Friday, September 30, 2011

Depression, ADD and Boundaries: A personal interlude...

Well, since I've told readers in a previous post about my health issues, I guess I should update all that...

The UC has settled down quite nicely, and though I have occasionally had mild flareups, they haven't been serious or long lasting, so officially I'm in remission.  Now the depression symptoms are another matter:

I originally talked to my doctor about my troubles late in 2009.  He suggested a course of a mild ssri antidepressant called cipralex.  Since I was in the process of weaning off prednisone at the time, I was in rather desperate need of something to mediate mood swings (and anyone who's known me for a while knows I'm not exactly a passive person...  When I go nuts, I go really nuts...).  So to keep from continually frightening my girlfriend, I agreed.  It actually worked quite well to level me out, and even if I was still quite lethargic and apathetic, at least I wasn't overreacting to minor anxieties...

I can't remember exactly when, but I think it was February of 2010 (By then I was completely off prednisone and moved on to a full dosage of azathioprine.), that I returned to my doctor to see if we could find a way to get my energy level back up.  We both agreed that adrenal insufficiency was a likely culprit, exacerbating the native side effects of both the azathioprine and the cipralex.  I started a course of wellbutrin in an attempt to give my a bit of an energy boost and get my productivity on the road back to pre-turning-40 levels.

Clinical depression is something that is still a bit of a taboo subject of conversation between friends and family etc.  There's a cultural tendency to try and hide any signs of mental illness.  After all, who wants to be pitied or thought of as crazy?  It really wasn't until I read a Scientific American Mind article about the differences between the symptoms experienced by men and women that I truly started to go along with the diagnosis. Apparently anger and restless agitation are primary symptoms for men. And I have to admit, I've been avoiding dealing with those signs since my late teens.

Martial arts training has been a great help, but I've had periods when I haven't trained, and the anger always comes back.  Something that's frustrated me about understanding where it comes from is that I don't have any real abuse in my background.  I was bullied somewhat, but that's normal in school.  Smart un-athletic kids get picked on (Though once I started judo, they only did it from a distance for some reason!).  I think it's a rule somewhere.  And we always have the last laugh, as we go on to bigger and better things after high school and our bullies languish in white trash hell (mwaaah haaa haaa!).  So increasing anger as I age doesn't make sense.  It should have declined rapidly after graduating, but didn't (I'm recalling a particular instance when, after finishing a kitchen shift, I was having a drink or two with friends and became so animated in the conversation I was having that my co-workers nervously approached to tell me to stop pounding on the table as customers were leaving in fright.  I had no idea what they were talking about!).

Becoming a massage therapist has also helped.  The act of treatment has a tremendously calming effect.  It's hard to stay angry and agitated while helping someone else relax.  And the process of becoming a therapist had it's own lessons in self-observation.  I don't think I know anyone who's managed to complete their massage training without facing some unpleasant truths about themselves.  "Fixing" that unpleasantness is another path however, and even after I've moved forward with this one, I know I'll be dealing with another.

Not long after starting the wellbutrin, I decided it was time to talk to someone and see if I might benefit from talk therapy.  I researched some of the options in the building I practice from, and booked an appointment with Dr. Angela Corradini.  We had a great session, and her recommendation was that I seemed to be on the right track, and that I didn't really seem to need extensive therapy, though I could come in once a month if I chose (Reduced productivity has made that difficult, but it's on my list as I get my affairs caught up).

One of the difficulties of pharmacological treatment for depression is that it's mostly trial and error.  Try.  Wait.  Assess.  Adjust.  So it takes time and patience.  By the end of 2010, I was frustrated with my lack of progress and returned to my doctor.  We discussed increasing the dosage of wellbutrin, but didn't act on it.  It wasn't until the spring that we finally did increase.

The limits of exploratory treatment had been reached however, and over the summer, I became even more lethargic and apathetic.  My extremely patient and understanding girlfriend was reaching her limit.  I started to think that perhaps the depression is a symptom rather than a cause.

