Bug report — context and analytic framework

Severity: Critical

Description: My mood suddenly crashes.

Steps to reproduce: I have absolutely no clue.
Well, that's not entirely true. Through the decades I have been looking for workarounds to this problem some patterns have emerged. It's much more likely to show up if I'm hungry. If I'm tired, or haven't slept well. If I run into frustrations. If I'm picked on, or people poke my insecurities too hard.

So those are (uncomfortable) steps to reproduce I guess?

Actual results: I break down crying, or shout at people, or tense up hard trying not to break stuff around me, or hit inanimate objects until my hand aches, or run away from wherever it is I am right now, or possibly I just go really really quiet and stop interacting with anyone or anything.

Expected results: Not crying over relatively insignificant stimuli. Having a causal path leading up to my emotional reactions. Scale my emotional reactions.

Report log:
2000: Original filing of this behavior as abnormal and requiring support attention. Susanne V
2002: Tagged bipolar mixed state, therapy and lamotrigin stabilized the system, and bug was closed. Spånga youth psychiatric team.
2011: Bug reopened. Problem has existed for many years already, time to do something about it already. Me.
2012: Accepted for work. Edinburgh psychiatry, Scotland.
2012: Dropped due to platform change. Edinburgh psychiatry.
2013: Accepted for work. Liljeholmen psychiatry, Sweden.
2013: Re-tagged mild depression with anxiety. Added SSRI. Liljeholmen psychiatry.
2013: Added Bupropion to fix the additional problems induced by the fix. Liljeholmen psychiatry.
2013: Query about ADHD from me. Response: Irrelevant — you finished school, didn't you? Liljeholmen psychiatry.
2014: Removed Liljeholmen psychiatry from the ticket. Do not assign again. Me.
2014: Accepted for work. Huddinge hospital, Sweden.
2014: Re-tagged bipolar not otherwise specified. Removed SSRI. Huddinge hospital.
2015: Added lamotrigin. Added bupropion. Ran CBT group therapy for bipolar disorder maintenance. Increased lamotrigin. Added SSRI. Removed SSRI. Increased bupropion. Huddinge hospital.
2015: Re-opened ADHD as a possible direction. Me.
2015: Ticket sent to ADHD experts for evaluation. Huddinge hospital.




I find thinking about bug reports instructive when trying to work with my own mental health.
The observed bug is not that difficult to describe: I have less control over my emotions than I should have. I cry over things, I break over things, and it is causing me problems in my daily life.

Far harder is debugging and fixing the problem. Far far harder.
This is no surprise to anyone who has ever worked on software maintenance.
It is harder than in software however — debugging the brain works on hardware nobody understands, software nobody understands, crude debugging tools (whaddayamean inspect current state? good luck with that one!), and crude ways to introduce fixes (let's flood the brain with this signal substance — and see what happens!). The thing you're trying to diagnose changes as you try to diagnose it, and many possible explanations overlap quite a lot in expression, but far less in treatment recommendations.

So for me at least, building a context is a hugely important part of a diagnostic process. Sure, medication, especially if it does Good Things. But if I can understand what the hell is going on in my brain, and re-label my mood swings into something that triggers a bit less personal guilt, that'd probably help me stabilize.



So far, the context I have had is of an affective disorder. It's emotional dysregulation, so let's label it as a disorder of emotional regulation. This means depression, or bipolar, or something similar. I've never fit very well into this box: both mixed state and not otherwise specified are diagnosis-speak for huh, that's weird...
Whacking me with affective medication has worked sometimes, for a bit, or at least changed the flavor of my problems. Sure, I don't suddenly crash out — that ever-present apathy and growing frustration with no longer having any research drive isn't a problem? right?

And if it is bipolar, it means that the way I handle my disorder is by medicating to stabilize, and then doing behavioral adaptations: when I notice my mood going in one direction, pull out concrete actions that pull it in another direction. when I notice my thoughts getting stuck on one thing or one interpretation, seek out alternative interpretations and prepare ways to dislodge myself from when I get stuck on something.
But since I don't fit the box well, these remedies have been somewhat underwhelming so far.

