Tuesday, 5 January 2021

Interpersonal Therapy (Take Two) Session 1

(TRIGGER WARNING: Mentions of Self Harm and Suicidal Feelings)

 After a major Depression and mood swings relapse, and encouraging words from loved ones, I decided to ask for help again. Initially, I thought I just needed my medication/dose changing but when calling Access/Crisis team, I was told I would probably benefit from therapy again, and my GP should be able to review my mental health medication. I reluctantly called Primary Care/IAPT to book an assessment and see what therapies were available (thinking they would just put me onto CBT again) but luckily was assessed by a wellbeing practitioner who realised that I had been through CBT many a time; resulting in some help for my anxiety disorders, but no improvement of my depressive episodes. The Primary Care team decided that I would be a good fit for Interpersonal Therapy instead. 

Interpersonal Therapy is intended as a treatment specifically for Depression (whether as a condition in itself or a part of another diagnosis) and focuses on how relationships can have a significant impact on our mental health. It could be things such as role changes (becoming a parent, carer, taking on a new job to name some examples), a loss or bereavement, arguments within relationships of any kind, or a major life event. This type of therapy aims to look at these factors and help the client to build up skills around them in order to improve their symptoms of Depression. There are 16 sessions to this type of therapy. The first 4 aim to get a picture of how Depression manifests for the client specifically, the middle 8 sessions aim to help build up skills to help improve symptoms, and the last 4 aim to conclude the therapy and get the client ready to continue practising those skills once therapy has ended. 

I had a few sessions of Interpersonal Therapy with someone prior to my diagnosis of Borderline Personality Disorder. I was very unwell at the time, however, and due to some things my therapist said as well, the therapeutic relationship broke down and I was unable to continue. I am looking forward to going through the process of this therapy with a different therapist though. 

My initial phone call with the new therapist went very well. I felt she was easy to talk to, and listened well to my problems. We decided that my diagnoses, symptoms, and issues would be a good fit for this type of therapy, and I was happy to go ahead. 

Before the first appointment, I had the PHQ/GAD/Phobia etc questionnaires to fill in, as well as a therapy agreement, consent for my therapist to record our appointments (she is a trainee IPT therapist, so her supervisor needs to monitor the sessions), and a symptom review sheet. 

The Symptom Review worksheet is a grid containing many different possible symptoms of Depression. My task was to tick each symptom I felt had been a problem within the last week, then pick 5 that specifically needed addressing. I did tick a lot of the symptoms, and found it hard to pick just 5. I put a star next to the most pressing symptoms, but through talking to my therapist in our first session, I found that each of those branched out into the other ones, were very similar in the way they manifested, or were linked quite closely together. What looked like a simple task, became a more complex one, the more I tried to explain each of the symptoms!

I felt like I was rambling throughout the conversation, and I worried that the therapist would not be able to organise what I'd said into cohesive notes. I should've had more faith though, she was very helpful and understanding. She would bring me back on topic when needed and would focus on the symptoms that seemed to bother me most. Between us, we decided that I was struggling with the following issues most in the past week:

  • Irritability - I would find conversations and too much noise overwhelming, with led to a type of sensory overload which resulted in irritability. I may not always have made this apparent to the person/people I'm around, but I coped with it by turning on myself and either punishing myself (self harm) or isolating myself (going in my room). Generally, this is something I do if conversations online become too overwhelming or difficult. It's as if I'm suffering an emotional pain and I either want to escape it or turn it into a pain that I find easier to deal with. 
  • Always tired - I experience extreme fatigue, due to my physical health problems, but I know that Depression plays a big part too. I find this symptom links in with lack of motivation and lack of energy (other symptoms on the symptom review sheet). This week especially, I have found I am constantly exhausted and want to stay in bed for longer and longer. I know that this is partly due to the Depression because my moods affect my levels of energy, and the worse I feel, the more sleep I need. Unfortunately, although sleep can have a positive effect on mood, oversleeping can have the opposite effect. I felt as if I hadn't achieved much at all in my week, I saw myself as lazy, and I worried others would see me as lazy too. 
  • Mood swings - These are problems I have experienced a lot recently, which is why I think my mood stabilizers (Aripiprazole) have stopped working. I feel things in the extremes, to a point where I can feel as if I can't cope or I am out of control. The extremes weren't as bad as they could have been this week, but they were bad enough for it to be a problem. I didn't get the hypomanic emotions this time, but I did swing from considerably depressed and down, to irritable/angry, tearful, anxious, and even numb. I explained the numbness further, as my therapist said that it wasn't written down as a particular depressive symptom (which I found interesting, as a lot of people I know with Depression do feel numb quite a lot!). It's something I hadn't realised in myself until I connected with others with similar conditions and symptoms. When numb, my self awareness of how ill I am tends to decrease, and I'm not sure how to respond to the question "How are you?" because I simply don't know. When numb, I can dissociate too, although not always. I explained how I experience dissociation, to my therapist. She found that interesting too. We discussed how some of my symptoms had become coping mechanisms, as my numbness and dissociation can occur after days/events/conversations that I had found overwhelming. Again, it was a matter of extremes. I either felt too much, or not enough. 
  • Feel worthless - I am often very self critical, although this is something I am trying to work on. I try to say more positive things about myself these days, but I do worry about coming across as arrogant, or just being wrong. When I'm not able/don't have the motivation to do much in my day, then I feel worthless and pointless as a person. This can lead to the suicidal feelings, as, in order to feel like I should be on this earth, I want to feel I have some sort of purpose, I am doing something to improve myself, or I'm doing some good for other people. It's a bit of a chicken and egg situation, as if I feel worthless, I lack motivation, but if I lack motivation and therefore don't do much, I feel worthless. I'm never sure which started first, but it seems endless! 
  • Bored - As a symptom, this seems like a very mild one, but boredom can be unbearable for me. When I lack motivation and are not doing much, obviously I get bored. I have things I could do, but the thought of being disappointed if I do not enjoy them, or struggle to progress with them, can be very hard to deal with. Being bored can lead to becoming frustrated, angry at myself, extremely low and self critical, and even lead to suicidal feelings if I feel everything is going wrong. Doing something I enjoy (seeing a friend, not possible at the moment of course! Playing a musical instrument, cross stitch, a TV show etc) can lift my mood, but overthinking the possible result (not enjoying it) can make me talk myself out of even starting. I can usually push past this worry and do the activity anyway, but when very low, any disappointment feels like a big risk. 