My mother tells the story of my toddler years as somewhat trying.  We lived in a two story duplex in Montreal.  The landlords and neighbours were an older German couple who routinely complained about the amount of noise I would make charging about the apartment.  In their opinion, I should be tied down and drugged until I grew out of this unpleasant stage (It sounds like a joke, but no.  They were quite serious).  My parents (thankfully) refused, and while they certainly didn't encourage my energetic behavior, they recognised that trying to "beat it out of me" wasn't likely to help.

When I started school, teachers were frustrated with my apparent inattentiveness, but had difficulty punishing me for it as I was more often than not still able to answer their question about the current lesson.  I don't know the exact circumstances, but I was labelled "superactive" (I can't find anything about the term, but suspect it was on the Connors Scale rating back in the 1970's.  This diagnostic tool seems to be really well protected and I can't find out much about it's previous versions other than that it has been revised over time.  Please let me know if you know anything!).  As far as I can tell, we now refer to the same symptoms as ADD (attention deficit disorder, as opposed to ADHD, attention deficit hyperactive disorder).  The recommendation was that my parents put me on ritalin.  They refused (Quite wisely, I think.  I can't help but hypothesise that mediated chemical changes to a developing brain would cause more harm than good.  In an adult brain, at least the basic developmental structure is there, so treatment with pharmaceuticals that alter brain chemistry might have less permanent effect.  This is very lateral thinking, but I've noticed that tribal societies don't let their young men use psychotropic plants until they're considered to have reached adulthood.  Perhaps they knew that these plants might damage a person whose brain that was still partially undeveloped.  It might also help explain how some young men failed their manhood ritual:  If their brain developed slower than their peers, they might suffer sever neurological injury from the chemicals in the plants.  Don't quote me on this though!  It really is just interesting conjecture.), and eventually I developed my own coping skills.  Unfortunately I was a little too smart for my own good and while I finished high school with good grades, I never really developed  proper study habits.

While in the Biological Sciences program at the University of Guelph, my over-active brain became a liability.  I think I only survived the first two years by tutoring people in the more difficult classes, as I rarely did any work of my own.  I gather that things have changed a fair bit, but twenty plus years ago, one could only go so far by just being smart.  At some point, students were expected to learn on their own and if they didn't, they failed.  And I hit that wall in my third year.  I was disbarred at the same time as I officially dropped out.  I was frustrated, angry, disillusioned and (I can admit this now...) scared.  Certainly, I was extremely depressed.  And being the stubborn young man  I was, I dealt with it by ignoring the problem entirely.  I've surfed the ups and downs of mood and behaviour in a similar way ever since.

The concept of adult ADD is relatively new, and poorly understood (In my estimation anyway.), though that's gradually changing.  I was reading the linked criteria on Wikipedia, and decided that it was time to change tracks.  My doctor agreed, and as I write this, I've just begun my  first week on a full dosage of concerta.  It seems to be helping, though it's too soon to tell if that's just a psychosomatic expectation, or actual pharmacological effect.  I've mentioned The Brain That Changes Itself and the study of neuroplasticity in a previous post.  My eventual plan is to take advantage of that plastic growth potential and engage in cognitive therapy to train my brain to do some of the things it doesn't want to do (I.e.  Anything I don't take pleasure in.).  It will have to wait until my affairs are in order, but that's why I'm taking medication instead of just going right to it.

That brings us up to date!  I'll certainly be blogging about this path as it continues.

A thought that keeps nagging me as I've been writing has been whether sharing this kind of personal health history is a good idea for a health professional (This post has already gotten quite a bit more in depth than I'd intended, so why not just go all the way!).  I'm in two minds.  One is that it's a blurring of the professional boundaries any health professional works hard to maintain, and the other is that hearing my own troubles helps patients open up about theirs.

Clear boundaries are necessary for any health professional in order to protect the safety of both patient and practitioner.  When boundaries blur, we can fall into the trap of transference and counter-transferance.  For professionals engaging in psychological treatment (psychiatrists, psychotherapists, and psychologists), this is an essential tool for aiding in the growth of the patient, but for the rest of us (Massage therapists are particularly prone to its dangers due to the intimacy of our treatment process.  We also lack the depth of training in psychology to use it as a tool.  I know many RMT's won't agree with me, but I'm not a supporter of somatoemotional release as a treatment modality.  In general, I feel we just don't have the training.  When I feel there is a likelihood of a deep emotional release, I try to suggest to the patient that I am there to witness and be there for them, but that they should find someone to talk to with the appropriate training.), it's something to watch for and stay clear of.  From this perspective, talking about my own problems, even if the patient has asked about them, can be seen as a breach of those boundaries.

