just be mindful and live in the present, I wouldn’t be so obsessed by Bad Thoughts, but the Bad Thoughts stop me being able to attend to the present. Coming back to the now and trying to be present does help me when I’m being obsessive, and I think it’s a skill at which one can get better with practice.
I am grateful to and encouraged by everyone who has written to me about my blog. So many people suffer alone; it is time to stop the stigma of mental illness. For a long time I thought I was alone in suffering from obsessional thinking; if we all shared more we would be less isolated, less frightened, and maybe just a little better off. Please feel free to share this blog with whoever you might think would benefit from it.
Hubris: Collapse (June 2016)
After my last blog on how I have fought to cure my depressive illness, the gods would have it that I have had a relapse; it was in fact not so much a relapse as a collapse. Things have been pretty damned awful.
It was triggered by a life event, the details of which I’d rather not go into. It wasn’t unexpected and it wasn’t objectively that bad. But I switched from a state of feeling good and optimistic about everything, to total suicidal despair and extreme anxiety, within a few hours.
Of course being very depressed is incapacitating, and it has really put back the writing. I couldn’t have written this blog from scratch, but fortunately I had some of it ready and am just filling in the gaps. Blogging by numbers. I have written before about how one of the worst aspects of depression, and one that is rarely mentioned, is how it steals our life and our time. I occasionally wish that I was bipolar, when I would have highly creative, fertile periods between the down times. But for me it’s just all time wasted.
I suppose no one is depressed in just the way the textbooks say a person is. We each have our own way of being mad. I have written about what severe depression feels like to me in the book I am currently writing on the science of depression, No birds sing. (Note to publishers and editors: I am looking for someone to publish this book.)
Imagine feeling sad, but much, much more so, sadder than you’ve ever felt before. Imagine all the lights being turned off in your head. Imagine your mind turning black; black is the colour of depression. All of sudden you’re living in a monochrome world where all feeling and emotion except pain has been turned right down. Imagine a dark ball at the centre of your being that is so cold it hurts. It’s like an icy knife in your soul; it’s worse than any physical pain. You just want to go to bed and cry, to fall asleep, or even die. Die; don’t care if I do. It would be a relief. Death is an end to the misery. In any case, who cares: alive or dead, what’s the difference in the end? I hate myself and my life and I want to die. The idea of doing anything is impossible to contemplate. There’s nothing to look forward to, and nothing gives me pleasure, not even the things that in better mental states I can rely upon to excite me. My despair is utter. Everything is hopeless; I’m never going to get better. I feel a terrible sense of doom and fear, not just that I’m not going to get better, but that the universe is a threatening, mysterious, evil place. And everything is such a bloody fight; everyday life is exhausting. Managing to do the little things can wipe me out after I’ve used up so much energy making myself do them. I feel exhausted all the time. Imagine not being able to concentrate long enough to be able to complete simple tasks, and in any case often forgetting what you were going to do nearly as soon as you form the intention to do it. I make mistakes in the simplest tasks. I have no motivation do to do anything anyway, and no interest in anything. I feel nothing other than total despair. Oh, I do feel amazingly, incredibly guilty about everything, as though I’m lazy, incompetent, and everything wrong with the world is my fault. I deserve to suffer so much. Everything is overwhelming, and I am paralysed. I don’t just have very low self-esteem, I am also full of self-hated. I am the lowest of the low and completely worthless; the world would be a better place without me. If I’m depressed for any period of time self care tends to go a bit out of the window: what is the point of shaving? Can I really be bothered to wash my hair? Who cares if the kitchen sink is filthy? I overeat and overeat convenience food, because that’s all I can be bothered to cook. I sit, finding myself in tears, and I’m not sure why. I feel completely alone; no one can possibly understand how I feel just now, and even it there is a person who can, I couldn’t be bothered to speak to them. And in one final little trick of the mind, time seems to slow down to prolong the agony. Every second is torture. So I try to sleep for as much of the day as possible, and I drink wine and take pills to make sure I can sleep. You feel physically ill as well, with aches and pains exaggerated to distraction. There’s a tickle and lump in your throat. I perpetually tug at my eyebrows, and occasionally pull them out so that they contain strange bald patches. And the ear-worms – those annoying tunes stuck in your head that drive you mad. I also worry that I’m a black hole when I’m depressed, sucking in joy around me, ruining the lives of others – so it’s fortunate that I prefer to suffer in isolation. It is paradoxical that I am lonely and yet want to be alone at the same time, but depression is full of paradoxes.
