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What course(s) of treatment to try next?


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So I was diagnosed with severe depression nearly 10 years ago, and after various forms of utterly worthless treatment, I was wondering where next to look for-- well, what I'm actually looking for is oblivion (be it via suicide, heavy sedation, or developing impregnable indifference to all sensory stimuli), but people keep going on at me about how I should be looking for some sort of treatment instead.

The main problem, I think, is that I cannot conceive of a better life (my life, being an aspect of me, is axiomatically the worst thing imaginable). The only option is to stop being, and the best compromise I can offer these busybodies is that I stop being me, and start being someone else. How is this to be achieved by talking to people who never say anything back at at cost of nearly $100 an hour? That's where you come in.

Until very recently, all the treatment I've had (with costs going to every failed tax-dodger in Britain) has been at best utterly worthless, and at worse has caused a great deal of pain while messing up the very thing it was trying to make better. Not bad as a capsule description of my life, as it happens -- it occurred to me that the treatment has been merely mirroring the failure and destructiveness that defines my existence.

(I realize that this is coming over all biographical, and so might be better in the Springer forum, but I'm hoping that the responses this may generate will be relevant here.)

For as long as I can remember, I've had:

desire never to have existed (with suicide regarded as satisfactory compromise in that direction)

obession with death (as in non-exsitence, rather than as in cadavers or iconography of skulls, coffins etc)

intense self-hatred (as distinct from self-loathing)

complete incompetence at all but the simplest tasks

a quick temper, directed at myself

destructive urges to wreck everything I've been involved with

intense free-association leading to very short attention span (or vice versa?)

difficulty understanding people speaking because of the above

a need to do pointless and counter-productive things when I should be doing something else

a strong literal bent, with extreme difficulty handling concepts such as metaphor or non-verbal communication

lack of any kind of initiative or creative thought (except to dream up new reasons to despise myself)

difficulty forming or maintaining social relationships (because of the above, I can never think of anything to say to  people)

inability to function under background noise (which my brain is happy to provide if my ears can't)

lack of physical fitness or coordination, leading to detestation of sports and extreme physical self-consciousness

poor school work (a 30-minute homework assignment could take 4 hours or more)

difficulty in writing legibly (or at all; sometimes the pen just flies out of my hands)

complete lack of emotional insight (I don't even know what that is; guessing lucky?)

difficulty in communicating with people (speech therapist friend suggested I may have auto-receptive aphasia, but "I'm not sure as I've just made that up")

all-encompassing cowardice and laziness

appalling memory for anything important (e.g. to take my meds; or that I have a job)

quite a good memory for anything trivial

extreme anxiety about interacting with physical matter (of which people constitute a subset)

complete failure at every undertaking in my life, including ending it.

How this has manifested itself:

I've never held a job for more than 18 months (I quit because I didn't want to be a burden on everyone else).

At every job I have had, I have spent months doing --literally-- no work (just occasionaly sobbing to myself at my desk, reearching suicide methods, or calling the Samaritans) and noone noticed any difference from my normal productivity.

I was ranked last out of my entire school (not just my class).

I have no friends, and scarcely any acquaintances.

My rejection rate in trying to start relationships runs at 100%.

I was moved into the slow stream at school because I failed my exams that year; it simply hadn't occurred to me to write anything on the paper.

Things go catastrophically wrong if I make an effort to do them right, so no I never bother.

The repair bill in my house from psych-outs runs to about $2000, and I've been unemployed for years.

I've recently taken to smashing my head against hard surfaces, and punching myself in the face.

People find me arrogant and obnoxious, telling me "You think you're so much better than everyone else", when the reverse is the case.

People also saying I'm intentionally complicating matters at just those points when I'm trying to present things clearly and simply, or that I'm having a joke (at their expense) when I'm trying to be serious.

When my Dad forced me to go to rugby practice at weekends, I wasn't just beaten up by the other team (that's part of the game) and my own team (they all hated me for infesting their team), but also by the coach.

I've squandered what is by any standards an incredible good fortune (a loving partner, an expensive education, a well-timed inheritance, and what I'm told is a fearsome intellect) by having no desire to engage with the world.

