8 Stitches and Conquering Urges

I’d like to suggest that if you struggle with self-harm not to read this post, I know I’d find it triggering.

So, I know I said in my last post that my Neulactil reduction wasn’t going to happen until my next admission, but DR decided to give my morning dose a very tiny reduction. I felt fine for the first six days, and then on Sunday I decided it would be a great idea to slice my arm open, requiring eight stitches, a first for me. I have wounds which should have been stitched and are now just a big gaping scar, but this is the first time I’ve actually had stitches for self-harm. I know this is an example of my screwed up thinking, but I’m proud of them. When I was at my back-up clinic (as it was Sunday) waiting for the GP I sat there hoping the cuts were bad enough to get stitches and I was (quietly) thrilled when he said they needed them. I had to go to my usual clinic today for a psych consult and a dressing change and it was great to see the cuts and all the bruising. I haven’t been able to look at it because it’s got a dressing and bandage on it.

As you can see below, one of the effects of Neulactil is to help control impulsiveness. Self-harm, for me, is often an impulsive activity. On Sunday it popped into my head and within a couple of minutes I’d done it. Other times I can dwell on it for a full day and successfully fight off the urge. On Monday I wanted to cut my throat, my leg wouldn’t have satisfied the urge, it had to be my throat. I could feel it without doing it, that’s how it often works. I can feel the cut, I can feel the blood trickling away from the wound and I anticipate the release from the urge. But cutting my throat, if it didn’t kill me (which I think would be pretty hard to achieve) would have left me with a scar I’d have to either explain to people or have them make assumptions about me, neither of which I’d be keen on.

I have to get through to Friday when I see my DR (psychiatrist) again, in the meantime I’ve got another appointment with my regular GP tomorrow and plenty of Xanax to take, maybe not two pills together though, that made me sleep 14 hours two nights ago. It’s completely shitty living with these urges and the anxiety that builds from resisting them but I really want to get off the Neulactil, I want my mind back.

From http://www.mydr.com.au/medicines/cmis/neulactil-tablets

The active ingredient of Neulactil is pericyazine, one of a group of medicines called phenothiazines.

Neulactil is used to treat patients who feel very anxious and/or tense.

It is used in patients to control symptoms such as impulsiveness and aggression.

It is also used in patients with severe mental conditions when a person loses contact with reality and is unable to think and judge clearly.

Drugs, Hospital, Cognition and Writing

I know the year isn’t so new anymore, but I’m just building up the motivation to write this now…

I ended last year badly, spending the end of November until mid-December in hospital and then after being home for six days I took an overdose of Stilnox, had a night in Emergency, got sectioned and admitted to the public psych ward only to be discharged after about two hours because my psychiatrist arranged for me to have a private admission instead. I then spent 10 days in the private hospital I used to go to, including Christmas day. I was given 12 hours leave for Christmas day, so at least I got to spend it with my Mum and brother. I’ve actually been pretty good since leaving hospital, with the exception of some nightmares and anxiety I’d say things are going well.

So a new year begins and my life remains pretty much the same. Instead of weekly 30-minute appointments with my psychiatrist I’m having twice-weekly 45-minute appointments with the intention of practicing schema therapy during those times. I’m not going to explain what schema therapy is because I don’t have a strong grasp on it my self, if you’re curious a simple Google search will help. I have few childhood memories and these are important for schema work, I’m worried I’m just going to unintentionally make things up. I have a lot of false memories from looking at photos, I look at it and think I remember the moment but I’m just inventing something from what the photo looks like.

I’ve started the painful task of reducing my medication. I’m thinking very slowly and can’t comprehend or remember well; the likely culprits being Neulactil and Stilnox. Last Monday night I took one-and-a-half Stilnox instead of the usual two and kept that up for the whole week. Last night I cut down to just one and had a very interrupted night of rest, still I’ll do it again tonight and see how I go. I’m going to reduce Neulactil too but not until my next hospital admission, last time I tried I became very suicidal very quickly so my DR wants to wait until I’m in a safe environment. I hope by going through the pain of reducing, with an aim to ending the use of these two meds I’ll get back the use of my mind.

I’ve started work on a novel, well just character development so far, and I’m terrified. Even whilst reading I can’t follow a plot. I’m reading Sense and Sensibility for the first time at the moment and I’ve had to look up characters and check how they relate to each other because I forget where they came from and why they matter to the story. If reading is so hard I can’t imagine how I’m going to keep track of the plot of something I’m writing and successfully make it interesting. I guess just keep a lot of notes. I’m working on the characters first. When writing in the past I’ve made solid characters and then kind of thrown them in a situation together to see what happens. My main character in this novel will be alone most of the time but there will be scenes from her past and the future with others in them.