As you can imagine, going through the symptom review took up most of the time in the therapy session. I was very apologetic and nervous throughout, but my therapist tried to put me at ease by saying she could understand what I was saying/what I meant, and she felt she had learnt a lot about me that day. She confirmed that, going on the questionnaires and what I had told her, I was still suffering from moderate to severe Depression. Apparently this type of therapy expects a diagnosis to be made and for Depression to be the main problem that needs addressing in order to go ahead. I know labels aren't useful for everyone but I like to have a name to put to the problems I experience, so I know what I am dealing with and what is likely to be helpful for me. 

She then told me what the other sessions would cover (possible past trauma/events, key relationships, arguments, role transitions etc) and asked me to complete the PHQ etc questionnaires and symptom review for next session as well. 

This concluded the session, and after checking there was nothing else I needed to discuss, we booked in for the same time next Monday. 


Resources




Sunday, 22 November 2020

The Connection between Chronic Illness and Self Esteem

 (TRIGGER WARNING: Internalised fatphobia, body image, weight, mental illness, medication)

I've rarely had high self esteem, thanks to years of bullying, but my self esteem has taken such a knock since I've had chronic illnesses.

Throughout my treatment of chronic physical and mental illness, I have been on various medications, some of which have caused considerable weight gain. I try so hard to be body positive but I don't feel like me anymore and I'm desperate to get back some of my old self. I worry that others will think I've given up taking care of myself even though a combination of meds with weight gain side effects, inability to exercise sufficiently, and comfort/stress eating due to depression and anxiety, have led to significant weight gain and body change. I follow body positive people on Instagram in order to help with the disordered thinking I have about weight and diet. I read anti-diet books too. I think any change (not just weight gain) can have a serious effect on a person's self esteem. In my experience, in the past I have been known as the "skinny one", so I suppose, wrongly, I have made it part of my identity. I have liked being called things like "pixie", "petite" etc and when I don't see myself that way anymore, I feel very disappointed, at a loss, as if I've lost part of my identity and need to take on a whole new one which I don't particularly like. I know that this counts as fatphobia and I try so hard to reject those awful thoughts.

My balance problems and chronic pain, that come with Fibromyalgia and Hypermobility Syndrome, have changed the way I walk. I am a bit wobbly, I walk with my feet turned in (as much as I try not to), sometimes I limp. I have been stared at and mocked for this, and so my self esteem has taken a hit. I try not to let it bother me, but if I notice someone is staring, I am extremely aware of my manner of walking.

I often need to go to the toilet, due to Irritable Bowel Syndrome, Overactive Bladder Syndrome, and some bowel/stomach problems that are yet undiagnosed. If I'm particularly bad, I have to cancel plans last minute. Even if my friends are very understanding and compassionate, friends in the past haven't been and this has affected my self esteem too. I feel like a flaky, disappointing inconvenience, rather than a valuable friend. I feel all I do is annoy people and let them down. I know I cannot help this, because I would not do this if it weren't for my physical and mental illnesses, but it does not stop me from feeling this way.

Bladder and bowel issues can be (although they needn't be!) embarrassing and seen as a bit disgusting. I find I refer to them as "TMI problems" and try to describe them as delicately as possible to friends or people in Facebook groups. A lot of people have problems like this though, and a problem with bladder or bowel is nothing to be ashamed of! I do worry about it affecting my dating prospects though, although I would not want to be with a partner who was immature and easily disgusted by my health issues!

Part of mental health is self esteem, but mental health problems in themselves can have a severe impact upon self esteem. (Are you with me?). I'll explain. Anxiety can hold back so many things a person may want to accomplish for example. This could be taking on a dream job, travelling, or maybe even just meeting a friend for coffee. When someone has to cancel plans like these, or when they feel panicky whilst doing them, it can have a real knock-on effect. They can be frustrated with themselves for cancelling or acting in a "not normal" way. They may worry that others will pick up on the anxiety or the fact that they have cancelled multiple plans, and may treat them differently. I've certainly lost friends due to the way I've acted! These were friends I had felt quite close to as well. It does make you feel very low about yourself, as if there is something fundamentally wrong with you. 

Carrying on the mental health conversation, when very depressed we may push people away and isolate, maybe because we don't see a point in talking, maybe because we feel we are not worthy of friendship, maybe because we feel overwhelmed. There are many reasons why someone may isolate. The consequences of this could be losing friends, friends acting differently, friends not reaching in to persuade you to talk. Of course there could be many reasons why a friend might act differently that doesn't necessarily mean they see you as any less of a friend to them. When very depressed though, personally, I will perceive any change in their behaviour as a direct reflection on me and my personality. I may isolate, but I still want friends to reach in and try to contact me. If they don't, I feel that maybe they weren't that close to me after all and "of course" that's my fault for acting the way I do. I feel I can't help how I act though, so I believe I can't do anything about it. And therefore, self esteem = rock bottom. 

I'm constantly told by friends to not care what people think. I'm OK and I don't need to change for anyone. This is easier said than done though, especially when chronic physical and mental illness have ripped away my sense of self and confidence. I have a lot of paperwork from past CBT sessions, to do with negative thinking, all or nothing thinking etc. When very depressed, I don't see the point in looking through them. I also don't feel I deserve to have high self esteem. I think we all deserve to feel good about ourselves if we are good to others though. We beat ourselves up far too often, and usually for very small (although not to us) reasons.

I hope, in time and with practise, we will get that self confidence back.

What knocks your self esteem? Have you found ways of building yourself back up? Comment below!


Thursday, 15 October 2020

My Experiences with Borderline Personality Disorder

(Disclaimer: The information given here is mainly about my own experiences of Borderline Personality Disorder. The ways I act, react and feel are not necessarily universal to all people with BPD and this should not be used as medical advice or a replacement for formal assessment. If you feel you have any symptoms such as mine, and especially if you have been self harming or suicidal, I urge you to contact your GP as soon as you can. Please let someone know how you feel. You deserve to get help.)