I once destroyed my home computer with a hammer, containing days' work. I had carefully backed up the data to disc. I just as carefully destroyed the disc with the hammer.

I erased all the work I had done for my dissertation because, as a product of me, it was better off not existing (and destroying something so important would be a bigger FAILURE -- something I crave and bring about constantly).

I frequently hide under the covers for hours at a time to make the day go by faster, and to avoid doing anything (which is, axiomatically for me, to do it WRONG).

Three psych professionals have independently stated that I'm unlike anything they've ever seen or heard of -- but none of them can say why they believe this (they shrug and make hand-waving gestures).

My days are spent wandering from room to room in the house, constantly remembering something that needs to be done in another room and then forgetting what it is when I get there.

For a while in 2002-04, I was getting "stuck": unable to move exept to regluate my breathing. I once crouched down to open a kitchen cupboard, then slumped on the floor and it was three hours before I could get up again.

If engaged in some manual activity (writing, carrying, using a screwdriver), my hands sometimes go limp and I drop whatever it is I'm doing, or sometimes scream at the top of my lungs and hurl it across the room with great force.

Once I found myself unable to get to my feet until I written a piece of 6502 assembly code in midair with my left hand (I'm right-handed), and this is typical of the pointless things I compulsively sidetrack myself into doing.

I constantly hear scraps of tunes and nonsense phrases churning round my head when I try to sleep or concentrate, and am strongly tempted to screech along with them very loudly in as high a pitch as I can manage.

Within seconds of trying to tidy up or do anything practical, I am filled with urge to knock things over, smash them  to pieces and scream at the top of my voice.

I once called the emergency mental helath helpline number and all I could do was scream repeatedly down the phone.

My girlfriend complains that I don't understand her, even though the fact she *wants* to be my g/f renders her incomprehensible from the start.

Anyway, when they diagnosed me (aged 19, after a non-cry-for-help suicide attempt which, like everything else in life, I fucked up royally), I was placed on Efexor and have been on it, on and off, ever since. I've never seen the slightest benefit from it. The problem has been that whenever I have had meds introduced or changed, there has always been a significant change of environment, so the affect of meds cannot be tested in isolation. In this case, I was placed off sick from my job (which is what tipped me over the edge; I was the third in as many years) until my contract expired.

Since then, they've tried:

"Constructions" (messing around with people's names on bits of paper - WTF?)

Counselling (a misnomer, as to counsel someone is to advise them; these people never said a cunting word)

Group Therapy (we all united in hating the therapist as much as ourselves)

Solo CBT (involved me writing pages and pages about my emotional state; after a few weeks, I simply forgot to attend).

(To give you some idea of my efficiency, I'm now in my seventh hour of writing this. My bath has gone cold.)

I then forgot about the whole thing, like I do with everything important. I once called the psychologist to arrange an appointment only to be told he'd retired... and so had his successor.

Then in 2002, I completely fell apart. I was commuting 100 miles a day to a work on a project that was obviously doomed, and this rubbed my face in my failure all day, every day. (Two years after ship date, they still haven't released anything.) In addition to the depression, I had been developing nervous tics, and a strange guttural growl when I was moved to such furious self-hatred that I couldn't form words (several times a day). I quit (again) and just disintegrated at home. The stress of moving house took me to pieces completely, and it was then that the outbursts of violence started in earnest.

I then started on:

Hypnotherapy, and

Lofepramine (a trycyclic).

The hypnotherapist (I had found convetional psychotherapy to be wholly futile; they just sat there and nodded occasionally) refused to treat me after I started screaming and smashing myself in the face while hypnotised, so he referred me to someone more expensive (to be fair, he offered to treat me at the old therapist's rates, until he met me and promptly cancelled the offer on the grounds that I was "a challenge").

The outbursts increased in frquency and intensity after taking the Lofepramine; I don't know if I should infer a causal connection here.

During this time, I had a routine meet with to the pysch, which went well enough until the very end when I had an episode so violent she kept me in (technically voluntarily, but I didn't fancy pushing it) in for 3 days, after which they proscribed me:

Efexor again (now up to 150mg daily)

The David D Burns Feeling Good Handbook (self-help)

Six weeks' day-patient care at the unit, featuring CBT, anxiety management, relaxation techniques, and "personal development"; all of which, naturally, exacerbated the very problems they were meant to treat.