The alternate argument comes from the experience of having patients leave off important sections of their health history.  Due to the social stigma around mental illness (I'm including mood disorders and learning disabilities in the rather broad category), many patients are ashamed to disclose psychological diagnoses.  When they learn that I've been struggling with depression, anger management and ADD, patients will often open up about their own struggles, and find that they can more fully relax in my treatment environment.  I've also found that they are more likely to be honest about their reasons for last minute cancellations if they aren't afraid to admit to having a bad day and are feeling too fragile to leave their homes.  Sometimes they'll keep an appointment because they can tell me that they're feeling bad. The challenge with this tactic is to gauge whether there is any need to expand the therapeutic relationship in this way.  For lack of any external guideline, I've been going on intuition.

Hopefully some of you reading this will have some input, as this is a challenging topic.  I don't feel it's a simple as "No.  This is not in our standards of practice."  Principle II of our Code of Ethics is "Providing sensitive, compassionate and empathetic quality massage therapy.".  As I'm attempting to increase empathy with the patient, my disclosures seem to fit.  Please feel free to comment!  Hopefully we can expand this discussion in future posts.

Footnote:
Many of you will note my reliance on links to Wikipedia in my posts, and particularly this entry.  It's my intention to provide links to expanded information with cluttering my writing unnecessarily.  I've heard some criticism of Wikipedia as a reliable research/information source, but I find that unless the topic is controversial or un-researched, it seems to be as accurate as possible for a general reference source.   Even the post on its reliability is well referenced.  I did try to find a better review of research.  Anything I found is both referenced in their article, and too technical for most people to appreciate.  If any of these posts are sought after for more professional publication, I'll make a more critical approach to my references.  Until then, I'll keep using Wikipedia as a convenient and approachable reference resource.


Sunday, September 25, 2011

Blog the Tenth: Thoughts on exercise.

Exercise is confusing for a lot of people.  The vast majority of people seem to have the impression that if you aren't collapsed on the floor following a session, you haven't exercised and it isn't worth doing.  The way I see it, the level of activity any given person should be doing should be relative to what they are trying to achieve.  Basically there are three main categories of exercise that I talk to my patients about:  Rehabilitative, lifestyle and performance.  

Rehabilitative Exercise:

This category of exercise is about recovery from injury and dysfunction. Most people are familiar with physiotherapy, whose practitioners specialize in helping their patients engage in rehabilitative exercise following injury. While injury specific exercise is certainly important during the acute phase of an injury, I personally believe that a good long term strategy is to incorporate rehabilitation into day to day life. 

For athletes, this is relatively simple.  Some of the necessary mental changes include: 

-A shift of focus from competition, or performance to a concentration on improving biomechanics.  Form is everything.  And most sports injuries can be traced back to a problem with HOW a sport is performed, not the sport itself.  And of course, athletes often get their worst injuries off the field (I once put my back out quite badly not from the personal best deadlift set I'd performed an hour before, but from hopping carelessly over a puddle on my way home!).  Even so, an athlete can go back to their sport to find their way back to health.  Most sports after all, can be traced back to life activities somewhere in our past and as such can be modified to help with injury recovery.

-Learning not to "finish". In this context, I'm referring to that moment of explosive force than tends to complete (or begin) an athletic action.  Some might also call this "english" or "juice".  In Hapkido, we refer to it as that moment of intense muscular contraction that focuses the kinetic force of our attack into our opponent.  An injured body will NOT benefit from finish, so it should be avoided.  Loose and easy are the rehabilitative focus. 

