Breakdown

In April 2014 I had a breakdown. Not a fully fledged, admitted to hospital, breakdown, but an acute episode of anxiety and depression that rendered me unable to cope with day to day life.

I snapped one morning in clinic. I had seen two well known patients and dealt with their concerns. The next was someone I didn’t know. I suddenly felt completely unable to think or make decisions. I felt that my brain was breaking apart. I developed a full blown panic attack, and despite knowing that it WAS a panic attack I was terrified and completely unable to get control of myself.

I was rescued by my dear friend and senior practice nurse, who calmly phoned my partner, cancelled the rest of my clinic, and got me an appointment to see an experienced GP.

The next few weeks passed in something of a blur. I was extremely anxious – at times it was hard to go out at all; I couldn’t THINK – and for someone who has always been decisive and relied on a sharp intellect and quick grasp of complex problems, this was truly terrifying. I was suicidal, in that I could see no way out of my problems other than jumping off a high building. I went only as far as planning which high building, and the rational part of my brain knew that suicide would be devastating for my family – but I still could see no other way out. I achieved very little in those first weeks. Lola, my dog, was a 3 month old puppy and I managed a short walk with her most days. That was about all.

I was well cared for, by an excellent GP who provided just the right mix of sympathy, support and direction; and by a fantastic service for physicians that was set up a few years ago in London. I was medicated and allowed to recover.

So far, so pretty normal to be honest. It didn’t feel like it, when it was me, but I had a fairly standard period of mental ill health and made a pretty good recovery. I was off work for 8 weeks.

The thing that struck me yesterday was that I was sober when this happened. The first time I stopped drinking was October 28th 2013 – so by April I had been largely sober for 5 months. (two evenings slip in that period) I had always thought that I broke down despite the fact that I was sober.

Now I wonder if it was because I was sober.

And that scares me. Because I feel truly awful right now. Anxious, irritable, flat, despairing, trapped and a bit desperate. My concentration is shot to pieces. I lack motivation to do anything at all.  I’m exhausted but struggling to sleep. And I am 5 months sober next Friday. What has alcohol been medicating all this time ? Currently I take an SSRI, which i was not doing last time… but …

I don’t know what to do

PAWS

Again. At least I think so. Or hope so ? Because if it’s not …. .

I’d never really heard of PAWS before I became a non drinker; when after the initial difficulties and emotional roller coaster of withdrawal, I didn’t exactly enter the happy calm space I was anticipating … No, I found myself still subject to mood swings, unexpected bouts of depression, sudden onset of anxiety symptoms, insomnia, and emotional uncertainty …

Then kind members of the sober community enlightened me, and I started reading about PAWS.

After acute withdrawal, the next stage of sobriety includes symptoms known as the Post Acute Withdrawal Syndrome (PAWS). This stage has fewer physical symptoms, the manifestations are more emotional and psychological.

As I understand it,  Post-acute withdrawal occurs because your brain chemistry is gradually returning to normal. As your brain recovers from being regularly poisoned,  the levels of your brain chemicals fluctuate as they approach the new normal equilibrium, and this fluctuation causes PAWS.

Over the past decades, much has come to be known about the long-term effects of drugs of addiction, especially on the neurobiology of the brain. Most substances of addiction, like alcohol, benzodiazepines, opiates, and stimulants lead to lasting changes in the brains handling of learning, motivation, and pleasure. Primarily, these drugs hijack the brain’s “reward” circuits, a critical part of which is dopamine. In the case of alcohol (and drug) abuse and dopamine, the brain not only becomes tolerant, but it also gets used to, and “expects” an excess of dopamine, meaning the newly sober user  experiences a simultaneous lack of dopamine (which is unpleasant) AND increased brain craving for the trigger that provides dopamine. In other words, not only does an addict feel bad without the drug, his focus turns solely to it to make him feel good again. Great ! Cravings explained in one easy sentence ….