Most people who aren’t depressed think that being depressed is like being very sad, as though a loved one has just died. A sense of strong sadness and a sense of loss pervade depression, but there is much more besides that to it. Anhedonia is the inability to gain any pleasure from anything; the things that normally give me pleasure, such as reading, watching movies, my garden, and music, give me nothing at all other than a sense of profound boredom. I get up in the morning and I see the day stretching ahead with nothing to look forward to other than being able to go back to sleep again. But what most people don’t seem to understand is the pain of depression: it is mental torture. It is a knife being stuck in your mind and being turned around and around so that you want to scream with the pain – or more realistically just kill yourself so that you can get away from it.
I wake up every morning filled with dread. I have great difficulty in getting going. Often I find that the murk lifts for a few hours around 11. I usually have coffee then, which helps even more, but I get the uplift even if I miss coffee out. I haven’t seen a great deal about this 11 am effect in the literature, but I know from speaking to others that I am not alone in getting some relief then. When I was an undergraduate at Cambridge I was taught about a distinction between reactive and endogenous depression (a distinction that no longer stands up), with endogenous (or psychotic) depression being the worse, and characterised by particularly low mood early on in the day.
And then throughout the day there is panic. There is a persistent low level of anxiety that’s worse before 11 but to some extent there every day. Then there are occasional panic attacks; today I had a panic attack while in a car in a tunnel. I just wanted to escape. I wasn’t driving, it was dark, and I could sense all these other cars and people around me, and I just needed to be out of there. I couldn’t breathe. My heart felt ready to explode, and I was drenched in sweat. When you’re really anxious consciousness seems to shrink to a pin prick; the reduction in awareness feels physical, as though your sense organs have been eviscerated. We now at least understand how depression and anxiety are two sides of the same coin.
There is a huge literature out there on OCD, but I find while I get very obsessed, I no longer suffer much from compulsion. (I did when a teenager.) I can find very little on thoughts just taking over our minds, other than rumination, the idea of going over and over some thought, such as the meaning of life. I find that I just can’t stop thinking about something. The thought is all consuming but there is nothing I can do to release it. I think I’d rather the O be accompanied by a C so that at least I could discharge it occasionally. Instead the same thought, image, or just idea, goes round and round in my mind.
I seem to be very prone to ear worms – tunes stuck in the head. I think I get these worse immediately before an intense depressive episode, but I don’t know of any research on this speculation. But when a song gets stuck in my head – and I mean stuck! I can hear it with crystal clarity, at loud volume, every intake of breath and strum of guitar – I know I’m in trouble, And there’s a limit to the number of times a chap can hear John Denver sing “Annie’s song” and stay sane.
How to cure yourself of depression (June 2016)
That’s a big claim to catch your eyes and score highly on the search engines. I hope.
To be honest I don’t think you can cure yourself without help from others or drugs or both. I didn’t. And in fact I don’t think you can be cured of depression: I’m not. In fact this blog has been delayed because I’ve had a relapse, and have been feeling extremely depressed this past few days. At the moment (who knows in the future?) depression is a life sentence without a cure; the best we can do is keep it in abeyance for as long as we can, and if we’re very fortunate, that might be for the rest of our lives.
But there are many things we can do to help to help ourselves, and I’m going to talk about some of the things that have helped me. I think everyone might find them helpful; if you’re not suffering from depression, then maybe these will help you to live just a little better life.
And apologies if they seem blindingly obvious to you; they weren’t to me. I’ve learned them the hard way.
If you are really depressed, and if it has been going on for any period of time, you almost certainly need them, and you have to see a medical practitioner to get them. In the UK that means your GP or a psychiatrist, who then writes to your GP. They will almost certainly start you off with an SSRI. Do some research: there are many anti-depressants out there, and they work in slightly different (and mysterious) ways. They take time – weeks, months – to take effect though, so don’t be too dismayed if nothing has happened the next day. You should hopefully start to see an improvement within a few weeks. If the first one doesn’t work, then you will need to try another. It’s preferable that you have someone to monitor your mental state and behaviour, because you are often not the best person to judge if you are getting any better. Different drugs have different side-effects on different people, and if you find yours unbearable, again you should discuss changing drugs with your medical advisor. There are alternatives you can get without prescriptions (e.g. St John’s Wort, SAM-e), but these had no discernible effect on me. If you’re interested, after many years and changes of medication I have settled on Duloxetine (Cymbalta) for depression and Quetiapine for anxiety.