(TRIGGER WARNING: Mentions of Poor mental health treatment, Stigma against BPD, Self harm, Suicide, Alcohol and Sexual behaviour)


It was World Mental Health Day a few days ago. A day where I always feel the obligation, as a person with multiple mental illnesses, to do something such as write a blog post. I try to vary the specific subjects such as talking about one of my illnesses, how I cope with various ones, and/or the importance of awareness days, as well as supporting people every day.

Unfortunately life got in the way this time (doesn't it always?!) and I didn't manage to write my blog post in time. Mental illness happens every day though, not just on awareness days, so any day is a good day to raise awareness, talk about the importance of support, reaching in as well as out, having appropriate services for anyone who needs them etc.

Today I want to talk about a mental health diagnosis I have that is often misunderstood and stigmatised; Borderline Personality Disorder (BPD). Let's start with the diagnostic criteria:

The following is found on the NHS website:

Assessment

Internationally recognised criteria are used to diagnose BPD. A diagnosis can usually be made if you answer "yes" to 5 or more of the following questions:

  • Do you have an intense fear of being left alone, which causes you to act in ways that, on reflection, seem out of the ordinary or extreme, such as constantly phoning somebody (but not including self-harming or suicidal behaviour)?
  • Do you have a pattern of intense and unstable relationships with other people that switch between thinking you love that person and they're wonderful to hating that person and thinking they're terrible?
  • Do you ever feel you do not have a strong sense of your own self and are unclear about your self-image?
  • Do you engage in impulsive activities in 2 areas that are potentially damaging, such as unsafe sex, drug misuse or reckless spending (but not including self-harming or suicidal behaviour)?
  • Have you made repeated suicide threats or attempts in your past and engaged in self-harming?
  • Do you have severe mood swings, such as feeling intensely depressed, anxious or irritable, which last from a few hours to a few days?
  • Do you have long-term feelings of emptiness and loneliness?
  • Do you have sudden and intense feelings of anger and aggression, and often find it difficult to control your anger?
  • When you find yourself in stressful situations, do you have feelings of paranoia, or do you feel like you're disconnected from the world or from your own body, thoughts and behaviour?
As well as talking about what BPD is, how it is diagnosed and treated etc, I want to speak about my experience of living with it. I have had symptoms of BPD for as long as I can remember, but I have been formally diagnosed since 2017. I have various mental illnesses, whose symptoms overlap, but the ones I think I can attribute to Borderline Personality Disorder are explained below:

  • I am terrified of being alone, as well as rejection. I have practically begged bullies to stay "friends" with me so that they wouldn't take away my real friends and leave me without anyone. I have constantly phoned a partner when they hadn't spoken to me for a few days, to find out why, in the hope I could convince them to not dump me. (It didn't work). I go through regular phases of reassurance seeking which I'm sure annoys my friends, no matter how kindly they respond. No matter how many times I try to get reassurance that my friends won't leave me however, I can never reassure myself. I go round in circles with this. I admit I have checked a partner's messages too,  to make sure they hadn't found someone else. I also wanted to find out what they "really" thought of me. What I found out upset me a lot, but honestly I should've just spoken to my partner. Communication is so important! There are probably more examples of seeking reassurance, avoiding rejection/perceived rejection etc but I think I've said enough on that subject.

  • In the past, I have gone from relationship to relationship, with not much of a break between them. I just couldn't bear being alone and single. A lot of the relationships I've been in have been pretty intense and unstable; not always through my fault though. I have been in at least one definitely abusive relationship, and although I made mistakes myself, I would never blame myself for how they treated me. Other relationships have involved love, marriage, and children being mentioned very quickly; burning out almost as soon as they began. I have also mistaken having feelings for someone, for being deeply in love with them. I have made everything about them and believed we had a future, even when it is pretty clear they didn't feel anywhere near the same way. 

  • I still don't know what kind of person I am. I can say that I believe I am kind, passionate, and determined, but even then, I doubt that. I always rely on other people to prove they know me, and to tell me what kind of person I am, what makes me "me", what I'm good at, what my trademark is etc. Any comments about my character, I feel deeply. Good and bad. I'm more likely to believe the bad ones of course, but that's not necessarily a BPD thing. My unstable sense of self can even get so rocky that I literally don't recognise my own reflection in the mirror. The person in the mirror could be anyone, but I do not feel they are me. I have days where I feel attractive, and days where I feel extremely ugly. Nothing has physically changed, only my moods. Again, not necessarily a BPD thing, but it's worth mentioning as a mental health thing. I would love to truly know who I am, and I often feel lost and not grounded because I don't know.

  • As for impulsive activities, I do engage in some, but not as many as I used to. At university in particular, I would engage in risky sexual behaviour. The only way I can explain why, is to say that I had very low self esteem, I often felt alone and unwanted, and that one night with someone I barely knew would make me feel wanted, if only for a few minutes. I would always feel guilty and ashamed afterwards, but I try not to now. As well as this, I am prone to drinking impulsively. It is a coping mechanism and although I know it is unlikely to lift my mood when I am particularly depressed, it feels like a good idea at the time! I drank a lot in my later teens and 20's. It was something I'd do to celebrate, commiserate, destress, forget, or just cope. It was binge drinking and thankfully I don't do it nearly as much now. It didn't help and I could've damaged myself. Right now, I don't self harm much, but I do still do it impulsively. A bad day, a bad comment, a low mood, a stressed mood, agitation, too many thought, too many mood swings. It doesn't take much. These are some of the most potentially dangerous impulses I have/had, but there are others that would take all day to talk about. 

  •   I am suicidal. I'd say passively nowadays (thanks to good antidepressants and mood stabilizers), but I have had plans, and almost-attempts in the past. I have made "threats" too, although I do not like the term. It feeds into the stigma (which I will explain below). As in the previous post, I self harm occasionally too (it used to be every day though). 

  • I used to have very severe mood swings, but thanks, again, to mood stabilizers, these are not so bad now. These mood swings can go on for hours, days, maybe even a week. They are very hard to cope with and when my moods are particularly high, I am scared about the comedown. Sometimes I can very rapidly go from deeply depressed, to anxious, angry, and hyper, then back down again. Sometimes I feel all these at once. For me, that is the worst and is often when I will feel more suicidal or self harm badly.