There are several other key neurotransmitters involved, as well as dopamine, including serotonin ( mentioned here https://wordpress.com/post/alcoholfree2016.com/2097 )

While different drugs of abuse seem to lead to different sub-sets of PAWS symptoms, PAWS that occur from alcohol and benzodiazepines are generally more similar because they’re pharmacologically more similar in mode of action – key things are irritability, anxiety, and sleep difficulties. I have read that how long people experience these paws symptoms is typically a reflection of how long they were using  the drugs as opposed to how much.  great . So my 30 odd years of alcohol excess is definitely going to come back and haunt me here ….

The most common post-acute withdrawal symptoms are:

Mood swings  (triple tick)
Anxiety. tick
Irritability. Tick
Tiredness. Double tick
Variable energy, double tick
Low enthusiasm. Triple tick
Variable concentration double tick
Disturbed sleep tick

Im utterly fed up right now. I’m stressed , fighting with Mr Lily over problems that are insoluble, anxious about the responsibility I’m taking on in our upcoming holiday, worried about no 1 son – and totally alone with no support in this one, I feel fat, sluggish, lazy and unmotivated. So unmotivated I even missed my favourite yoga class this evening.
This feels like a total rollercoaster of symptoms. At the beginning; the first two weeks were really tough – my symptoms would change minute to minute and hour to hour. Then I had a period of pink cloud – when I felt AWESOME …. I enjoyed that 🙂 But in the last 3 months of so, I don’t feel I’ve made any significant progress . I get these awful low moods, then they will disappear for a few days / a week , only to return again. I hoped that  the good stretches would get longer and longer, I’m not sure that’s happening and the bad periods of post-acute withdrawal are just as intense and last just as long.

Thank goodness I’m not craving alcohol right now, as I’m feeling so very vulnerable ….

Serotonin

 

I’ve been really struck in the last few days at the number of blog posts I have read from people struggling with guilt and shame at having to take, or being recommended to take, antidepressants / medication for anxiety.

I work as a General/ Family practitioner and I see this so often. People struggling with crippling anxiety and debilitating anhedonia, who somehow believe this is a sign of ‘weakness’ or  a character flaw. That if they could just “pull themselves together’ it would all go away.

This is just NOT the case. Low mood / anxiety are two sides of the same coin and they are both due, in part at least, to low levels of the neurotransmitter serotonin. This is FACT. An individual can no more control their levels of serotonin than their levels of insulin. Ergo, will power alone will NOT , CANNOT manage anxiety and depression.

Anxiety / Low mood is very,very, very common. Probably about one in three people will visit their doctor at some time with this complaint. Sometimes its presented as fatigue, sometimes as somatic symptoms. But the underlying low serotonin, if treated, will improve all these symptoms

(and before any one jumps on me, not everyone with fatigue is depressed, obviously, but its very common)

This is a somewhat simplified version of the role of neurotransmitters, as my aim with this blog post is not to discuss the finer points of neurophysiology, but offer evidence that might make someone who is low, feel less stigmatised about being offerred / taking antidepressants.

NEUROTRANSMITTERS are the brain chemicals that communicate information throughout our brain and body.  They relay signals between nerve cells, called “neurons”  The brain uses neurotransmitters to tell your heart to beat, your lungs to breathe, and your stomach to digest.  Serotonin is a neurotransmitter which affects mood, sleep, concentration, weight, anxiety, appetite, memory and learning, temperature, and behaviour. Norepinephrine, dopamine, endorphines and oxytocin are also involved in various aspects of mood.

Lots of things, obviously affect mood. Social circumstances, relationships and thousands of other things. But low serotonin levels- are definitely one of the factors that affect mood and one of the factors that we can modify. The diagram below shows the overlapping relationships between some of the neuro chemicals involved

7346353

We can ‘help ourselves’ with exercise and a variety of other techniques, we can try to manage stress levels, and we can avoid substances that deplete serotonin – eg alcohol… BUT, for many people, medication is a very useful tool to improve mood and reduce anxiety. I will often explain to my patients that lifting your mood allows one to create a ‘virtuous circle’ – when you feel a but more motivated, you are likely to exercise more, get more done – this makes you feel better – and so on…

so please, if you are low, depressed, anxious, unmotivated, exhausted, struggling with mood disorder, please recognise that this is an illness; Its not under your ‘control’ and there is treatment that can help.

DOI. I take a serotonin reuptake inhibitor, and I believe it has, if not saved my life, helped me beyond measure.

