The subtle effects of an SSRI

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One of the things that has puzzled me as my dose of Paxil has gotten lower is the way that old friends marvel at all the changes they see in me.  Even causal, but long time, acquaintances say that I seem like a completely different person.  They’re even people who I haven’t told about my Paxil tapering.  Somehow, I’ve transformed in front of their eyes over the past year.  I haven’t questioned them too closely about how I’ve changed, even though I’m very curious.  To me, I seem exactly the same.  I’ve always been “me”, haven’t I? I keep looking for specific things that I do differently, but they seem like little things.  I don’t interrupt other people’s conversations to say something that just popped into my head anymore.  I think that’s different.  Still, that seems like a small personality change, not something that people would notice immediately.

That changed a bit yesterday.  I had a difficult day at work.  I was configuring two routers in our network to talk to each other for a customer.  The interfaces weren’t built, the NNI was designed on the wrong router, I had to redistribute MPLS routes across two different sections of our edge network.  Suffice to say, it got complicated.  And, it lasted for 14 hours.  By the time I got home, I had only eaten a few candy bars in the previous 36 hours and I was dead tired.  I stuffed a couple cheese sandwiches in my mouth and went to bed.  I had to be back at work 7 hours later.

This morning, I woke up tired and grumpy.  I had a bit of a persecution complex as I showered and watched the DVR from last night.  I shuffled into work and started getting ready for the day.  A friend of mine asked if I was going slomo today.  Everyone else noticed the difference, too.  “Are you ok?” “How late did you stay last night? I left at 10 and you were still here.”

I realized that I was feeling the same way I had felt every day while I was on 40mg/day of Paxil.  I never seemed to get enough sleep, and I was always irritated.  There were long stretches where I would sleep for 12-14 hours a night, and still wake up exhausted.  Every little thing annoyed me.  I didn’t contribute at work, I just went through the motions.  The difference today was that irritated feeling faded away like it would for a normal person.  By the end of the day, I was joking and helping my next door neighbor with a config.  In my Paxil days it would have lingered all day, and I would have gone home much as I had left it, irritated and tired.

I didn’t think yesterday was a good day.  Looking back, it was pretty good.  I got the customer working eventually, and I learned something about the ways that I’ve changed since I started tapering off Paxil.  It turns out, Paxil made me feel like I was working on an intractable problem for 16 hours a day, every day.

Repetitive Thoughts in SSRI Withdrawal

It spins me round

SSRI withdrawal symptoms can range quite a bit.  There are physical symptoms, emotional symptoms, mood symptoms, and bizarre symptoms.  One of the more difficult symptoms to deal with are repetitive and recursive thoughts.  These are thoughts that keep repeating over and over again in the mind.  They can be about anything.  Sometimes, they feel like a dark mantra that won’t stop.

I talked to a person in withdrawal who repeated the same sentence for four hours.  “If only I could…”  It varied a little bit over time, but it didn’t really change for that whole conversation.  Repetitive thoughts grip your mind and won’t let go.  It’s very hard to break out of the mental cul de sac that they create.  Everything you try to replace it with inevitably leads back to the central thought.  Usually, the thought is a regret, or a memory.  It’s very common to critically review the past in withdrawal.  Somehow, the past becomes incredibly important and inescapable.  In our society, we grow up believing that the emotional and intellectual parts of the mind are separate.  “Mind over matter”, “Walk it off”, “Pick yourself up and go on”.  In reality, the intellectual and emotional parts of our minds are two sides of the same coin.  You can’t ignore one without damaging the other.

The first thing to do in combating a repetitive thought is to recognize it as one.  That seems like an obvious thing, but it’s not as clear in withdrawal.  Even irrational thoughts take on a certainty and weight that they wouldn’t normally have.  For a “normal” person, the memory of pulling a girl’s hair in kindergarten would be a passing regret.  In withdrawal, that regret becomes the centerpiece of an elaborate story about self inadequacy.  I was a terrible person for pulling her hair.  That has only grown as I have grown, and now I am the result of a lifetime’s worth of regret.  That’s the thought process in withdrawal.  It sounds remarkably like a diagnostic marker of depression, and it is.  That’s why withdrawal is often misdiagnosed as a new or existing condition.  The difference is that withdrawal is iatrogenic, caused by the drug, not a condition.

The thing that makes it hard to recognize a repetitive thought in withdrawal is that each step from the original thought feels natural.  The progression from the memory of pulling a kindergartener’s hair to a dark assessment of your adult life seems rational and correct.  We naturally filter out the more wild connections our minds are capable of making and don’t realize that something’s wrong when that check is missing.  In withdrawal, you need to make a conscious effort to moderate thought.  That’s not very easy when the thoughts are so persistent.