  • I feel very lonely and empty on a regular basis. Most of the time, this is how I feel when I'm not having mood swings. When I feel empty, I find it hard to respond to the question "how are you?". Sometimes I even think I'm doing ok, when I'm really not. 

  • I can feel intensely angry, but not very often. I act in rather than out too (punishing myself rather than lashing out at others). I can have kneejerk reactions to things but find it hard to express myself. Sometimes I will act without thinking but thankfully that has not involved me doing anything physical as a result. 

  • In stressful situations I often dissociate. This involves feeling as if nothing is real. I might not feel as if I am in my own body, or even that I am real. It can last from a few minutes to a few hours. The stressful day, or moment can go by like a blur and I'm often not sure of what I said during that time. I may have lashed out verbally, or had a big panic attack, and I just don't remember the details. There are a couple of times I can think of. One time, I was on holiday with a partner. He was threatened by someone in a bar. I knew I was shouting and swearing at this person but I honestly cannot remember what I said. I burst into tears and was shaking afterwards. Another time, I was at a Work Programme induction, where I was taken into a group session without my prior knowledge. At the time I found group situations terrifying and extremely stressful. I know I spoke over the person leading the session, and apparently had a panic attack that was severe enough for me to be led out of the room. I know I spent the rest of the session signing some documents a work advisor put in front of me. I couldn't even tell you at the time what they were about though. I managed to sign them but I didn't read them and it was as if I was on autopilot. I often found Work Programme appointments very stressful and if I wasn't dissociating, I was paranoid. I used to believe any unfamiliar car or van outside my drive was a government official spying on me. If a stranger looked at me for a few seconds longer than "normal", I would believe they were spying on me too. I still find myself getting paranoid about various things, but I am a little better at calming myself down. I can ground myself a little more effectively too.

Treatment

I feel like all these symptoms are a lot to cope with. I have been at crisis point on multiple occasions and you'd be forgiven for thinking I had somewhere to turn when things become too much. Unfortunately, a common misconception about BPD is that people with it are too reliant on services, so mental health teams often discharge us before we are ready. It is very hard to convince someone you need help, especially when you are in a distressed state. It can look like over-reliance even when you truly need that help because you are in crisis. If you look at some of my previous posts, you will know that I have been assessed multiple times by the Access (Crisis) team and Community Mental Health team, and discharged straight after, or after a few sessions of help, even when I clearly wasn't ready. I believe it would take something drastic before I would have any intense help. Due to lack of funding and resources, however, I don't think I will ever get enough appropriate help.

According to NICE, therapy for BPD may include Dialectical Behaviour Therapy (DBT) if self harm is a particular issue. Brief psychological interventions (less than 3 months) are not recommended specifically for BPD either. Choice of therapy should be tailored to the individual's needs. In theory, this sounds promising, but as someone who was only ever offered a few months of CBT in Primary Care, and 4 sessions each of Distress Tolerance, and Self Compassion Therapy, in practice the needs of an individual with BPD are not always met. I think it mainly depends on how much knowledge your healthcare professionals have of this condition, and what sort of resources are actually available in your local Mental Health Team (be that Primary Care / IAPT or Community Mental Health Team/Secondary Care). 

Medication

In my experience, various mental health professionals have said that, with BPD, medication rarely helps and certainly isn't the be all and end all of treatment. It can help though, and does have a place in treatment. For me, Duloxetine helps the depressive moods I have, and Aripiprazole helps my mood swings. It allows me to get to a level of mental wellbeing where I am able to actually engage with therapy. Without medication, I would simply be too unstable and suicidal to accept any help. This might sound drastic too, but I do believe I would be dead without mental health medication.

Myths

There are various myths about people with Borderline Personality Disorder. A big one is that we are seen as manipulative. The truth though, is that we struggle to reassure ourselves that people actually want to spend time with us. We are scared of being rejected and sometimes we will do seemingly drastic things to gain that reassurance. 

We are seen as "threatening" self harm and suicide too. Actually, many of us are suicidal and do self harm but we do not do this/talk about this as a threat. We may in fact be asking for help and trying to be honest about how ill we are. People often misconstrue this though, especially when we have the BPD label. 

Also, we are said to be over-reliant on mental health services. That is not necessarily true though, and certainly isn't a particular symptom of BPD. We ask for help because we need that help. Mental illness is invisible too. Someone can seem fine on the outside, when they desperately need assistance. It can take presenting with physical injury for a mental illness to be taken seriously. Even then, the person may just be patched up in A&E then sent on their way with little to no aftercare. Last time I overdosed, I had to specifically ask to be seen by the Psychiatry Liaison team. I feel I've had to fight and almost beg for any scrap of help I've received. 

You can read about other myths here but I would advise avoiding this, or at least being careful not to overload yourself if you find these triggering at all. I am careful to only go on the myth-busting sites, rather than exposing myself to places with very upsetting misinformation. 


How Do I Cope?

I do have some unhealthy coping mechanisms, which I certainly wouldn't recommend, but I am learning healthy coping mechanisms too, and trying to replace the not-so-healthy ones.

For me, talking to trusted friends and family helps, but being in therapy can give me space to vent my feelings without judgment or fear of a loved one's reaction. It all depends what you feel ready for but in my experience, bottling it all up is a very bad idea

Having distractions can help with coping too. Gaming, cross stitch, going for a short walk (only when not in an unstable, suicidal place in my head though), studying short courses, reading, watching an episode of something or even a short Youtube video can help. I find I get overloaded very easily, and that can lead to major stress and self harm. I may manage a film, but when it seems too long or too involving, a few simple funny or cute Youtube videos will at least get me through some of the day.

If I'm particularly agitated, keeping my hands busy can help calm me down or at least channel some of my frustration. I am a lover of baking, and focusing on a task such as this, and creating something delicious can help me get through if not boost my mood even! The result is a tasty treat and the fact that I haven't punished myself for however many minutes or hours that particular bake takes.

When dissociating, I have learnt two things that sometimes help. 

                    1. Grounding. This involves doing simple things to reconnect myself with the outside world. It intends to remind me that the world around me, the people around me, and myself are real. It also brings me to the present time. One way of grounding myself involves focusing on one thing that stimulates each of my senses i.e. something I can see, something I can hear, something I can smell, something I can feel, and something I can taste. Even focusing on just some of these senses can ground me slightly.

