Angela and I had lunch last Friday and here's what's transpired since.
When she picked me up (on Fridays I'm carless as Marty teaches and needs our trusty 1999 Honda Accord) I couldn't believe how thin she looked.
Over the last few months, she's lost weight and claims she wants to lose more. Though she's often said she tends to forget to eat, lately she's been working out – and it shows.
Also, last Friday was a dreary, windy, bone-chilling day. Raining hard. Miserable. Depressing. An old back injury of hers was acting up and she was in pain. She's so drug resistant, only morphine helps, she claims. She didn't have any handy, so she was trying to ignore the aching in her lower back, but I could see it in her face, and in her eyes.
Plus, she drives a sporty Jeep that prides itself, she informed me, in providing bouncy, bumpy, jerky, jarring rides. Ouch.
LAST FRIDAY'S FIRST BILATERAL ECT WAS NOT FULL-THROTTLE
We drove over to a local Middle Eastern restaurant about five minutes from here called Shoom Shoom, which means "Garlic, Garlic" in Hebrew. Angela likes the chicken Shawarma there and I like the fig and walnut salad.
En route, she mentioned that her first bilateral electroconvulsive therapy treatment the previous morning (her 13th thus far in her 12-week course of 24 in all) "only brought me to a threshold because they wanted to see how I'd handle it," she said. "I'm going to get the full treatment on Monday."
Her psychiatrist had just told her that about 90 minutes earlier during one of their regular bi-weekly sessions.
She seemed more subdued than celebratory. The spunk and spirit I thought I had heard in her voice on the phone the night before had drained away.
Over lunch, our conversation flipped around. We caught up, mostly. Small talk. Her sister was coming in for the weekend and we talked about her upcoming wedding. We discussed her mother's health. She chatted about the complications of her life. We shared stories about her therapy, and mine.
She showed me pictures on her iPhone of her latest sculptures and the abstract paintings she has started. "I tore that one up," she kept saying, despite my pleading with her to never destroy her art.
HER MEMORY SEEMED FINE
I was mindful of the tempo of the conversation and there didn't seem to be much difference. Her memory didn't seem to be slowing her down. She wasn't searching for answers to my questions.
However, this week, since her Monday "full-throttle" ECT treatment, that tempo and her tone has changed.
On Monday afternoon, about six hours after her treatment, she seemed more volatile than I remember her. Frustrated. Anxious. Angry. She was feeling "ripped off" – but definitely spirited. There was an edge in her voice that I didn't recognize. I had some thoughts about what was happening, about the relationship between anger and depression. Was the ECT doing this? I'm no expert.
AFTER HER STRONGER MONDAY ECT TREATMENT, SHE SOUNDED ANGRY
Rather than speculate, I consulted my resident expert, Dr. Ron Pies, Editor-in-Chief of Psychiatric Times, professor of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse and clinical professor of Psychiatry at Tufts in Boston. He is, with S. Jacobson and I. Katz, author of Clinical Manual of Geriatric Psychopharmacology, and a number of psychiatric texbooks. His most recent book is Everything Has Two Handles: The Stoic's Guide to the Art of Living his upcoming book, "Becoming a Mensch", is to be published late this year by Hamilton Books.
I've never been depressed. I tend to voice my frustrations. Loudly. But, I'm not Angela, and I've have many more years of psychotherapy than she has. I'm also a lot older, though not necessarily wiser, than she – 24 years older.
Ron responded quickly, as always to my question about whether "depression is anger turned inwards."
IS DEPRESSION ANGER TURNED INWARDS?
Here is a section of his answer. It's general. I never ask him specific questions about Angela as that would be betraying a confidence and unethical:
"The notion that depression is ''anger turned inward' has a long pedigree — it goes back at least as far as Freud and his theory of 'melancholia'; he held, in effect, that after the death of a loved one, the melancholic’s unconscious anger with the deceased becomes directed at the self, which has 'incorporated the lost person through introjection''. If it sounds complicated and dubious, it is!," Ron wrote.