On the other hand, if my problems at their roots are neuropsychiatric: ADHD or autism, then there is a completely different interpretation to my reactions. Maybe I start crying not because I have an anxiety attack (some things fit, not all), not because I am in a depressed episode (a few things fit, most don't), not because I am in a dysphoric hypomania (seldom really seems to fit), but because I have sensory overload? or because I have built up massive guilt complexes from always feeling like I am performing under my full potential? or because I am Just Not Wired for handling frustration?

These last few months I have started reading up on ADHD, and I have started watching my behavior with somewhat different goggles. What are my sensory inputs right around when I crash out? was there a reason I might be exhausted when I take a nose-dive? was there some kind of frustration around? maybe even changes of plans that I wasn't expecting?




One of the big things I am seeking when I am seeking out an ADHD evaluation right now is a new set of possible treatment options.
Another one is to gain tools to push back against my self-loathing. If sensory overload is a thing for me, and inability to handle frustration gracefully, and decreased ability to handle changes in plans, then there are concrete things there I could manage. And maybe tracking my sensory load is not only easier, but going to be more effective than trying to Increase My Sensory Impressions when I am feeling sad and overwhelmed?
And maybe, recognizing that many people with ADHD have their emotional gain turned to 11 means I can stop freaking out when I suddenly get a wash of emotion. Sure, my emotions are stronger than everybody else's — but maybe I can stop at the point of feeling a strong emotion, instead of spiraling down into a panic rat race of despair over having the emotional reaction in the first place.
Maybe, just maybe, I can watch my emotions show up, let them take some place, and then let them go. That seems like an amazing thing other people apparently do.
And if I get more emotional control through tracking my sensory load, and by disengaging from uncontrolled stimuli when I'm starting to feel the tension build, rather than after I go to pieces, that'd go a faaaar way to help me work more satisfactorily.

This change of perspective changes absolutely everything.
The symptoms are the same, but the potential fixes are different.
The symptoms are the same, but if it's sensory overload, not lack of emotional control, then I'm not lazy, I'm just incautious.

Fine

This is another guest post by Dorothy Donald.

Thursday

 “I’m fine,” I say.

(Josh makes a face that says ‘I call bullshit. I’m not going to embarrass you by doing it very loudly and publicly in this coffee shop because I’m your friend, but I do.’ You’ve all seen this face, I’m sure.)

“Really, I am. I’m going to see CBT man tomorrow –”

(Eyebrow)

“But it’s just a follow-up, to see how I’m getting on. I’m fine.”

(Silent bullshit-calling face)

“It’s just… No, I am fine, it’s just I… find Christmas difficult.”

(“I know. That’s why I asked how you were.”)

Damn you, Josh, and your horrifying insight. Please don’t go away.

Friday

“I’m a lot better than I was,” I say. “But I just don’t seem to be able to concentrate at work. I’m not being very productive.”

So far, so familiar.

“And… I don’t really know how well I am. I know I’m better than before, but I also think that I’m not… that great. I don’t know if my problem with work is to do with depression, or if it’s just that I’m lazy, or that this is just how things are, or what.”

Neil suggests a little assessment inventory. The questions are familiar to me (this is not my first experience of depression inventories) and by the time we’re at the end I’ve already had a few clues that I’m maybe in the ‘cause for concern’ category.

The verdict: ‘moderate to severe’ depression. Perhaps, Neil suggests, it’s no wonder I have difficulty concentrating at work?

I’m actually rather relieved. I had somehow convinced myself that it wasn’t legitimate to hope for any further improvement. This assessment has reminded (told?) me that “Not continually preoccupied with ending own life” is a poor benchmark for adequate mental health. It is true that I am a lot better than I was, and that’s good and important. But I am not yet ‘fine’. (Sorry, Josh.)

Then we talk about some strategies for dealing with the Christmas break.

We already knew I could worry

On May 5 and 6, 1988, Graeme Hick scored 405 not out playing for Worcestershire against Somerset. This was the best score in first class cricket in England for more than 90 years. In next year's Wisden Cricketer's Almanack, the captain of Somerset - Peter Roebuck - wrote an article about this brilliant batsmanship under the title "We already knew he could bat".