Breaking the cycle of repetitive thoughts is something that takes practice.  Being mindful of your thoughts is a frustrating thing at first.  It can feel like you’re just watching as things fall apart in front of you.  It’s important to keep trying to control those thoughts, though.  It starts with recognizing that a particular chain of thoughts is originating from withdrawal.  If you notice that the whole chain of thoughts keeps referring back to a single event to propel it, that is most likely withdrawal related.  It’s almost impossible to “discard” a whole chain of thought, but recognizing it can help in dealing with it.  Try to focus on something else, something with its own chain, like a story or a game.  It may not be in keeping with the societal norm of heroically overcoming a struggle to reach the happy ending, but the goal is to overcome, not to be a hero.

The Just In Time Government

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Just in time delivery is a system that improves efficiency by only producing items that are to be sold in the short term. It wasn’t really possible until the advent of faster delivery like UPS and Fed Ex. Once all the parts of the supply chain were capable of keeping up with different levels of consumer demand, JIT became more feasible. Say you run a clothing store that sells 5 shirts per day. It’s inefficient to stock 10 shirts. It’s better to stock 5 shirts, then take delivery of 5 more shirts each day. It reduces inventory and makes sales more efficient. It works for some things, but not for others. JIT works well in situations where demand can be forecast accurately. Manufacturing and delivery ramps up during holidays and ramps down during the rest of the year. You make more chocolate around Halloween than you do around the Fourth of July. You make more barbeque tools around the Fourth of July than you do around Halloween.

JIT can’t be applied to everything, though. A mall parking lot seems like an enormous waste of space in July. There are hundreds of parking spaces that go unused day after day. The mall maintains a large parking lot because they will need that capacity during holiday periods. If you go there looking to create efficiencies in July, you might be tempted to cut the number of parking spaces. That would be short sighted, because you would be woefully under capacity in December.

Recently, there has been a trend to try to apply private sector efficiencies to government programs. Like JIT itself, it works better in some situations than it does in others. Achieving efficiencies in supply can be good when demand for services and products can be forecast. Just like the mall parking lot, looking for efficiencies in situations that don’t lend themselves to easy prediction can cause problems. A good example is regulatory agencies. When businesses are working well, there doesn’t seem to be a need to regulate or inspect them. Why use government resources to confirm that there are no problems? The difficulty is the same one that happens when you look at the mall parking lot in the summer. Even though it seems like a waste, the excess capacity becomes necessary at some point. People seeking to improve government efficiency looked at the regulatory situation in the Texas fertilizer industry and thought that reducing the inspection capacity was a prudent solution. This led to fewer inspectors and made it possible for unsafe, insecure, situations like the West Fertilizer manufacturing plant to continue until there was an accident.  The West fertilizer Plant had not been inspected by OSHA for almost 30 years.

For a business, the sudden popularity of a new shirt fashion means that demand exceeds the production and delivery chain, leading to lost revenue. Governments exist, in large part, to deal with unforeseen circumstances. That reduces the instances where Just In Time efficiencies can be applied.  Politicians see a surplus and do not see it as an opportunity to bank against a future need.  Instead, they see it as an opportunity to further trim government, to make it more “efficient”.   That doesn’t mean that we need unlimited government, but we do need to empower government to do its regulatory duty.  Government is the way that we collectively face the unknown and unforeseeable.  We need to have a government that is capable of responding to new events and circumstances.   Letting government grow too large can lead to intrusive and unnecessary regulation.  Letting government wither away by trimming it in the name of “efficiency” isn’t the answer, either.  Creating the right balance of capabilities and efficiencies is more complicated than a soundbite or slogan.  Saying that all government is bad is no better than saying that government can solve all problems.

Inside the SSRI bunker

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SSRI withdrawal is a notoriously variable thing. For most people, the symptoms vary from day to day, even hour to hour. This variability makes planning a day in withdrawal very difficult and leads to a general fear of the future and an inability to plan ahead because of anxiety about which “me” will show up tomorrow. Withdrawal also breeds a profound desire to withdraw from life and other people. It’s sometimes hard to deal with your own internal state, let alone social interactions.

It’s still important to try to push the boundaries of personal comfort during withdrawal. One of the strange aspects of withdrawal is that it’s very hard to tell when symptoms are improving. Often, the best way to gauge progress is during a social interaction. You may notice that today’s trip to the market didn’t produce as much stress as last week. Even though your internal state may feel the same, having a successful trip outside can show you subtle signs of progress. Getting out can also be a way to “make” progress happen. Powering through an encounter can provide confidence going forward.