Struggling

This is weird. Today is my 125th consecutive sober day. That’s more than I have had (consecutively) since I was 18 years old. I feel better. I look better. My drinking app tells me I have saved approx £1,250 and 140,000 kcals. I am (fractionally) slimmer. I am definitely healthier. I sleep better and I’m no longer anxious about what I might have said/done when drunk. I’m not ashamed of myself any longer.

SO WHY AM I STRUGGLING TO CONVINCE MYSELF THAT I DON’T WANT TO DRINK ?

I do want to drink. I really do. I want to sit outside and open a bottle of wine and RELAX. I want to get tipsy and escape from the relentless activity of my brain. I want cocktails; I want vodka and gin and big bright mixed drinks with cherries. I want Limoncello and cider and cold Cava. I want to feel drunk. and released from tension, frustration and disappointment in myself.

I bored. I’m frustrated. I’m scared of never reaching that contented sober place that I see other posters have got to. I’m angry , I’ve done everything RIGHT. I’ve reflected and prioritised my sobriety. I haven’t pushed myself, I haven’t cheated, I haven’t taken on too much and exhausted myself (or maybe I have).

I don’t know what to DO.. I can not drink today, I can deny myself for a while, but if this persists this tactic will not be successful long term. I don’t WANT to go back to that place where I was guilty and ashamed, where I was slowing pickling my liver and stultifying my brain with poison. Where I was stressed and anxious, preoccupied with alcohol and how to get enough .. 

But I don’t want THIS reality either. This, where I can’t concentrate at work, and feel like I’m wading through treacle trying to organise myself; where I’m constantly pushing a  boulder uphill to get anything done at home. Where the landscape is grey and relentlessly dull with sentient consciousness. Where the futility of my attempted interventions with son#1 are brutally highlighted every single day and I can’t escape from it. Where I’m stuffing a packet of chocolate biscuits down to satisfy sugar cravings or a ‘need to eat’ and then hating myself. Where I can’t be bothered to exercise and instead spend money I don’t have (how much I don’t know because I can’t be bothered to check my credit card statement, but its in the £thousands rather than the £hundreds) on stuff I don’t need even if I want it. This where I am SMOKING again because I ‘need’ something to manage by stress level… FFS I stopped smoking YEARS ago. I feel bloody rubbish about this – full throttle cognitive dissonance

This is pretty shit too. 

I want to STOP. concentrate on myself for a decent amount of time. Stop working. Stop having to endlessly meet the needs of the hundreds of patients who come though the door every week. Stop having to manage staff disputes, problems, and domestic upsets. Stop listening to my partners with their agenda’s. Stop fretting over tasks done/ not done / the direction of the business. Stop trying to predict the next twist in the story of the NHS, with the implications for funding. Stop listening to the petty whining of the salaried doctors. Stop juggling all the things different people want / need from me. Stop having to shop, cook, tidy, organise, wash clothes, stop juggling finances, stop pacifying my mother, stop organising dog walks, school stuff, …..stop stop STOP.

Maybe the truth is that I drank because I couldn’t cope without drinking. That actually , just maybe, nobody could cope with what I expect of myself, maybe the life I have fashioned for myself is actually unmanageable, especially now I am 51 not 31.  Not one of my female doctor friends with kids works full time. Add to that that I am a single mother – (ok, I live with my partner and he does help, but not with the THINKING, and only with the practical stuff that suits him) and maybe its not surprising I feel I’m am going nuts. 

Maybe the purpose of all this is to MAKE me take a long hard look at my life and work out what is sustainable. But that might mean some VERY big decisions and I’m SCARED of them too … no  wonder I want to hide at the bottom of a bottle.

FFS this is NOT what I expected to be thinking / feeling at more than FOUR MONTHS SOBER. Where is my serenity? my calm conviction that I have made a good decision. ? Where is optimism, peace? where is a better life ??? Maybe its NOT going to happen for me and I’m doomed to either life as a drunken sot or a demented harpy with a fat bottom and rotten teeth and stinking breath…. Maybe the end is cirrhosis from drink or lung cancer from fags ….

FUCK BUGGER BOLLOCKS. That’s all folks 😦