The Feeling Good Handbook was difficult for me, in that I only got as far as the first Mood Log (I felt inadequate at not being able to think of anything, as I do with all open-ended questions, so logged that) before I was screaming, writing a hate-filled screed against myself in my notebook (two or three illegible letters per page, so I filled up the book pretty fast, but only the right-hand pages), and pressing so hard the pen ripped through several pages.

The reccommended that I not continue the book.

The CBT was a complete failure (for everyone else as well as me, from what I could tell), a during it I picked up some strange twitches in my face and right arm which, 18 months later, have yet to completely subside. The only bit I recall of the course, aside from the intense emotional pain which accompanied it, was the therapist explaining the  importance of Non-Avoiding Behaviour.

She explained that her son had been beaten up and threatened by the school bully, who held a cutthroat razor against his face, and said he'd slice him up the next time he saw him. Her son, naturally distraught, tried to get the next day off school, but she forced him to go, explaining that letting him stay at home would be Avoiding Behaviour. After some weeks (presumably involving abject terror on the part of her son, though she glossed over this), there was an "incident" with the razor-wielding bully and another student so severe that she decided to move house to a different catchment area, and thus her son to a new school, leaving the bully to slice up kids at the old one. This was presented as the moral of the story, but how this act of literally running away from the problem constitutes Non-Avoiding Behaviour was beyond me. Anyone who can explain it will gain my bemused thanks.

I was utterly baffled by the course after that, especially the bit where they tell you think more upbeat thoughts, or rewrite them to be less distressing; when I tried it, the thoughts immediately metamorphosed into "DON'T YOU FUCKING DARE! YOU'RE A FUCKING WORTHLESS MISERABLE PESTILENTIAL FAILURE AND YOU FUCKING KNOW IT!" or similar repeating over and over in my head for several minutes, which may not have been the desired effect.

The anxiety management led, of course, to states of rawest panic I have ever known. The only technique I recall in detail now was the "triangle tracing technique", where you trace a point along an imaginary triangle and use it to regulate your breathing. Whenever I tried it, the triangle loomed over me, jittering like the vertical hold had failed (one of my favourite words there) and the disorientation left me drenched in sweat and shaking like a leaf (as I am now, recalling it).

Relaxation class was taken by an insane new-Ager who had crystal-fondling, gnome-chanting, coyote-dancing, and Christ-calling (while carefully explaining that it had "nothing to do with Christianity", a disclaimer she didn't feel the need to attach to any other belief-system she ripped off). She also told us our chakras had changed colour since the planets recently aligned, and that Jehovah, Allah, and all other gods had in fact been humans at some point in the past, so we should pray to their god instead. I did learn one useful lesson: Amazing Grace on pan-pipes sounds bloody awful. You can guess just what all this did to relax my Mind, Body, And Spirit.

Personal Development was thinking of nice things to mention at job interview, and cutting pictures of mouths out of magazines. Your guess is as good as mine, frankly.

They suggested I might have Asperger Syndrome, and sent me to a specialist. He determined that I didn't (without having met me or communicated with me in any way, but I suppose that's why he's a specialist) on the grounds that I had insufficient self-esteem, and that I was, in fact, less autistic than average. I'm still not sure what to do with this information, though someone did suggest putting it on a T-shirt.

None of this did any good for the depression or the violence (which was only ever directed at myself and other inanimate objects). My new hypnotherapist had abandoned all hope of treating me (not before he'd trousered a few hundred on the way), so he reccommended me to someone even more expensive (who never even offered me a break on the rate). At same time, my doctor expanded my meds, after I'd admitted myself as an emergency case. So now I had:

Risperidone 0.75mg in addition to the Efexor

NLP with this new hypnotherapist.

It is perhaps unfortunate that I started both of these at the same time, as I had no way of knowing to which cause to ascribe any change. The NLP guy did some work with me with idio-motor responses (you're taken into a trance and and "unconsciously" move one finger for Yes and another for No in response to questions). It was this that provided me with my first and only piece of information about the causes of my condition:

I was five years old when It Happened.