You cannot fight severe depression alone. You hopefully have already seen your doctor, but probably should be seeing a psychiatrist as well. I have tried different sorts of clinical psychology and therapy, and have eventually found a cognitive-based therapy system that looks at your childhood, attitudes, and relationships to be a revelation. Different things though seem to work for different people. You will need your friends too, and need to be open with them that you are depressed. Fight that stigma!
There are many changes I have made that I think have contributed to my shift towards wellness.
For want a better name – that thing that someone else pays you to spend your time doing. In the first instance you might need a period of time off work – look into your sick leave entitlement. Contact your HR department.
I took a long hard look at my academic job and decided I had had enough. There are many things I liked about it, but an increasing number of things I no longer enjoyed and that seemed to me to be pointless. On the other hand I love writing and journalism, so I decided to “retire” and become a full-time writer. It’s a financial risk. It might not work out. I might be poor for the rest of my life. But at least I feel that I am in control, and doing only what I think is worthwhile.
You might say I’m lucky being in the position to retire and become self-employed, and you’re probably right. But what is your health worth? What big changes can you afford to make? Is the big house and fast car really worth what you’re having to endure? And big changes don’t apply just to work either: is that toxic relationship really worth staying in?
I think you have to be starting to get well to make some of these changes, or at least not in the pits, but I decided I had to lose weight and get fit. I, like many depressed people, am pretty useless at self-discipline. So I joined a gym and signed up with a personal trainer. It’s one of the best calls I’ve ever made. I’ve lost over 25 pounds so far and my weight is still going down. I feel so much better; I have more energy and after each exercise session my mood is lifted. There’s plenty of evidence for the positive effects of exercise so get to it. And no, I still don’t really enjoy doing exercise, particularly cardio, which I find painful and boring.
Fresh air and light.
Many of us who are depressed really benefit from more light. I try and maximise my exposure to sunshine, even sitting outside when it’s sunny but in the cold depths of winter. I have a light box that I use even in summer when it’s dull. I try and get as much fresh air and to get outside as much as I can even when I’m busy working at home.
I have tried many diets (in the sense of modes of eating) and as I have blogged before find the science complicated, confusing, and contradictory. One certainty is that you have to cut sugar and refined and processed food right out of your diet. I have also greatly decreased the amount of carbohydrates I consume. My breakfast will be something like prawns, berries, another piece of fruit, and nuts; my lunch fish, sweet potato, and home-made baked beans; dinner lean white meat or fish, lots of vegetable, and nuts. It’s a bit boring and expensive, as I don’t like spending large amounts of time cooking for myself, but I see no alternative. I also take good quality fish oil supplements. I have cut back on the amount of wine I drink but still find some each evening calms me down; fairly harmless self-medication in moderation.
Mindfulness and meditation.
I find meditation difficult – sometimes it hurts my mind too much to sit still with nothing but my thoughts, even for as little as ten minutes – but I try. And I do gain a great deal from being mindful – trying to live in the moment and be present. The evidence suggests that mindfulness training might be as effective as medication. There are many good books and resources on mindfulness training, so give it a try.
I have tried to change my cognitive structure – saying “I am not my illness”, working out what the really important things are in my life and changing those things, trying to be honest with myself, and trying to be kind. I accept responsibility for things I do wrong and acknowledge the role of others when things go well. Or rather at least I am trying to do these things!
I have written about my search for a perfect routine so many times before (blogs ad nauseam). How can the writer find a perfect day when they can write something good every day and yet fit everything else in? But a routine of some sorts is essential if you are or have been depressed. It’s boring and others might mock you for it, but you’re the one that’s ill or have been ill.
My problem, particularly under medication, is staying awake at night and waking up in the morning. However I used to have terrible trouble getting to sleep. The most important thing is to choose regular times and stick to them, come what may. I have a particular problem with waking in the morning, so I set my alarm for 7.20 and get up at 7.30. Occasionally I really struggle, but I will always be out of bed by 7.55.
My friend Ian Jay swears by a gratitude diary – somewhere towards the end of each day you list three things that day for which you’re grateful.
It’s important to do the things you have decided help you, particularly if you feel yourself becoming ill again. If you’re getting a bit down and start skipping your exercise you’re going to be in trouble. So write out a list and tick the things off every day.