Withdrawal is not just an emotional or intellectual problem, though. It’s also an imbalance of neurotransmitters. After having Serotonin levels managed artificially by the SSRI, it takes a while for the brain to find a new balance. serotonin is intimately involved in our emotional state. As much as we would like to believe that we can control our emotional state, our minds are much more complex than that. The mind has intellectual and instinctual elements. It’s important to heal both aspects during withdrawal. Just as you wouldn’t “walk off” a broken leg, you can’t push through some of the symptoms of withdrawal. The broken bone analogy is apt when discussing withdrawal. When recovering from a broken bone, it’s important to exercise to speed healing, but over doing it can actually set back recovery. The same applies to SSRI withdrawal. Pushing the emotional boundaries of withdrawal can speed healing and make for a stronger internal mental state. Likewise, pushing through social interactions that produce a lot of fear or stress can set back recovery.

It’s important to manage stress during withdrawal. It’s hard to apply general principles to it because each person’s tolerance to stress is different. An individual’s stress tolerance can change over time, too. Since withdrawal follows a chaotic pattern, it’s hard to manage. The only way to manage stress is to take it day by day, even interaction by interaction. You may reach your stress limit after one trip to the market. Tomorrow, though, you may be able to go to a movie theatre. Try to be flexible and only retreat when you feel you need to. Don’t hesitate to retreat a bit if you become overwhelmed, but also don’t hesitate to jump out there again.

Emotional Biases in SSRI Withdrawal

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If you flip a coin 4 times, and the first three come up heads, there is a built in human bias to assume that the next flip will be tails. Even though the coin has no memory of previous throws, the human mind still assigns a bias to the series as a whole. Similarly, withdrawal symptoms create their own momentum. The timeline of withdrawal is much longer than a short series of coin flips, but the principle can still apply.

For many people, withdrawal occurs in windows and waves. It oscillates between times when symptoms are lighter and times when they are more severe. Since the mind always seeks to find or create patterns in what it experiences, it’s natural to try to anticipate the next cycle, and predict what it will be like. This can be good and bad. In the middle of a wave, it gives the mind something to look forward to. Instead of being mired in a wave, the mind can anticipate the symptoms improving. Likewise, a window can be seen as an opportunity to consolidate gains and take stock of overall progress towards recovery.

The relief that you get from lighter symptoms can be squandered by anticipating the next wave, though. In many ways, it’s a one sided bias. There is fear of slipping into a wave during windows, but no anticipation of a new window during a wave. There is an emotional weight associated with each stage.  It’s like our perception of a coin flip instead of the actual binary nature of the flip. While you’re in a wave, that negative feeling gains a sense of permanence that it shouldn’t. Even though waves inevitably give way to windows, except in the case of a chronic conditions (withdrawal is usually episodic, not chronic), there’s no anticipation, just suffering in the moment. That fear persists into the next window, coloring our interpretation of the window. Instead of recognizing it as an improvement, it’s seen as a brief respite or interlude before the next wave.

One of the big mental tasks in making progress during withdrawal is to separate waves and windows. Instead of viewing them as two sides of the same coin, inevitable partners, they should be viewed in the larger context of recovery. The window/wave pattern is a sign that the brain is recovering. Once the symptoms begin to break up, the waves should get shorter/milder and the windows should get longer/better. Waves and windows should also be viewed in isolation from each other, like a coin flip. Feeling better is not the cause of the next wave, just as feeling bad is not the cause of the next window. Those cycles are signs of deeper restructuring taking place in the brain. There are things that you can do to mitigate waves and extend windows. Mindfulness can help.  Being aware of the cycle between waves and windows can mitigate the bad, and extend the good.  It’s important not to obsess about your emotional state, but be cognizant of the ebb and flow of emotions.  At the same time, waves and windows need to be dealt with individually.  You can’t always be looking forward to the next change. At first glance, a window seems like an easy thing to deal with.  You’re feeling better! Normal!  What’s to do?  Actually, windows are opportunities to take stock.

Windows

Windows represent your progress towards normalcy during withdrawal.  It’s very hard to compare your mid window state with “normal”, though.  We all live in a relative mental state.  It’s very hard to step outside yourself and compare the way you are now with the way you’ll be after recovery.  It is possible to perceive changes from one window to another, though.  Keeping a journal can help quantify your well being during a window.  It’s human nature to avoid dwelling on negative emotions when we’re feeling good, so it takes a bit of discipline to go back to your journal during a window.  Many people post on withdrawal sites until they start to feel better, then only come back when they experience a wave.  Just like a course of antibiotics, it’s important to keep the mindfulness momentum going during a window, even if you feel better.