(Or at least, when he volunteered the possibility that I was five, I moved my index finger for Yes.)

What It was, and what to do about it, remained a mystery. I wasn't expecting to recover any suppressed memories or anything, but I was hoping that I might gain some conscious insight into just *how* my mind has been fucking me over all these years. However nothing has ever happened to undr hypnosis that hasn't hppened consciously at about the same time. The trouble with NLP is that it affords no insight at the time: you just wake up one day and find that you're better. Or, as in my case, you don't.

He also tried me on some Leusher cards: the report came back saying I "craved stimulation", which struck me as odd, as it's been the ulitmate lack of stiumlation -- death -- that has been my lifelong goal. I can't remember anything else about it, except that I disagreed with those parts I didn't find incomprehensible, and people I showed it to said it had me nailed perfectly. As with everything important in my life, I lost the report.

He then tried a couple of CDs to be played before I went to sleep. One was his own (and had a lot of seemingly irrelevant stuff about Cellular Healing on it), and the other was a Pilgrim Tape from http://www.realsmart-hypnosis.com. The former was quite unpleasant (I don't know why he gave me a recording that said nice things about me; when real people do that it's like a knife in the gut because I know they're so desparately wrong), and the latter -- well, I'll just say that an email I wrote to my therapist about it contained the phrases "made my skin crawl", "despising every foetid syllable", and "had to swallow my own vomit", and let you fill in the gaps. This was made all the more galling by the fact that the Pilgrim Tapes guy had hand-picked the tape out for me specially based on some tests, resulting in one containing just the kind of gibberish ("powerhouse mind"; "multi-vibrational levels of reality"; "non-vibrational side of zero", how many cuntfucking sides has it got, it's a *number*; a regression so far back into the womb we're supposed to read our mothers' minds at the moment of conception; and a reliving of our births that's wholly invlaid if like me you were born via cesaerean and slam-dunked into a ventilator) that drives me to fury at the best of times. I stuck with it in the hope it might have some cathartic value, but my therapist eventually confirmed that it was, like everything I tried in my life, utterly fucking futile where it wasn't actively dangerous.

The only beneficial effect I've noticed in all the years of ploughing through this shit occurred some weeks into the NLP/Risperidone combo I stopped screamming and twitching while under hypnosis, and after that I stopped flinging myself out of the chair onto the floor, and groveling at his feet begging him (or somebody, *anybody*) to please fucking kill me right now because it's all I deserve. I still consciously maintain this viewpoint you understand, as I have all my life, but I my unconscious no longer feels the need to shout about it. Now the outbursts of violence are minimal provided I maintain near-total inactivity, but they can still be brought on by trying to do anything. I had to tighten a leaky washer on a radiator one day, and half an hour later my throat was raw from screaming, there were gouges in the bathroom floor, and the bedroom wall has a head-shaped dent in it that'll need re-plastering. And my life is such that I have to regard this as a step up.

The NLP guy claims credit for the change, but it seems to me the credit for attenuating psychotic episodes might more sensibly by granted to an antipsyschostic, given that's what it says it does on the label.

So now what? I've bored you all shitless with tales of what hasn't worked and why; can any of you offer something constructive?

Thanks

JP

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JP -

I am tempted to respond with a series of positive statements about you, compliments that you would, of course, dismiss out of hand because your mind will not permit you to accept them, or even accept the possibility of them.  Suffice it to say that your story was very readable, and indicates a sharp wit.

You say that you were diagnosed with "severe depression" 10 years ago; it is obvious to the most casual observer that there is much, much more going on here than common-or-garden depression, even Lanternfish-dung-on-the-floor-of-the-Abyss level depression.

If your descriptions of your treatments are accurate, it appears as though you have hardly been treated at all.  "Solo CBT" is to my mind an oxymoron, for instance.  And, if there is a biochemical component to your ailment, it seems unlikely that all the hypnosis in the world will do anything for you.