                   2. Safe Place. I'm still learning and practising this one, as I find it hard to focus and take myself away from whatever stressful situation has triggered my dissociation. It involves imagining a pleasant, calm place that can either be real or something completely made up. An example could be a quiet, sandy beach. I imagine myself there at night, with no one around. Again, I can focus on my senses in order to make that place as real for me as possible. I may think about the taste of a fruity cocktail, the smell of the sea, the sound of the waves or the feel of a gentle breeze through my hair. Once I feel calmer, I can gently bring my awareness back to the present moment in the hopes that I will have stopped dissociating and feel more able to deal with the situation I am in, or simply walk away from it if that is possible. 


Conclusion

So, I am in no way a success story, and I'm definitely not looking for sympathy (well, maybe a bit if I'm having a bad day?). I simply wrote this blog post to let you know about how Borderline Personality Disorder feels for me, and how my experiences of it compare to the diagnostic criteria, recommended treatments etc. 


Resources

Diagnostic Criteria - https://www.nhs.uk/conditions/borderline-personality-disorder/diagnosis/

NICE guidelines for Borderline Personality Disorder - https://www.nice.org.uk/guidance/cg78/chapter/1-Guidance#general-principles-for-working-with-people-with-borderline-personality-disorder

MIND Dialectical Behaviour Therapy - https://www.mind.org.uk/information-support/drugs-and-treatments/talking-therapy-and-counselling/dialectical-behaviour-therapy-dbt/

MIND About CBT - https://www.mind.org.uk/information-support/drugs-and-treatments/cognitive-behavioural-therapy-cbt/about-cbt/

IAPT - https://www.nhs.uk/service-search/find-a-psychological-therapies-service/

Community Mental Health Teams - https://www.derbyshirehealthcareft.nhs.uk/services/mental-health-and-emotional-wellbeing/neighbourhood-community-support/cmht-adults-working-age

Five things people get wrong about BPD - https://www.sane.org/information-stories/the-sane-blog/mythbusters/five-things-people-get-wrong-about-bpd


If you feel you need to speak to someone, after reading this blog post, I am leaving some mental health links below. Please also comment below, if you know of any other links to inclusive mental health helplines.

Samaritans: https://www.samaritans.org/how-we-can-help/contact-samaritan/?gclid=CjwKCAjw5p_8BRBUEiwAPpJO61KYfF83b5CLcYslbI7Nz2_yJ-SwSqWHR31ZLgMF0nGpFFFqDv_VDRoCN9kQAvD_BwE

Mind: https://www.mind.org.uk/about-us/contact-us/

Stonewall: https://www.stonewall.org.uk/help-and-advice

(Please be aware that a lot of these links are for listening services. The people you speak to are unlikely to be allowed to advise you, and should not replace speaking to your GP, mental health professional, or even A&E if urgent. They do have a place in mental wellbeing however, and it can be helpful to hear a friendly, compassionate voice).


Saturday, 18 July 2020

"Square Peg....Round Hole"

(TRIGGER WARNING: Medication, including dosage and overdose, mentions of self harm, suicide, trauma, hallucinations, domestic abuse, and abortion)

For many months, I've been on Citalopram for my Depression. The past month or so, I've been on 40mg (the highest dose). At first, I seemed to be doing well but, especially since trying to contact some charities to help me with my trauma from the abusive relationship I was in, I relapsed badly.

My suicidal thoughts have returned, I am being more impulsive with drinking, self harm, and taking small overdoses to help me sleep. I have not been sleeping well recently, I have had very graphic nightmares and flashbacks, and my appetite has been all over the place. Getting out of bed has been very difficult, as I am either very distressed or extremely low. Everything seems pointless.

I finally decided to speak to my GP on the phone the other day. I was due to have my mental health medication reviewed anyway, and I guess I was just expecting her to put me onto something else and book another review in a few weeks' time.

When she rang, she asked me how I'd been getting on with the higher dose of Citalopram, and how I'd been feeling recently. I explained everything, and I think I sounded quite panicky. She was very concerned, especially about the suicidal thoughts. She told me to ring the Community Mental Health Team, to see if they would see me. She also said that I would need them to refer me to a psychiatrist to see what other medication I could be put on.

I guess I didn't realise how bad things had become. I suppose I've been so used to having suicidal thoughts, but no real help for them, that I'd given up fighting for support (especially immediate support from crisis team/access team etc). I told her about my previous experiences with CMHT and how the last time I went to A&E after an overdose, I spoke to the Psychiatry Liaison Team who said that I wasn't ill in the "right way" for CMHT. My GP still insisted I rang them though, and got back to her with what they'd decided.

I was very panicky by the time I rang access/crisis team (you ring them to be triaged and referred to CMHT) but I spoke to a very nice, compassionate person. They listened to what I had to say, asked about my mental health medication (40mg Citalopram, 10mg Aripiprazole), asked me how I'd been feeling, and went through the risk assessment with me (suicidal thoughts, plans, self harm history, hallucinations etc). I also mentioned the trauma I had experienced from a medical abortion at 19 and an abusive relationship soon after. I told them I'd spoken to some LGBTQ charities to try and get support for the trauma. I'm bisexual and agender. I didn't expect to come out as agender to this person, but it sort of slipped out when I was explaining why I'd decided to contact LGBTQ charities instead of Women's Aid (the place I was signposted to by my last therapist). I was quite worried that I'd come out so suddenly. In the past, I had come out as agender to a therapist/nurse who then proceeded to deliberately call me a "lady" multiple times. This set off my gender dysphoria, and I didn't feel mental health services would understand me being non binary.

The person on the phone acknowledged my gender (although I'm not sure if they understood or believed me). They then asked about my daily functioning, and whether my symptoms had affected that. I told them about the nightmares, flashbacks, lack of sleep due to feeling unsafe, distressed, and having a lot on my mind. My appetite has been quite bad recently too. I've eaten, but I haven't been very interested in it. Again, everything feels pointless. I'm extremely stressed about the future too. I'm on ESA and PIP (sickness and disability benefits) and at the age of 30, I really want to move on with my life and rent a place of my own. I would have to get a job if I am to afford it though. I really do want to get a job, but I'm not sure how I would manage it physically or mentally. If I can't move on with my life though, do I want a life at all?