Waves

Dealing with waves is a defensive thing.  Being mindful that the symptoms of a wave are not a normal part of your mental makeup is a good strategy.  In normal thought, we only consciously perceive a small portion of what happens in the depths of our minds.  Our cultural and mental makeup parses most thoughts, and they don’t become conscious thoughts.  Anger, fear, anxiety, even psychosis, are all parts of everyday thought.  We only see the small part that our conscious mind actively thinks about, though.  Psychotic, angry, and fearful thoughts are normally not part of our daily interactions, so we don’t give them much “processor time” in our active minds.  We present the side of our minds that we want to the outside world.  In a wave, the normal checks and balances are suppressed.  Instead of automatically suppressing thoughts we don’t want, the mind presents everything all at once.  It’s important to actively take over the parsing role until that automatic system has a chance to re establish itself.

So, in a strange way, waves and windows should be seen in the larger context of overall recovery and also viewed as binary things (heads or tails).  It’s not easy to take the long view of withdrawal while still dealing with each individually.  One of the symptoms of withdrawal that makes it particularly hard is the suppression of cognition.  We simply don’t think as quickly or deeply as we normally would.  It creates a vulnerability to the symptoms that makes the waves more powerful and the windows less satisfying.  Even if you fail to have much of an effect on the cycles in the beginning, that effort will pay dividends over time.  It’s hard to keep trying through multiple “failures”, but you’re building a mental reserve that will eventually have an effect on the whole process of recovery.

Lollypop Favorites 2013-2-17

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I tried something new while taking my photos at Lollypop Farm today.  Instead of printing out the report of cats/small animals that need pictures, I ran the report on my iPad and exported it to a PDF.  Then, I used a neat PDF markup app that I found to write down the picture numbers on the iPad.  It worked pretty well, and I’m now paperless.  I volunteer at the shelter taking pictures for their adoption website.

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This little guy was my favorite this week.  “Bootsy” was meowing the minute I walked into cat adoption.  I think he would wind up being a little more aloof once he gets a home, but he was super friendly in the adoption area.  We played for a few minutes before he went out for an adoption interview.  I didn’t have to take a picture of him for the adoption website, but I decided to take a couple since I was playing with him.

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James S Heaney 1926-2013

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James S Heaney, 1926-2013

Main Line Times Obituary

My father passed away last week.  I loved my dad a great deal.  As I look back on his life, I think he is one of the luckiest people I’ve known.  Not lucky in the sense that he was given everything he wanted, but lucky in the sense that he took the unfinished opportunities that life gives us and made the most of them.

He grew up during the depression, but was insulated from the worst of it because his father had a good job at a food market.  He spent one year at the Wharton school before volunteering for the Army Air Corp in 1944.  He was part of the contingency force for the invasion of Japan.  He gained the rank of Corporal as a crew chief for a Consolidated B-24J Liberator bomber.  He was one of the people who was saved an uncertain fate in Japan by the Atomic bomb.

After World War 2, he went back to the Wharton School.  He loved rowing, and was part of the University of Pennsylvania rowing team.  After graduating, he continued rowing for the Vesper Boat Club.  As national champions, Vesper was chosen to represent the US in the 1952 Olympics.  He also rowed in the Pan American Games in 1955.  He stayed active with Vesper long after his active rowing days were over.  He was a stock broker for over 40 years.  He loved being a stock broker, and didn’t retire until 2006.  He entered the field during the golden age of managed investing, and retired before the industry underwent the fundamental changes of online trading.

Dad coached me in soccer when I was little.  He was a demanding, supportive coach.  He didn’t want to show favoritism towards me, but I think he truly did think that I was the best goalie on the team without parental bias.  He would have told me if he didn’t think that way, but he would still have rotated me in because I was his son.  We did pretty well under his leadership.  Our club had by far the finest soccer field in the league.  We played on a field that was used for grass tennis courts during the summer.  It was magnificent to play soccer on such a finely manicured field.  It was also the only field in the league were the players were required to replace their divets after the game.  Dad also played squash and tennis every week.  He stopped playing most sports a few years ago.  His knees bothered him and his mobility was reduced.  He still enjoyed talking about strategy and the nuances of the games, though.

In recent years, he often said that this was the happiest time of his life.  He seemed to get happier as time went on.  How many of us can truly say that?  I certainly grew happier with our relationship as time went on, and I will be sadder for the loss of it.

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