Your account is a little sketchy on the degree to which the pschiatric pharmacopia has been exhausted in your case.  Many of us have found it necessary to try many different meds, and even many different combinations of meds, before arriving at a truly effective treatment.  If you've dont the entire med-go-round, there is also Electroconvulsive Therapy (ECT), although I'm not qualified to speak to that.

I would dispassionately observe, as a chronic, refractory Double Depressive, that your writing betrays classic symptoms of depression, including an unrealistic assessment of your self-worth.  A good therapist using active CBT should be able to assist you in identifying the and intercepting the logical fallacies that generate your self-hatred, but it will likely be necessary that you first find a relatively effective pharmaceutical intervention to stabilize your mind so that therapy can be effective.  It can be done.  I did it myself, and I assure you, the zeal of my own self-hatred was prodigious.

It sounds like you're simply going to have to continue your quest for competent care.  I'm glad to know that you are capable of checking yourself into hospital when the need arises.  I trust that others on these boards will chime in as well, who may have more familiarity with your other symptoms and what they may indicate.  And, I would encourage you to register with us as a member, so we can better support you.

You were not born to feel this way.  Hang in there.

Cerberus

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Ok, sounds like you are having and have had a rough time.  I understand. 

Firstly, which meds have you tried and what are you on now? 

Secondly have you been into therapy at all? 

Provide a bit more info and I'll try and point you in the right direction.

Regards

Chimp

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I am tempted to respond with a series of positive statements about you, compliments that you would, of course, dismiss out of hand because your mind will not permit you to accept them, or even accept the possibility of them.

Not so much "dismiss", as "develop an antidote for". You might regard the process as a form of immune abreaction, and the effects as a kind of fever.

You say that you were diagnosed with "severe depression" 10 years ago;

I think it may have been "acute", with much hand-waving over where it lay in the endogenous/reactive continuum.

it is obvious to the most casual observer

...and so, by implication, to the seasoned professionals who appear to have missed a trick in this instance?

that there is much, much more going on here than common-or-garden depression, even Lanternfish-dung-on-the-floor-of-the-Abyss level depression.

I think this is the first time I've heard such a sentiment expressed (certainly with a marine metaphor, anyway). I've always just thought of it as Being Me, and no-one who's worked with me has felt a need to fine-grain it into multiple causes, being mostly concerned as they with symptoms and their alleviation.

If your descriptions of your treatments are accurate, it appears as though you have hardly been treated at all.

A telling quote from the chief psychologist: "We believe you are beyond the reach of modern psychotherapy." This kind of implied to me that we'd run the gamut and were fresh out of ideas. He did suggest pyschodynamic therapy, but the department who run that turned it down. Certainly I agree that my treatments have been ineffective, but are you really suggesting I've barely dipped my toe into the sea of possibilities?

"Solo CBT" is to my mind an oxymoron, for instance.
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no-one who's worked with me has felt a need to fine-grain it into multiple causes, being mostly concerned as they with symptoms and their alleviation.
Precisely.  They are not evaluating the cause, therefore not treating the cause.  You have to get to the root of it.

Certainly I agree that my treatments have been ineffective, but are you really suggesting I've barely dipped my toe into the sea of possibilities?

I can only go by what you tell me, but if your narrative reflects your experiences, then yes, that is exactly what I'm suggesting.

I'm not sure. I certainly didn't gain anything from having a bunch of other people around. And the doc reports good success from that David Burns book.
I'm not talking about group therapy.  I'm talking about finding a good therapist who is willing and able to go toe-to-toe with you and your intellect to find the cognitive process that will breach your quite formidable defenses.  You are a prisoner of your own intellect, I strongly suspect.  Your story sounds very familiar to me in the sense that I had built around myself a fastness of logic that used my own intelligence to support the false conclusions my depression presented me with.  It's like having a high-powered attorney defend a guilty criminal.  Unless you get another highly skilled attorney on the prosecution, that criminal may have free rein.  You need someone with intelligence, patience, time, and perseverence to discover the weak spot in your fortress and help you exploit it to overturn the false thinking.  It is impossible for you to use CBT on yourself without this other person, because you are mentally either unable or extremely resistant to recognizing your own false thought processes as being false.  You need assistance.  You haven't been getting it, or anything like it.