Mens sana in corpore sano (May 2016)
It’s under a hundred days to go now before my official “retirement” date and when my life as a full-time writer begins. I’ve made the big change – or at least the decision to make the big change – that I hope will lead to a more satisfying and mentally healthier life, and now it’s time to look at smaller changes I can make. I’ve already taken up exercise in a big way and been going to the gym regularly for some months now; I’m pleased – and surprised by myself – that I’ve stuck to it. I’ve reduced my medication gradually without too many ill effects. I have now sorted out my life, to some extent, and my depression is in abeyance, at least for now. I have identified a purpose – writing, in the first instance on consciousness. I now need to go further and tweak my mental and physical well-being. I also face many years (I hope) “post-work”, and I want them to be healthy, happy years. I can already feel a bit of arthritis in the fingers of my left hand, and I still feel more tired than I would like. I am at last doing enough exercise, so what else can I change for a better life?The obvious answer is diet.
Now I don’t think my diet is too bad – as I have coeliac (celiac) disease (I don’t like the phrase “I am celiac”, identifying myself with the disease), I already avoid gluten and wheat and too much dairy. I am fortunate in not particularly liking the taste of sugar, and avoid processed food. What else can be done for a better diet and hence better life? We are after all what we eat Note that I am using the word “diet” in a loose sense to refer to everything we eat, not specifically a means of calorie restriction.
Unfortunately the world of improving your health through diet is a nightmare. It used to be so straightforward: eat with the pyramid of a little fat, lots of complex starches, fruits, and vegetables, and avoid saturated fat, while doing moderate or more exercise three to five times a week.We can say with some certainty what is bad: smoking, too much alcohol, no exercise at all, processed food, sugar, modified sugars, trans and hydrogenated fats, and too many calories. But then things get very confusing. It’s pretty much agreed that leafy green vegetables are good for us (although opinion is divided on whether they are better lightly cooked or raw). But here is the list of some of the disputed foods:
– carbohydrates: much loved by “official” dieticians, treated with great suspicion by many food movements (e.g. Paleo, Primal, to a lesser extent South Beach). I’m assuming we’re talking about good carbs (no crisps, no cakes) that you get directly from vegetables. Sweet potato seems to be the healthiest.
– grains: many are a no-no already when you cut out gluten, but things like rice are disputed. I don’t like them much anyway.
– fruit: you thought you were on safe ground, but many are very high in sugars, particularly fructose, and Paleo and Primal limit their intake. Best fruit: berries.
– nuts: high in calories and oils and many have the wrong Omega 3:6 ratio.
– oily fish: generally agreed to be good, but some worry that they’re a source of contaminants, heavy metals, and colourings: wild or organic are best (if you can get them!).
– meat: disliked by many diets, but preferred in Paleo and Primal, particularly grass-fed and organic (again if you can get it).- saturated fat: despised in the traditional diet, but desired as a major source of calories in Paleo and Primal.
-mushrooms: full of fibre and vitamins – but argued by some to aggravate intestinal yeast infections. Is this anything more than superstitious thinking?
– garlic: how can garlic be evil? The Bulletproof diet says avoid because of its mind-altering properties.
– omega 3 oils (fish oil): as long as they’re heavy metal free, although the extent to which they are beneficial to adults remains disputed by some scientists.
– organic or not: surely it’s got to be better to eat stuff that’s free from pesticides and herbicides? Some scientists have argued it makes no difference.
– alcohol: preferably as red wine, a little is generally thought to be good by many.
What is most problematic is whether most of our calories should be coming from carbohydrates, or from fat, oils, and protein. Will fat kill us, or stave off the heart attack? It’s a high-stakes game.
But in the end, as my finger hurts and my back hurts and I decide to skip that glass of wine and measure out a nice, I sometimes just despair at the confusion. It’s difficult being an anti-ageing biohacker.
Removing the stigma of mental illness (April 2016)
Last week was UK Depression Awareness Week.
I used to be sceptical about these special days and weeks, but now I think there is a great deal of benefit to having a concerted surge of activity because at the very least it generates publicity.
There used to be a great deal of stigma and shame associated with any kind of mental illness. People felt forced to hide their suffering. They were discriminated against, made fun of, and even bullied – things that of course just made people even worse. At our school, many years ago, boys who were slightly odd were given nicknames based on the local mental hospital. People found it more difficult to get and keep jobs. I remember an employee, a long time ago and in a place far away from here, feeling forced to tell me that he had been off work for some weeks with a “very bad cold in the head” – whereas there were rumours that he had had a “nervous breakdown”. There was very little advice available in the NHS, and there was a much more restricted choice of drugs. Prozac only became widely available in 1988.