-Range of motion is key.  Short movements should be avoided.  The best moves to practice when injured should be long and loose.  Some sports don't have "short" movements (running, weightlifting, tennis, volleyball, etc...) in their ideal forms.  Some sports do compromise full range of motion to achieve particular goals.  Grappling sports come to mind as a particularly good example.  Grapplers tend to be tangled up with each other and in the battle for leverage often have to struggle from a restricted or unbalanced position.  While this is an accepted part of the sport, injured grapplers should avoid straining for positional change and simply tap out and start again.

-Drop the attitude.  Everyone wants to win, but the injured athlete has to put that aside in favour of their own long term participation in their sport.  There is a concept I came across in Chinese internal martial arts that translates as "investing in loss".  While it's often thought of as a route to mastery, it can also be applied in a more short term manner as a route to recovery.  Don't be afraid to give ground.  Injured athletes who can't put aside their egos tend to stay injured.  And if you can put it aside and accept your losses, you just might find you learn something new and expand your skills even while limited in the scope and intensity of your activity.



For non-athletes the task of rehabilitation can be even more daunting.  Non-athletes are often non-athletes for a very specific reason:  They don't like sports or exercise.  For this reason, such patients tend to require careful monitoring, guidance and encouragement from the health professionals mediating their recovery.  Now, that's a very large topic upon which entire careers are based, so for our purposes here, I'm going to try and focus on a few suggestions that an injured person with no athletic experience can try to encourage their own recovery.


-Look to life for healing activities.  For example:  I often tell patients with ankle sprains that balance training is important.  And of course their are exercise protocols that can be performed in sessions for that.  But for those that rarely keep to prescribed exercise routines, I encourage things like standing on one foot while washing the dishes or waiting for the bus.  Putting on socks while standing on one foot.  Washing one's feet in the shower while standing on one foot.  Incorporating rehabilitative activity into daily activities that are going to be performed anyway has the potential to significantly speed up recovery.

-Learn to understand pain.  This is a very complex topic, but I'll try to keep it simple.  Athletes and mothers who've experience natural childbirth often have this in common:  They have an internal vocabulary for their understanding of pain signals.  It's very similar to the Inuit and their words for snow, though it tends to be much more individual and difficult to express in language.  Pain is both your internal diagnostic system and a biofeedback mechanism.  Once you can accept that, you can begin learning to read it.  People who have difficulty interpreting their pain signals tend to perceive it as ON or OFF, but there is a lot more information there.  Learn the difference between "good" and "bad" pain.  Good pain can be though of as adaptive discomfort.  It's your body reinforcing in response to positive stress.  Bad pain is anything potentially destructive.  Once you can learn to tell the difference between these two broad categories, further differentiation will open to you much easier.



Finally, for everyone:  Take responsibility for your own recovery.


There is honestly no such thing as a mechanic for humans.  We don't work that way.  All health care is ultimately facilitation. 

Lets take the example of chronic knee dysfunction.  Over time, because of repeated injury the knee can accumulate debris that needs to be cleaned out.  One recommended treatment is arthroscopic surgery to trim up ragged connective tissue and "vacuum" out floating particles (I'm oversimplifying, but I'm not a surgeon, so please bare with me).  Now superficially it sounds like this is a complete solution.  Unfortunately, if you were to simply go home and never think about your knee again, you are likely on a long route back to the surgeon for more invasive knee surgery in the future.  It is essential for you to continue the rehabilitative process, whether that means working with a physiotherapist, or finding some other way to strengthen your knee and improve it's overall function. 

No one gets off easy, and no one gets to just sit back and let the healing happen.


Lifestyle Exercise:

There are two basic ways to engage in lifestyle exercise.

The first is doing any activity that can be considered "practice for living".  Now while any sport can potentially be adapted to fit this model, some have evolved specifically for it.  The best examples I can think of are hiking, traditional dance (I'm thinking of east African dance as I write this), yoga, pilates, tai chi and aikido.  Close seconds (and they don't make it into first because of their tendency towards competition) are eastern martial arts (karate, judo, wushu, hapkido, tae kwon do, kali, muay thai, etc), weight lifting, ballet, endurance running, cycling,   and climbing.  Feel free to add any others you can think of down in the comments section...  These kinds of activities can help to polish your mind and body in preparation for daily life.  Just practicing breathing alone has the potential to give you more energy and a better outlook on life simpy by increasing the oxygen supply to your brain.  It's tempting to look for a metaphysical explanation as to why these things can be so good for your way of living, but it's not necessary.  Just looking at what we know about these activities is enough.  They help your body become stronger, more flexible, and energy efficient.  And that means everything gets easier and more enjoyable in the rest of your life too.