The person asked a few more questions then told me they would speak to one of their colleagues and get back to me with their decision at lunchtime. They called soon after lunch and told me that they want me to have a telephone appointment with a CPN (mental health nurse). We booked the appointment, then they told me that I should ring anytime if I need them urgently. I thanked them for their time and for how kind they'd been.

Since then, I've been looking forward to the appointment, in a way. It's at least a crumb of support from mental health services, and for me to be referred for assessment at least means they feel my symptoms are complex and serious enough. My previous experiences of being assessed then discharged are making me pessimistic about it though. I remember the A&E Psychiatry Liaison Team trying to explain to me why I never seemed to be taken on by CMHT. They described me as a "square peg" and CMHT as a "round hole". I didn't fully understand why that was the case though.

What makes me so different as to not being right for CMHT? I have a history of self harm and suicidal thoughts (plans even, sometimes). I've suffered multiple trauma. I have experienced hypomania on rare occasions. Very very rarely I have had visual hallucinations (usually after an antidepressant overdose). I do not have psychosis, so I understand why I wouldn't fit the criteria for some of the CMHT pathways, but there's at least one pathway that I think I do fit the description for.

The one pathway that seems to fit me is the one called the "Community Intervention Pathway". It says it "provides assessment and evidence based time limited interventions for people who have complex mental health difficulties that are significantly impacting on daily life. This would include mood disorders, anxiety disorders, trauma related conditions, and other severe emotional difficulties"

I have Depression, Generalised Anxiety Disorder, Obsessive Compulsive Disorder, Borderline Personality Disorder, and Post Traumatic Stress Disorder. These fit into various categories mentioned above and at least some of these affect my daily life significantly. I socialise rarely (especially since Covid of course), I am currently unable to work (although I want to try), my sleep and appetite are affected. I think some of my relationships with others have been affected too. I've certainly lost some friends anyway. Sometimes I freeze and dissociate, which can affect me for hours; as I'll be staring at whatever is in front of me. I'll be sort of "stuck", unable to take in conversation, or focus on anything else. When I'm very depressed or anxious, I cannot process anything that isn't to do with whatever is making me anxious or how I'm feeling when depressed.

I think my problems are complex and severe enough for intervention from Community Mental Health Team, and I know I need psychiatric input in order to sort out my medication. Past experience is making me worry that I will simply be discharged with no support whatsoever. People are telling me to be positive and "cross that bridge when I come to it". I don't want to get my hopes up though.

Resources

Amy's Mystery Illness blog: I'm a Survivor -  https://www.amysmysteryillness.co.uk/2018/07/im-survivor.html

Symptoms of PTSD: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/symptoms-of-ptsd/#:~:text=A%20flashback%20is%20a%20vivid,events%20from%20start%20to%20finish.

Rethink: What is a Community Mental Health Team? https://www.rethink.org/advice-and-information/living-with-mental-illness/treatment-and-support/community-mental-health-team-cmht/

Amy's Mystery Illness blog: A Mental Health Nightmare - https://www.amysmysteryillness.co.uk/2019/08/a-mental-health-nightmare.html

Amy's Mystery Illness blog: Am I Triggered? - https://www.amysmysteryillness.co.uk/2014/03/am-i-triggered.html

Mind Charity: About hypomania and mania - https://www.mind.org.uk/information-support/types-of-mental-health-problems/hypomania-and-mania/about-hypomania-and-mania/#:~:text=What%20are%20hypomania%20and%20mania,period%20(usually%20a%20few%20days)

Mind Charity: About Psychosis - https://www.mind.org.uk/information-support/types-of-mental-health-problems/psychosis/about-psychosis/

Mental Health Community Services: https://www.mpft.nhs.uk/services/mental-health-community-services

Dissociative Disorders: https://www.nhs.uk/conditions/dissociative-disorders/#:~:text=Dissociation%20is%20a%20way%20the,longer%20(weeks%20or%20months).











Sunday, 24 May 2020

Trauma Focused CBT: Session Twelve

(TRIGGER WARNING: Details of early medical abortion, and mention of domestic abuse)

This was my last session with my therapist. I felt that I had come a long way, and although I still have the Post Traumatic Stress Disorder diagnosis, my symptoms are much less severe and persistent, at least in relation to my traumatic abortion.

This session was just to check in on me really, and see how I'd been getting on. I had managed to do more tasks for facing my feared situations, and I was continuing journalling in order to monitor my moods.

One particular thing I needed to do was contact BPAS to voice my concerns about my abortion and ask their advice, or for reassurance at least. When having an early medical abortion, the process was that you would take an oral pill in clinic on your first visit, then a number (I thought 6 at the time) of vaginal pills in clinic on the second visit; in order to complete the abortion.

When looking at early medical abortion advice on the BPAS website, it said to take 4 vaginal pills in clinic, and then 2 a few hours later. I thought I'd taken all 6 at the time, so worried that there may have been complications, which then led to me worrying about potential fertility problems.

I emailed BPAS to tell them about my concerns, and a couple of days later I received a call. When I spoke to one of the BPAS managers, she put my mind at rest. She said that, as my abortion was 11 years ago, the process was slightly different. I would've only been given 4 vaginal pills back then, whereas now it is 4 to take at first, then 2 later on. She also told me that she had spoken to their medical director. She asked me a few questions about how I felt physically when having the abortion. I told her about the excruciating pain, and huge amount of blood at first. She asked if it lessened over the days and weeks I was recovering, and it had. She told me this was to be expected of a medical abortion without complications. As I had normal, regular periods nowadays too, fertility shouldn't be a problem.

We had a long chat, which was difficult and triggering in some parts but overall, I was actually glad to get it all off my chest and speak to someone in the know. She was so apologetic about the way the nurses had treated me, and assured me that training is much more stringent nowadays. Although there are very rare instances of nurses being less than kind, they are dealt with through further training and disciplinary action if needs be.

I felt surprisingly light and relieved after the conversation! It felt as if I'd had closure finally, and although my worries were not completely gone, I felt I had made massive progress and was able to cope with my PTSD over this (for the most part).

In the future, I would love to be a psychotherapist or a clinical psychologist. I would also like to help counsel people who have been through similar situations as me. I feel like I am almost ready to do that!