"To my knowledge, there are few empirical studies that have supported the 'anger turned inward' model of depression. I also think there is very little empirical evidence that 'getting mad' as such is of any real help to people with serious depression. I think this is mostly part of the 'let it all hang out' philosophy that dominated the late 60s, and I think most mood disorder experts don’t put much stock in it.
"There is some truth to the idea that if you constantly walk around feeling that you have been “short-changed in life”, “ripped off”, “victimized”, “screwed over”, etc., you will undoubtedly feel angry, and probably depressed as well—or at least demoralized and impotent," Ron continued.
"The idea, then, is to examine your presuppositions about what the world 'owes' you—as in, 'Who said the world is fair? Who said that the world owes you what you think it owes you?' etc."
This really resonated with me because Dr. Bob has often said, "Who said life is fair?" when I bemoan the fact that I'm now chronically ill because a former psychiatrist of mine neglected to monitor my Lithium levels properly and I lost my kidney function and had to have a kidney transplant after two years of dialysis. The drugs I take to prevent rejection have dire side-effects, like chronic anemia.
Or because I was raped at the age of 14 in a psychiatric ward by an orderly when I was there for observation and that assault precipitated my psychotic episodes and has left me with permanent emotional scars.
However, the difference between me and Angela is that I don't blame anyone for anything. What's the point?
Blame is a waste of time and solves nothing. Just like guilt and worry. They're not part of my emotional make up anymore, but I work hard at this. I guess that's what more than 49 years of psychotherapy has taught me. You don't get that kind of insight out of a pill bottle and all the time and work in psychotherapy makes for a much more peaceful psychic existence.
IS BILATERAL ECT FINALLY HELPING HER DEAL WITH HER REAL FEELINGS?
I kept wondering if the ECT was freeing Angela's mind and helping her to get closer to her real feelings.
"Here is where REBT (Rational Emotive Behavioural Therapy), CBT (Cognitive Behavioural Therapy), and other cognitive-behavioral therapies come in — as well as the stoic philosophers discussed in my "Handles" book. Another approach is to teach the chronically angry and depressed person to be more assertive, in a constructive way — not throwing tantrums or screaming, but taking assertive, appropriate action to bring about desired change. (It is a misunderstanding of stoicism to think of it as saying, 'Just accept things the way they are' or 'Suck it up!'. Rather, stoicism is more like the now well-worn maxim usually attributed to Reinhold Niebuhr:
God, grant me the serenity
To accept the things I cannot change;
The courage to change the things that I can;
And the wisdom to know the difference.
"All that said, the relationship between anger and depression is probably very complicated, with a question as to which is the 'chicken' and which, 'the egg.' A full answer to your question would probably take a book, Sandy, but the bottom line for me is that when people are chronically angry, it probably has an 'erosive' effect on their mood."
"DIFFICULTY RETRIEVING INFORMATION FROM MY BRAIN, BUT IT COMES BACK IN A MINUTE"
Yesterday, when we spoke on the phone, 36 hours after her second bilateral ECT treatment on Monday, Angela sounded less frustrated and angry, much calmer. We talked about The Serenity Prayer, which she'd heard of and then I asked her about her memory.
"It's interesting," she said, sounding perfectly fine, intrigued by the way her mind and memory were reacting to this new-for-her ECT modality – she's switched from unilateral ECT. "The things I'm forgetting now are the things I know, but it takes me extra time to find them. It takes more concentration. Like if I'm driving somewhere and I know that I know the route, I have to concentrate on where I'm going, whereas before, I didn't have to think about it. It was automatic," she said.
"I'm have difficulty retrieving information from my brain, though in a minute or two, it comes back. I wouldn't call it memory loss because the information is there and I know it. I just need a little more time. I have to put extra cognitive thought into strategically focussing on finding it. But it's there and it always comes back."
Meanwhile, she's getting things done. She's out and about, working on getting her life back in order with more energy and determination than she's shown in months.
Tomorrow morning, she'll be having her third bilateral ECT treatment. I'll keep you posted.