The second is finding exercise in life.  The best way to describe this is to use the example of my father, Paul Blacker.  He's worked as a tool and die maker for all his adult life, and even in to retirement he still takes contracts and seems to enjoy it.  As far as I know, he's never played a sport or worked out in a gym.  Exercise for him has always been working at a physical job, and finding ways to make it physically challenging or mechanically efficient depending on his needs in the moment.  I can remember him having a chin up bar between his workshop and the garage/storage area.  He'd walk under it and either hang, or do a few chinups on his way from one area to the other.  Because his job requires him to move various quantities of metal from one place to another, he seems to delight in finding ways to move even the heaviest of pieces by himself.  And when he felt he needed a break, he'd often go for a walk (ok, ok, and a smoke.  He's given that up in recent years), instead of just sitting and staring into space...

Now, not everyone works in a labour intensive job suited to incorporated exercise.  Sitting behind a desk for most of your day may not lead you to be the most active worker.  Nevertheless, there are several ways to optimise your activity level.  Probably the best way is right at the start of the work day:  Don't drive.  Walk, cycle, even run to work.  Worried about getting to work sweaty?  Well, lifestyle exercise isn't about intensity, it's about movement.  So you don't have to push yourself while commuting, you just have to leave yourself enough time to get where you're going without arriving dripping with sweat.  You could climb stairs instead of taking escalators or elevators.  Sometimes it might mean making things less efficient and making things harder than they have to be.  For example, moving boxes or water bottles in your arms instead of finding a dolly.

Ultimately the key here is intention.  You have to INTEND to exercise. 

To put the term in context, I'm not referring to planning.  I'm referring to mentally engaging active participation in exercise.  I suspect it's the reason why when you look into a construction site, you'll generally be able to divide the workers into two groups:  The strong and robust, and the overweight, out of shape and broken down.  The first group engage in positive self talk:  "I like being active and outside" or "This job helps me stay fit".  The second group engage in the opposite:  "When is this day going to end..." or "Only ten more years to retirement..."  or "My back hurts... again...  I wonder if I can get on disability?". 


Performance Exercise:

This one is about goals and competition.  It's the engagement in an activity or sport with the intention (there's that word again...  I have a sneaking suspicion I'll be doing a blog specifically about that topic at some point!) of pushing personal, societal and athletic limits.  The central concept is achievement.

There are just so many more qualified people out there writing and speaking about human athletic performance, what it is and how to achieve it, that this is going to be a surprisingly short section.  Rather than giving in to the temptation to go into great detail, I just want to say this:

The pushing of your limits is a commendable goal, but you may not be leading yourself to optimal health.  The world of sport is littered with record holders with broken bodies.  For every world class athlete who retires into a healthy active life, there must be hundreds of others who spend the rest of their lives with compromised mobility and pain.

A common gym mantra is "no pain, no gain" and while certainly true, it needs to be taken with perspective.  As I said above, there are different types of pain, and it's essential for anyone intending to push their limits to develop an internal dialogue with their pain.  This is a very personal opinion, but I feel that you should embrace pain and fear.  They tell you useful things about what you're doing and how you're doing it.  Ignoring them may lead you to stratospheric levels of performance if you're lucky enough to get there without a career ending injury or psychological dysfunction, but it seems highly likely that you'll be left injured, and probably unhappy with the remainder of your life now that you can no longer look forward to new achievements.  Personally I'd rather take longer to go through the crucible and come out stronger, than force my way through and come out broken.

I'm not an Olympian or any kind of champion, and not a trainer of them either.  But I do like to push myself and reach higher.  And I like to help others do the same.  I think that to strive for achievement means being not only the short term goal of that heavier lift, or that more challenging competition, but also the long term goal of health and happiness.



As always, feel free to comment, correct or criticise.  Hopefully it won't be another year before my next entry!