Back to therapy, I told my therapist about the phone call and my feelings during and after. She was so pleased to hear about the progress I had made! She asked if I felt I needed any more sessions regarding this, but I said I felt I could cope with my feelings etc about this on my own now, and had learnt enough skills for dealing with setbacks.

The next thing we spoke briefly about was the abusive relationship I'd been in. As it had happened at such a sensitive time for me (straight after the abortion in fact) it had become a double trauma, which needed dealing with. She reminded me that we had spoken last session about me contacting Women's Aid to see if they could help with counselling etc. I said I would leave it a month or two, as I felt I needed a break from therapy first. It's also the case that they are inundated with calls from domestic abuse survivors right now, who are in terrible situations (partly due to lockdown) that they need help to escape from. I do not want to take up the line with my feelings about something I am not in danger from anymore. I want to at least give a bit of time before ringing them.

My therapist recently sent me a form to fill in for my own resources, so I know what to do, who to contact etc should I have setbacks. This is very helpful because I often feel lost when in crisis, and need clear instructions.

Right now, I am doing ok though. I still have dreams and flashbacks, but I am able to distract myself most of the time. I'm trying to plan my days too, so I eat a bit better, exercise within my physical limits, and talk to friends too.

When/if I manage to get any counselling sessions with Women's Aid, I will blog about them.

Resources

NHS website: Post Traumatic Stress Disorder: https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/

Amys Mystery Illness- Am I Triggered?: https://www.amysmysteryillness.co.uk/2014/03/am-i-triggered.html

British Pregnancy Advisory Service: https://www.bpas.org/

Medical Abortion Up to 10 Weeks: https://www.bpas.org/abortion-care/abortion-treatments/the-abortion-pill/abortion-pill-up-to-10-weeks/

Amys Mystery Illness: I'm a Survivor: https://www.amysmysteryillness.co.uk/2018/07/im-survivor.html

Amys Mystery Illness- Trauma Focused CBT: Session Eleven: https://www.amysmysteryillness.co.uk/2020/04/trauma-focused-cbt-session-eleven.html

Women's Aid: https://www.womensaid.org.uk/

Saturday, 11 April 2020

Trauma Focused CBT: Session Eleven

(TRIGGER WARNING: Description of medical abortion, pregnancy, and sexual domestic abuse)

Although my moods (mainly due to Coronavirus) have been fairly bad, my moods overall (and specific to my abortion trauma) have improved. I thought this session might be my last one.

I was very overwhelmed on the day of this phone CBT session, as I'd been catching up on my homework. The things I needed to do for this session were to watch a programme about abortion, and to look up information about the process of medical abortion.

The week before this session, I'd seen a news piece about the change in abortion laws in Northern Ireland. From what I remember, it'd been legalised but the problem was that there was a distinct lack of services that actually offered abortion treatment. A woman in the piece had to travel to England for her surgical abortion and if I remember correctly, she'd been under anaesthetic but rules meant she had to travel back home that evening. It sounded extremely distressing. I thought I'd dissociate straight away or I'd avoid the news item altogether, but I found myself fixated on it. I did dissociate afterwards, after getting quite upset. It did stay with me for the rest of that day, even when I'd grounded myself. Even though this was pretty bad though, it wasn't as bad a reaction as I expected.

The day of the session, I'd been on the BPAS (British Pregnancy Advisory Service) website, looking through the process of medical abortion specifically (When I was 19, I had a medical abortion at 5 weeks pregnant). I did find it very upsetting and particularly triggering when looking up the physical effects of termination. It was very descriptive and brought on flashbacks of my trauma.

My scores on the PHQ-9 , GAD-7 , phobias and lifestyle effects questionnaires were a little better than the previous fortnight, so my therapist was pleased about that. I did tell her that I felt I reacted less extremely to topics of abortion too, although I still got triggered by descriptions of the physical effects. She asked if there was anything else I needed to talk about or ask that day. I explained about what happens when having a medical abortion. The first visit for the treatment itself, you take one oral pill. The second visit, you are given 6 vaginal pills to take. According to the BPAS website, you are only supposed to take 4 though (I said I think the spare 2 were for if any fell out). When I went though, I got confused and took all 6. Because of this, I was now worried that I may have caused complications and maybe that was why I was so ill/in horrendous pain so soon after treatment and for so long.

I got a bit worked up, when talking about the physical side of things. I also blamed myself a lot for doing things incorrectly. My therapist said I don't need to be so harsh on myself though. On the second day of the abortion, I had a lot of information to take in, and it was no wonder that I couldn't remember everything. It was a really distressing time for me throughout. The nurses should've been more compassionate and clearer with their instructions.

My therapist asked if there was a number I could contact BPAS from, in order to ask about what happens if I take all 6 pills instead of just the 4. Of course she couldn't give me medical advice, but maybe someone from BPAS could tell me, or signpost me to an organisation that could advise. I told her I wasn't sure if 11 years post abortion was too late to ring them, but we decided it would be worth ringing. Even if they couldn't offer me support, they most likely could signpost me to somewhere that could. 

After this discussion, my therapist asked about the abusive relationship I'd been in, after my abortion. She wanted to know whether I felt I needed help with that too. I said I reacted to storylines, information etc about it in the same way as I used to, about the abortion, so yes I did need help. I explained how the sexual abuse affected me the most, and I found that I would feel like I needed to scrub myself "clean" when thinking back to it. I reminded her that she'd told me to contact Women's Aid for support. I told her that I'd be calling them in about a month, as I felt I needed at least that much time for a break from therapy. I felt I'd be overwhelmed if I went from one form of therapy, straight to another, especially when discussing such traumatic things. She agreed that this would be a sensible idea, and that I needed time to process things, carry on with practising the skills I'd learnt etc.

At the end of this session, we booked me in for another phone session. As I had improved so much and I felt that I'd had enough therapy recently, I asked whether this could be the last or penultimate one. I explained I felt I am starting to depend less on therapy for this particular trauma, and I have improved enough to cope with the homework on my own. The therapist was fine with this, and was pleased that I felt this way.

I feel really pleased too. Not just because of improving so much, but because of how helpful and supportive my therapist has been. She has been encouraging, empowering, and has never rushed me. We have focused on my strengths as well as my struggles, and any homework etc has been discussed between us (mainly led by me to be honest) instead of her pushing me to do things I don't feel ready for. I would recommend this therapist to anyone struggling with trauma.