They're convinced that it is non-organic in origins

Rubbish, espcially if you're received any benefit from medications.  Also, if, as the *bubbles the chimp* you quoted stated "you are beyond the reach of modern psychotherapy," then the cause must, clearly, not be cognitive, therefore biological.  You are not an alien nor a mutant; you are human, and your mind is going to function or dysfunction in the same way as other humans'.

Efexor, Lofepramie, Risperidol, and that's it.
They haven't tried you on a single standard SSRI, but put you straight on Effexor and a tricyclic, and claim there is nothing more to be done medication-wise?  This beggars the imagination.  You have barely scratched the surface.  And yes, it can take weeks to come off one and start another, weeks to determine if it works, and weeks to transition to another if it doesn't.  It sucks out loud, but that's the way it is.  All of us on this zany ride have to put up with it, all muttering the mantra, "Which Sucks Less?"  I would submit that the inconvenience and frustration of exploring the pharmaceutical options is less onerous than feeling the way you've been feeling.

There's been a general reluctance to change the meds, partly 'cos of withdarawal symptoms (I've heard nasty things about coming off it), and partly because they're "working". I don't think they're working, but then I'm mad.

I take this to mean that the "general reluctance" is on your part.  I've come off Effexor XR three times, and yes, it can be unpleasant if you don't do it properly.  Titrating down slowly, with a step-down regimen of something like a low dose of Prozac at the very end, can render discontinuation symptom-free, or nearly so.  There are so many other things to try, I suggest it would be worth the effort. Incidentally, I am convinced that you are not mad; your writing evidences a quite rational mind.

At one point, my g/f said she'd leave unless I promised there and then never to have ECT, but she's since reconsidered her position.
There is fairly robust discussion of ECT on these boards.  I recommend it to you.

This is the problem I have with CBT. While I'm quite comfortable with logic (I'm reading Bertrand Russell), there is a world of difference between intellectually knowing a statement is necessarily false, and believing it in one's bones. 

Knowing this in advance means that I don't even get as far as examining the belief in the first place before the CBT-faliure association stake over. Imagine it as dialog between Logic and Emotion, where the moment Logic opens his mouth to speak he gets a smack in the teeth from Emotion's brass knuckles.

Bingo.  This is why you need a competent therapist.  And on your own, you might try turning your own emotions into a subject of study.  If your emotions are an 800-pound gorilla that bitch-slaps you whenever you think something positive about yourself, make yourself into Jane Goodall and start making field notes: "let us examine the gorilla.  It just lashed out at me.  Why did it do that?  What motivates the gorilla?"  When you put the autoemotional response itself under the microscope, it begins to lose some of its power.  You can make your intellect work for you.

Now, having said this, I will postulate one thing more:  It's possible that you're not yet ready to get better.  The people I've known who have made the greatest progress have hit rock bottom, and found themselves so tired of the battle that there's nowhere else to go but up.  I was there myself when I just decided I was going to beat this thing, and I've been working and improving ever since.

If it's chemically-induced stability you're after, you can't get much more stable than huffing carbon monoxide, and you'll have lovely rosy cheeks at the end of it...
A ridiculous statement, and unworthy of your intellect.  The chemically-induced stability I'm referring to is that which quiets the chaos in your mind long enough for you to see things in the way that someone not suffering from your illness sees them.  Suicide is a non-solution, and impermissible, especially for someone with your obvious gifts.  Much is expected of those to whom much has been given.

I wasn't born with any purpose at all. If I did have one, I'd just throw it on the pile with all the other things I'm failing at.

Yet another ludicrous utterance.  Everything happens for a reason, even if that reason is not immediately evident.  If you analyze each "failure," you would find the causality behind it, and can use that knowledge to progress. 

If your descriptions are accurate, I would consider your treatment at the hands of your state mental health care system sloppy at best, and grossly negligent at worst.  In any event, you are by no means out of options.  But the very first thing that needs to be done is that they need to quit treating symptoms and give you a full and correct diagnosis consistent with all the symptoms you describe, and a treatment regimen based on that diagnosis. 

You sound like a kindred spirit in many ways, and I wish you luck.

Cerberus

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