My lunch with Angela...

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.

Ron continued...

"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.

Comments

[ajw]

Everyone reacts differently from ECT - some people have severe "manic", euphoric or dysphoric reactions to the treatment. The kind of memory difficulties that Angela describes were ones that I also experienced. It can get worse. I particularly relate to her description of her difficulties with driving. It took me years to be able to drive to known places without either a map or having to constantly rehearse my route as I drove. These were places I had driven for many years in the town I lived in for most of my life. For those of us who take or have taken psych meds that can also impair memory, the line is always blurry in determining the cause of cognitive difficulties.

I wish Angela all the best but caution that memory problems my not seem obvious at the time. In a year, the only reason she may remember this time frame may be due to this blog, and her own records of the treatments. I have virtually zero recollection of that time. No memory of leaving the hospital and getting lost post ECT. No memory of cards and gifts given to me. My only memories, apart from a few terrifying moments, are ones that are preserved in a journal I kept where I joyfully proclaim "It's working, and my memory is fine."
What ended my relationship with ECT was waking up post bilateral ECT in the recovery room with no sense of who I was or even the language to articulate my confusion. It was the most terrifying moment - even if it was only mintues. After that, I refused treatment and my mood plummeted. I would not have ECT again. I do believe it "works" in that it changes mood, but a lot of things change mood and it doesn't mean they are advisable approaches to dealing with distress and suffering.
It's interesting to note that people who have seizure disorders report similar changes in mood, memory and cognition following grand mal seizures.

I think ECT has unfairly been given the lion share of criticism of current treatments in psychiatry. All treatments have risks and benefits, and we, as "consumers" or "patients" or however we identify ourselves need to mindful of that.

Sometimes the hardest thing is just accepting that life is difficult, and there are no quick fixes to suffering and distress. There is always a risk with any treatment. Psychiatry, due its paternalistic attitude and its fear of madness, has tended to "protect" us from information about the effects of its rather rudimentary treatments that blindly block receptors or "reset" electrical impulses in our largely unchartered, mysterious brains.

[Rossa Forbes]

Sandy,
I'm in the camp that melancholy has a lot to do with anger and vice versa. I lifted this paragraph from an earlier blog post on the subject of anger.
...Rossa

The French word for anger is "colère", in keeping with the words "cholera" and "melancholy", and is linked to the body's production of choler or black bile, one of the four ancient humours. Referring to black bile, Robert Burton, in The Anatomy of Melancholy, first published in 1621, observed that “there is no nook or cranny of the mind into which this ‘roving humour’ has not insinuated itself. It is ‘inbred in every one of us.’” He explained that he wrote of melancholy to avoid being melancholy. The famous schizophrenic "apathy, flat affect and lack of motivation" is this not depression and melancholy? If we all have it to some extent, cannot each of us find some resiliency in us to crawl our way out of it?

[Ann]

I have stumbled onto this blog and am finally relieved to know that I am not alone with respect to side effects due to ECT treatments. I am 51yrs old and have been receiving ECT approximately every 2-3 yrs since I was 25. I have always had memory difficulties around the time periods of the treatments. Those memories have never returned so I can only refer to my journal as a guide. The Pro's always outweighed the Con's when the depression would not lift and suicidal thoughts would consume all of my time. Ect would always lift me up enough so that the meds could take over...for a while. In 2003, I received bilateral ECT. This was the first time to the best of my knowledge. From that time on I began to have increased memory and cognitive difficulty. In the past 7 years, I have received about 5 series of 8-12 treatments. My last time about a year ago left me just how "ajw" described only my short term memory has also been affected. This leaves me with the difficulty of trying to retrain myself on things already learned only to forget it in 1-2 weeks. Everything I do, see or read, I must write down. ECT is no longer an option for me. Who knows what would happen or how it would affect my brain further.
I think my brain has had all it can handle of this type of treatment. Please don't misunderstand me, ECT allowed me to have basically 20 yrs of living. My only hope is that as medical science will discovery many more methods of treatment that will be available to me.

[Annie]

I find this really interesting, as I've been looking into whether or not ECT is my next treatment option.

I've already suffered a ton of memory loss from the mass quantities of drugs that have been pumped into me up to this point, so hearing about the increased concentration despite having to reach for the memories is encouraging.

You should come visit me sometime at It's Time To Get Over How Fragile You Are.

Annie