Things are by no means perfect even now, but every time a celebrity “comes out” as mad, there’s another step forward. Every time someone is honest at work or with their friends all of us are a little more liberated. Those of us who can owe it to the others to stand up and say we’re GLAD TO BE MAD. Well, maybe not glad, but we are, and there’s nothing to be ashamed of. Stop the stigma now.
The afterlife (March 2016)
I would love to be able to believe in God. I can see the advantages of the promise of an afterlife, the lure of goodies for ever as long as I obey a few simple rules in this life, we provided a way of living without having to think about myself, and meaning on a plate. I envy the faithful.
It is of course more difficult trying to live a good life if you have to work out what good is yourself from scratch. The Bible tells us what is good, and we just have to follow the good book. To be fair the Ten Commandments largely provide a short cut for a moral system, as stripped of their religiosity they are good sound ways of being good to others, or at least not harming them, based on the golden rule do unto others as you would like to be done by.
But it’s the meaning I envy religious people most. Meaning on a plate; ready meal meaning. The rest of us have to make do with having no meaning. But because I think there is no ultimate meaning, it doesn’t follow I think that there is no purpose. We could, for example, give ourselves maximum pleasure in life. The Greek philosopher Epicurus advocated finding pleasure in life, although his pleasures were rather more modest than stuffing ourselves with champagne and caviar; he sought the pleasures of friendship, freedom from fear, and peace. And we have to titrate short-term gain with long-term pain: I could rob a bank tomorrow, and in the unlikely event that I succeeded in coming away with a few pounds, blow them on a first-class flight to Sydney. Any pleasure gained from this escapade would be more than outweighed by the grimness of the inevitable twenty years or whatever in prison afterwards. In any case robbing a bank would violate my ethical system of trying to do unto others as I would be done by; if we all robbed banks we would soon be in a pretty pickle (and all in prison).
I often think psychopaths have been dealt a lucky hand in life. The ability to put themselves first and not worry about must be pretty wonderful. I on the other hand fret about every action and how it’s going to affect others. I’m still a pretty selfish person, but I worry. And how I worry about retribution.
The loss of God (to many of us) has of course led to some well known consequences. The existentialists in particular have thought and written about how we should think and live in a godless world where the only certainty is death, sooner or later. Like many other depressed and anxious people I am obsessed with death. If you have no hope of an afterlife then what we experience now and in our remaining days is all we can hope for. The philosopher Kierkegaard said that anxiety, angst, comes from within us, and our dread at the existential choices we have to make in the face of our fear of death. He said that confronting this fear expands the soul and fulfils the self – assuming we can resolve the fear and accept the ultimate meaninglessness of life.
“Learning to know anxiety is an adventure which every man has to affront if he would not go to perdition either by not having known anxiety or by sinking under it.” – Kierkegaard.
We have to accept that we will die, and that will be it. I find that idea very hard to accept. It’s unfair, but it seems that there’s nothing I can do about it. And although the idea of not existing is so incredibly painful, perhaps it’s only when I feel that pain that I feel truly alive.
Giving up (February 2016)
Surely everyone who has ever been seriously depressed has felt at some time like just giving up. I don’t just mean committing suicide, although that is often not far from the backs of our minds; I merely mean throwing our hands up in despair and sitting on the ground, like rebellious toddlers, and refusing to take part in life anymore. Sometimes this feeling comes from some silly event. The other day I knocked over a glass of white wine. It wasn’t simply that I couldn’t face clearing it up, but the event was imbued with some great significance. I am reminded of the scene at the end of the movie 2001, when the ageing Bowman eats his solitary dinner and then knocks over the glass on his table with his cuff; that clearly means something (although I have never been quite sure what). My broken glass signified for me that everything is pointless; all things come to an end, usually rather quickly. I just wanted to sit down and cry. I had had enough.
Sometimes I do some mundane repetitive task and think there must be more to life than this. I know I’m thinking a cliché, and that in fact my life is relatively comfortable, interesting, and good, but that knowledge doesn’t help. Doing the rubbish, collecting the trash, can often bring me to total despair. Looking at the toilet thinking I should clean it again. It’s the again bit that gets me most. Emptying the dishwasher. Washing the bedding. I feel despair wash over myself as I think, not again. This daily routine is killing me. On a good day I will wonder how many more times I will have to empty the dishwasher or clean the toilet before I die; on a bad day I think I can’t face doing it one more time. It is all ultimately so pointless.
The final words in the great Kenneth Williams’ diaries were “Oh, what is the bloody point?”. It is still debated whether his death was suicide or an accidental overdose, but for me that last entry can have only one meaning.