Maybe those of you reading this can ask me when you see me how the writing’s going, and keep me accountable. I’m scared of getting confused by it, of writing something awful and of just giving up when I need something productive to do with my life; I’m not up to working and I’ve studied (a little) writing so why not give it a try.

Roots

I’ve never felt at home.

As a two, nearly three, year-old I immigrated to Australia with my mother and father. I remain unsure if this was a wise decision on their part. Despite being so young when we moved I was acutely aware that I was a foreigner in a new land. I spoke differently to my new friends, I had no grandmother, oma, nanna, granny, grandfather, papa or plain old granddad to spoil me, to visit at weekends, for my parents to send me away to so they could have a break. I had no aunts, uncles or cousins to grow up alongside. I had a family of three. Mum, Dad and me. A fourth member tried to join us, but his life only lasted three days. When I was eight a fourth member successfully joined our small family, my brother S. S grew up with a different experience to me. He belonged to this land the rest of us were foreigners in, yet he lacked the extended family his friends enjoyed. His parents spoke funny and, for a while, so did he. Accents get lost when a child starts school, they are spending more time away from the family and become homogenised.

I wasn’t allowed to forget that I was a foreigner. We had frequent trips “home”. Home where I had my nannas, granddad and step-granddad; cousins, aunties and uncles. Home, where the houses had stairs and green grass, where it got cold, but never too hot. Where I didn’t speak funny. But I did. “Ohhh, listen to her cute Australian accent, she’s an real Aussie now.” No, I’m English but I live in Australia.

Over the years I became more of an Australian. Deciding in 1995 that I needed a football (AFL) team to support. I decided to pick whoever won the final that year – Carlton. I don’t think I’ve ever watched a game on television. I went once with a friend and her father, I don’t know who was playing, I don’t know the rules, just that they have to kick a ball through some poles and it’s better if it goes through the two centre poles. My accent diminished further, but I’d still be asked where I was from occasionally. Friends replaced family, but Christmas was always a lonely gathering of four, with the rest of my friends off to see their families around the state / country. I pretended I was a proper Australian and that I loved hot weather and going to the beach, the Sun was great – but not my friend, with delicate English skin.

In 1999 we had a long trip “home?” I was 14 and felt lost. For the first time I was spending a long period with these people related to me by blood, and not just the ties of short lived teenage friendships. I longed to go back to my other home, that is, after all, where I thought I belonged. I was glad to return. Two years later the time came to get Australian citizenship. We were doing this, not out of a desire to be officially Australian, but to get cheaper passports and not need re-entry visas. I was given a choice, but not really. I said no. “I’m not Australian, I’m English!” “But it’s dual citizenship”, said my mother. “You’re both, you just get cheaper passports and have to vote; that’s the only difference.” I did it reluctantly. When I fill in official forms today I tick the Australian citizen box, but then have to fill out the country of birth section, including year, and sometimes exact date of arrival to Australia. So I’m not really Australian if they still care about that.  But I’m not English either.

I’ve thought about moving back, to Scotland where my Aunt and Uncle live, rather than England and it’s not far to travel to see the rest my family. I love Edinburgh. I’m not amazing at making friends and my health is too much of a mess to uproot myself so for now at least I’m staying here.

Beginning Dialectical Behaviour Therapy

I started Dialectical Behaviour Therapy (DBT) properly this week, I say properly because I’ve already done what they call the foundation course. Tuesday was my first individual session and this coming Thursday will be my first group session - they started the individuals the week before the groups. Due to the commencement of DBT I thought I’d write a little about Borderline Personality Disorder (BPD) with which I am diagnosed but only just, enough to warrant treatment. I’ve had a look through my blog to see what I’ve already posted about BPD and DBT, finding that I posted a weighty article about BPD back in June 2013 and not much about DBT. Below is a little excerpt from Spectrum regarding BPD along with the diagnostic criteria. In bold and underlined are the ones I identify with, and just underlined are the ones I only sometimes or partially identify with.

According to the DSM-IV-TR (American Psychiatric Association, 2000), borderline personality disorder is diagnosed when there is a persistent pattern of unstable interpersonal relationships, mood and self-image, as well as distinct impulsive behaviour, beginning by early adulthood and present in a variety of contexts. These difficulties are indicated by five (or more) of the following:

1.      Frantic efforts to avoid real or imagined abandonment.

2.      A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation. 

3.      Identity disturbance: markedly and persistently unstable self-image or sense of self.

4.      Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). This does not include suicidal or self-harming behaviour. 