My homework for next session is to call BPAS and ask about the pills. At least then I won't be dwelling too much on the mistake I made in how many pills I took. It could be that it wouldn't cause any complications, but even if there was a risk, at least I'd know.


UPDATE: After reading the advice on the BPAS website again (probably with a clearer head too!) it recommends taking 4 of the 6 pills straight away, then the remaining 2 a few hours afterwards. I still don't know if taking 6 all at once would cause problems, but I will update this blog post again once I have contacted BPAS.



Resources

British Pregnancy Advisory Service: https://www.bpas.org/

Depression Test PHQ-9: https://patient.info/doctor/patient-health-questionnaire-phq-9

Generalised Anxiety Disorder Assessment: https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7

Medical Abortion Up to 10 weeks: https://www.bpas.org/abortion-care/abortion-treatments/the-abortion-pill/abortion-pill-up-to-10-weeks/

Amy's Mystery Illness - I'm a Survivor: https://www.amysmysteryillness.co.uk/2018/07/im-survivor.html

Women's Aid: https://www.womensaid.org.uk/



Wednesday, 25 March 2020

Trauma Focused CBT: Session Ten

(TRIGGER WARNING: Covid-19, Mentions of abortion, trauma, domestic abuse, physical, psychological, and sexual abuse)

In the week leading up to this therapy appointment, a lot had happened in the news. Coronavirus became a pandemic, hundreds of people dying from the virus, places (like cafes, bars, cinemas etc) closing, people urged to stay at home unless needing supplies from the supermarket, and lockdown was looking very likely. It's a very worrying time for everyone, even without an anxiety disorder on top.

Amongst other things, I have Generalised Anxiety Disorder, Obsessive Compulsive Disorder, and Post Traumatic Stress Disorder. I have found these have all flared up in different ways. I worry about everything more, I'm doing my checking rituals more often, and I have these thoughts that I am unsafe and something really dangerous is about to happen to myself or my loved ones. As well as this, my flashbacks have increased.

I am coming to the end of Trauma Focused CBT for my traumatic abortion specifically. My therapist and I have come to realise that my abusive relationship with an ex brought up traumatic symptoms for me too, but this lot of therapy is nearly over so I'd have to re-refer myself or find some other therapy or counselling to help.

As for the traumatic abortion, I think my PTSD symptoms have lessened slightly (overall, I mean) but the physical pain etc from it still crops up as vivid flashbacks. I may need the odd couple of sessions to give me tools to work on my feelings about this, but I think I am coping well enough to deal with this trauma generally, and use the skills I have been taught for this.

My therapist and I did talk about the abusive relationship, and how memories of that affect me now. It was a long conversation with lots of questions about how my ex partner treated me, how I reacted, and how I feel about it now. I spoke about a few things he had said and done, that affected me badly. I know that I'm not coping well with it, I do get intrusive thoughts, flashbacks, bad dreams etc and I find it very hard to trust men who are interested in me.

This relationship started just as I'd had my abortion, and I believe I was looking for a fresh start, as well as someone to look after me and support me. (You can read more about my abusive relationship here, but I will mention a few things that he said and did.)

My ex partner was very nice and gentlemanly at first. He bought me flowers, took me to nice restaurants, said lovely things and didn't push me to do too much. This soon changed though. I thought he understood that my abortion had been very distressing for me and this is why I was so depressed and quiet. In later arguments, he would bring this up and tell me that I (and others) should've focused on how he was feeling and paid attention to him more.

I found that everything was ok, as long as I agreed with him and everything was on his terms. As soon as I didn't, or they weren't, he would be cold, callous, and cruel. He would push and push me to do things I didn't want to do. On one occasion in particular, he tricked/forced me into doing something sexual that I wasn't comfortable with. Straight after, he acted as if nothing was wrong. I was left feeling confused, violated, and as if I was overreacting.

He would use the old cliche "you'd do this if you really loved me".

As well as this, he was psychologically controlling, he gaslit me, and tried to keep me away from my friends. It was as if he wanted to control any situation we were in. It took me a while to realise that he was so toxic. I tried to break up with him at one point, and he wrote me a long letter to supposedly apologise and promise to change. I foolishly took him back and things had unfortunately not changed.

When we did finally break up, we would still argue, and at one point he followed me back to my student house to "talk". I didn't want to, but he wouldn't take no for an answer (a running theme in our relationship...). I tried to walk away from him, but he grabbed me hard. At this point, I was scared that he would hit me. I couldn't get away because his grip was too strong. It was only when my housemate walked by and saw, that he let me go and ran off. I was understandably really distressed and it took a while for me to calm down. 

I told my therapist about this (amongst other things that had occurred in our relationship) and she confirmed that my ex was very abusive and toxic. She also believed that although he made me feel vulnerable, I was actually very strong for arguing back despite my fears about the consequences.

She told me that although these sessions of CBT were for the abortion specifically, after a break I could get re-referred so we could focus on this abusive relationship. She did recommend I contacted Women's Aid though, as they are apparently very good at providing support to do with domestic abuse. I could even get some counselling from them.

After this telephone therapy session, I felt very uncomfortable, unsafe, and as if I was being violated all over again. The psychological control was personally very hard to cope with, but I seem to be most affected by the sexual abuse I experienced. I feel so uncomfortable in my own skin, as if I want to scrub it all away?

I have decided that once these therapy sessions are finished, I will take a month or two's break, then I will contact Women's Aid to see what they could offer. I guess any counselling will be done over the phone for now (because of Covid-19 restrictions).

In the meantime, I aim to use my time to distract myself with games, movies, cross stitch even. I also want to be very kind to myself and as supportive as I can be towards my friends and family.

Resources

Lockdown: https://en.wikipedia.org/wiki/Lockdown

Symptoms of PTSD- What are flashbacks?: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/symptoms-of-ptsd/#WhatAreFlashbacks

Amys Mystery Illness- I'm a Survivor: https://www.amysmysteryillness.co.uk/2018/07/im-survivor.html

11 Warning Signs of Gaslighting: https://www.psychologytoday.com/gb/blog/here-there-and-everywhere/201701/11-warning-signs-gaslighting

Women's Aid: https://www.womensaid.org.uk/