When the world ends I will have a cold, so I won’t be able to treat even Armageddon with the concentration and focus it deserves. Big Things always happen when I feel unwell. The rest of the time it’s the accumulation of little things, the endless repetition of life, that gets me down. Doesn’t everyone worry that at the very best, when they brush their teeth they’re just going to have to do it again a few hours later, and at worst, this time might be the last that we ever do it? Or does everyday life just pass most people by?
When you’re depressed, every day seems the same. There’s no colour. There’s nothing to look forward to. What is the bloody point?
A brush with death (January 2016)
Just before Christmas I nearly died.
One Saturday I was feeling fine – rather stressed, but physically fine. Sunday morning I couldn’t urinate. Sunday evening I was in hospital. Monday evening my temperature was soaring, my pulse racing, my blood pressure falling through the floor, and I wasn’t breathing well. I was in a stae of severe sepsis – what my mother calls “blood poisoning”. Although I didn’t know it at the time, the stage I reached has a mortality rate of 50%. Fortunately I recovered; my infection responded to the antibiotics, and I had wonderful care at Ninewells Hospital in Dundee. Recovery was slow, and I still don’t feel completely well.
It turns out that there is nothing like nearly dying to focus the mind on what you should do while you’re living. We’re all going to die sometime; if I’m lucky I might have another 40 years or so, although how many of those will be quality years is unclear. What should I do in the next 20 – 30 years? What do I need to do now so that when in the future I am on my death bed I will be able to lie back satisfied and think “yes, that was a worthwhile life”?
It wasn’t just this near death experience that made me think about the meaning of life, although it has focussed my mind on it. I’ve always been a bit obsessed with how I should live my life, and how I should spend my time.
Someone once said something like “No one ever said on their death bed ’I wish I had spent more time at the office’.” (I think it was the American rabbi Harold Kushner.) I suppose though it depends what sort of office you’re talking about. Hillary Clinton might well end up saying “I wish I’d spent more time in the Oval Office”. It depends on your job in having an extremely good job: I am an academic, a Professor of Psychology.
For many years I even said “I don’t make any distinction between my work and my life”. My reasoning was that (most) academics are pretty much working all the time. You go on vacation (or “take annual leave” as it has now become) and you read a psychology book – are you now working on holiday? You think about a problem in the bath, answer a student email while sipping a glass of wine at midnight, you read a short article Christmas Day while waiting for the turkey to cook – you see the problem about defining work, holiday, and non-work.
Unfortunately some of fun, for me at least, has gone out of the job, caused by increasing bureaucracy and attempts to quantify academics’ time with the noble aim of ensuring that the public aren’t being ripped off. Of course the public should be able to sleep safe in the knowledge that university dons are earning their pay, but you, the public, can rest asure that there isn’t a widespread problem: we aren’t on holiday for half the year, because there’s always research to do, new teaching to prepare, PhD students to supervise, and administration to catch up on. A recent article suggests that many academics work considerably more than 50 hours a week. And now we have to account for our time, by filling in forms and keeping track of what we do. Mechanisms with names like TRAC determine how government money is allocated on the basis of these timesheets. Workload models proliferate, mostly giving us 1768 hours a year to account for – even though we might work more than 2500 hours! And they all suffer from the problems above: what exactly is an academic’s work?
For these sorts of reasons I no longer think that my work is my life. And certainly my job isn’t. The life of an academic has changed over the last 30 years, largely for the worse I think, and it is now full of countless meetings, evaluation, meetings, and forms to fill out. I don’t find that part of the job much fun (and I doubt if I am alone).
So now I do distinguish between my job and my life. It’s still a great job and better than most others. And there are still many parts of the job I love (writing and teaching enthusiastic students, for example). But after a brush with death I cannot find meaning in my job alone.
The mortgage has to be paid, but is it possible to do so while living a meaningful life? And where is this meaning to be found?
What is the meaning of life? Does the question even make sense? I don't think so, and I'm writing a book about it.
The preface of Time to Die:
"Are you scared to death by death? Do you worry that at any moment you mmight have a heart attack, or get in the car and be involved in a fatal crash, or be told that you have cancer and six months to live? How can people live when they know they are going to die? Do you dread getting older? How should I spend my remaining days?
I worry about all these things, and I don’t know why everyone else isn’t worried too. I’m so worried about the prospect of death I’d say it’s interfering with my life. Something needs to be done, and I’m going to find some answers.