I thought of this title this morning when I took the Penn State Worry Questionnaire. I scored 76 out of 80. I don't know if that is the highest score on the PSWQ in Scotland in 90 years, but it's definitely very impressive. I mean, we already knew I could worry, but ... well you can look forward to reading the full article about my incredible feat in next year's Wisden Worrier's Almanack.

Last week I visited a therapist who suggested that possibly a lot of my problems come down to worry and we should think about working on that. He also suggested a book - The Worry Cure - which might help. In the book it includes the Penn State Worry Questionnaire. It gives you 16 statements, you agree or disagree on a scale of 1 to 5 on each, and add up the scores. They are statements like 

• Many situations make me worry.

• When I am under pressure I worry a lot.

• I am always worrying about something. 

• I find it easy to dismiss worrisome thoughts.

The last one, by the way, is reversed, so if you disagree agree with this statement highly this is a 1 but you reverse it (subtract it from 6) to get 5.

The PSWQ, by the way, is a solid piece of research, not a random clickbait quiz. The paper about it has been cited more than 2500 times. The book says that nonanxious people score about 30, scores from about 52 can be associated with "some worry problems", while "really chronic worriers" score over 65.  I got 76 out of 80. We already knew I could worry.

There were two questions I only got 4 points out of 5. On one question I actually was neutral about and said 3 out of 5. That one was "When I am under pressure I worry a lot". I find that (sometimes) when I'm under pressure I just get on with it, so e.g. I do well in exams partly because I get interested in the questions and think about them, rather than worry about doing badly in the exam. I said 3 out of 5 instead of 1 out of 5 because in some kind of crises I work quite well, whereas in others I don't and collapse a bit, and because of worry. 

I can imagine a score around 50, but how on earth could somebody get a score less than 30?? I find that unimaginable. I often find myself realising that other people are not like me inside their heads. This is one of the most trite truisms you can imagine, but I definitely live my life just imagining that people think more or less the same way as me. Of course I have plentiful evidence to the contrary, and this is a particularly strong piece of evidence. 

Getting this score really threw me for half an hour or so. I mean, we already knew I could worry, but I had no idea. I found it quite upsetting. 

In 1988, Graeme Hick looked like a future superstar of cricket. He never fulfilled his promise in international cricket, and instead of being a legend is one of the most famous nearly-men in cricket history. I was going to tell you what happened to Peter Roebuck, but I don't want to now because I am worried it might upset you (please feel free to find out, having taken that trigger warning into account). These were people who could have - if they had known it in 1988 - had plenty to worry about in their future.

So having use the literary device of the apparently unconnected opening and then bringing it back, not only did I show I could use that anecdote to find a way to worry about those individuals, I also worried about what I was writing enough to change it. 

So I close with another literary trope of a constantly repeated refrain closing this piece.

We already knew I could worry. 

Christmas is Magical

This is another guest post by Dorothy Donald.

Winter festivals are magical for everyone, aren’t they? Whether you’re a cowering 10-year-old trying to make yourself as small and quiet as possible in the hope that your drunk, violent father won’t notice you; or a furious 16-year-old fighting again with your drunk, violent stepfather; or a lonely twentysomething binge-watching films alone under a blanket of depression; or an accomplished, happily single, social-butterfly thirtysomething having a lovely time with friends and not thinking about that old stuff at all because you’ve had ample time to get over it, really…

Oh yes. Christmas has always been magical for me.

How Do I Keep Finding Myself Here?

This is another guest post by Dorothy Donald.

My bad dreams have become more frequent again. My intricately detailed dream world is populated with boundlessly malicious, alarmingly inventive characters and they are usually coming for me.

The pounding in my chest as I realise what is happening; my legs filling with the electricity of terror and giving way beneath me; the weight of my body slumping forward; the pain, dull but insistent; my blood flowing warmly over my skin before dripping, red and dark, onto the floor in front of me; its metallic tang at the back of my mouth; the pounding on the door close by, too late; the curious, detached calm that comes on the far side of fear; the knowledge that I am about to die.

So yes, I wake up feeling pretty rattled.