5.      Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.

6.      Affective instability due to a marked reactivity of mood - intense feelings that can last from a few hours to a few days.

7.      Chronic feelings of emptiness.

8.      Inappropriate intense anger or difficulty controlling anger.

9.      Transient, stress-related paranoid ideas or severe dissociative symptoms.

Not all people diagnosed with BPD will present in the same way, as there are over 100 combinations of symptoms possible, if someone has five out of the nine criteria.

The diagnosis of BPD is only made when it is clear that these behaviours have been present over time (usually starting in early adulthood) and across a range of situations.

Reference:

http://www.spectrumbpd.com.au/pages/about-borderline-personality-disorder-bpd/formal-diagnostic-criteria-for-bpd.php

As you can see I identify strongly with three of the nine traits and partially with four of them, meaning I don’t quite fit the diagnosis. I should strongly identify with five of the traits. Because of this I’m unsure whether I should be pursuing DBT. I don’t know if there are people more deserving of my place, if I’m going to be sitting in the group not being able to identify with the topics because we’re talking about one of the traits I don’t suffer at all, or just sometimes or a little bit. I also have a lot of trouble with my memory and concentration. The group sessions go from 3:45 – 8:30, there are two breaks but that’s still a really long time it’s helped by being interactive but I get fidgety and restless and just don’t take anything in.

Below is the entire description of Dialectical Behaviour Therapy from the PsychCentral site. I don’t know how reputable that website is but having read through everything posted below I can tell you it’s right. I don’t have a good enough understanding of this to write it in my own words, but I know enough to be able to say this is right.

Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy developed in the late 1980s by psychologist Marsha M. Linehan to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders.

What is DBT?

Dialectical behaviour therapy (DBT) treatment is a cognitive-behavioural approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

People who are sometimes diagnosed with borderline personality disorder experience extreme swings in their emotions, see the world in black-and-white shades, and seem to always be jumping from one crisis to another. Because few people understand such reactions — most of all their own family and a childhood that emphasized invalidation — they don’t have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.

Characteristics of DBT

• Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
• Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
• Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.

Generally, dialectical behaviour therapy (DBT) may be seen as having two main components:

1. Individual weekly psychotherapy sessions that emphasize problem-solving behaviour for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviours take first priority, followed by behaviours that may interfere with the therapy process. Quality of life issues and working toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses (from previous trauma in the person’s life) and helping enhance their own self-respect and self-image.

Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviours, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.
(Linehan, 1993)

During individual therapy sessions, the therapist and client work toward learning and improving many basic social skills.

2. Weekly group therapy sessions, generally 2 1/2 hours a session and led by a trained DBT therapist, where people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught.

The Four Modules of Dialectical Behaviour Therapy

1. Mindfulness

The essential part of all skills taught in skills group are the core mindfulness skills.

Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills?”

Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question, “How do I practice core mindfulness skills?”

2. Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Borderline individuals frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioural sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioural sequence when analysing her own situation.

This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

3. Distress Tolerance

Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully.

Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality.

Distress tolerance behaviours are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus wilfulness.

4. Emotion Regulation

Borderline and suicidal individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed, and anxious. This suggests that borderline clients might benefit from help in learning to regulate their emotions. Dialectical behaviour therapy skills for emotion regulation include:

• Identifying and labelling emotions
• Identifying obstacles to changing emotions
• Reducing vulnerability to “emotion mind”
• Increasing positive emotional events
• Increasing mindfulness to current emotions
• Taking opposite action
• Applying distress tolerance techniques

Reference:

http://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/?all=1

I went through the assessments to do DBT a while ago, I think it’s been a couple of years now, but my doctor decided against having me do it because he worried I could be triggered by the struggles the others in the group are going through. I still worry about that because I am easily influenced by the suffering of others; I only have to see an ambulance to think of all the times I’ve been in them and what I could do to bring on one of those situations (that’s quite embarrassing to admit publicly).

I’ve become a bit lost in writing this. I don’t have a clear point to make, maybe just that I’m worried and reluctant about DBT starting this week. I don’t know how it’s going to fit in with my very frequent hospital admissions because you only have to miss two sessions to be kicked out and made to start that module from the beginning. Unless of course you elect to quit, something I’d probably choose over going over the same content from the start.

That’s this blog post done. Sorry it was long and didn’t really make a point.