Tag: anxiety

Listening to your body

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“Listen to your body,” they always tell you…whoever they are. “If you are feeling tired and exhausted it means you are overdoing it.” I used to tell people that to. After all our body and mind are inextricably linked. What is going on inside my head will have an impact on how I am feeling, and vice versa.

But what if you don’t only ‘listen to your body’ but watch it too? Monitor it closely every day for changes. Observe how aches and pains seem to shift mysteriously from one joint to another. How your heart misses a beat, or speeds right up more often than it used to. How the pain that you woke with again today in your right arm (which you have self-diagnosed as tennis elbow) has increased in intensity as the small hand has moved around the kitchen clock…probably because you’ve been thinking about it all the time. And the more you dwell on it, the worse it becomes. “Is it arthritis?” you are beginning to ask yourself.

The fingers of both of my hands are stiff now every morning, and the base of my left thumb was painful again today opening the jam jar at breakfast. I know that my uncle developed rheumatoid arthritis when he was my age. He went from being a fit and healthy middle-aged man to a stooped elderly person wracked with pain in the course of only a year. Could this be happening to me? I told one of the GPs I see about my joint pains recently. I’m supposed to have a blood test- but I haven’t yet. I don’t know if I want to know the status of my anti-rheumatoid factor. I’ve started to worry much more about my health than I used to. The number of chronic conditions I have is slowly increasing…and with them my level of anxiety.

I’ve seen many people in my life with what used to be called ‘Medically Unexplained Symptoms, (MUS)’ (and have now been given the name Bodily Stress (or Distress) Syndrome although terminology differs between psychiatric classifications and will almost certainly change again). Symptoms for which there is no clear medical cause, although many suspect that if you look really hard you might find some physiological explanation for them. They were once called ‘functional’ symptoms and milder versions are really common in primary care and out-patient clinics. For example, around 50% of people who are seen in gastrointestinal clinics with new symptoms have a problem for which no obvious medical cause can be found. However, some people are severely disabled by multiple symptoms. They most commonly occur in the presence of other diagnosed and often chronic illness, and may be a sign of anxiety and depression, but this is not always the case. A person with otherwise unexplained symptoms often denies having any other problems that are worrying them, either psychological or social. Sometimes it becomes clearer later that they do indeed have a medical cause for their problems; we found this happened in about 10% of patients over an 18-month follow up period. Missing ‘real pathology’ is what a doctor fears (although they do seem less worried about missing mental health problems). I specialized in not only trying to help people with unexplained symptoms, but in doing research into how to train GPs to help them more effectively and be more understanding about their concerns. And I will admit here I have always experienced them myself to some degree too.

And now I find one particular person keeps coming back into my mind.

Jeff (not his real name) worried about pains all over his body, which he had for many years. He had multiple investigations, almost all of which showed nothing very much of note. We sat down together to go through his general hospital case notes together so we could discuss all the tests that had been carried out in several different departments. I always found this a helpful exercise in beginning to find a common ground with someone. Checking out what we could agree were the problems both in life and with health, and where we disagreed. Whatever the health worries, we could usually agree that the disability and pain interfered with their quality of life and relationships in a major way. Jeff was confined to bed much of the time, and found it very difficult to manage any kind of regular activity outside his home. He was angry and exasperated with the medical profession in their failure to either explain or help him. While we turned the pages Jeff asked questions, and I attempted to answer, explaining what particular phrases meant.

“So ‘at the top of the normal range’ it says there,” he pointed to a particular blood result, “that’s not good then is it, I mean its high isn’t it?”

“Well, it’s still within the limits of what is normal. That’s what’s important. It will also probably vary a bit each time its been checked.” We looked through previous pages and indeed the numbers went up and down. We were both relieved. We carried on much in the same way for about an hour then I noticed Jeff had fallen silent.

“So what do you think?” I asked.

He was looking down at his hands and flexing his fingers as though testing their range of movement. “Well I’ll be honest with you, doc.”

“Go on…”

“All these tests and scans…they’ve never checked my out here have they,” he said pointing to his left flank. “And that’s where the pain is worse at the moment. They’ve never scanned me right here have they?”

At that point I really didn’t know how to reply.

And now I know just how Jeff felt. Before my recent appointment at the kidney unit I was having persistent discomfort in my left flank too. I was constantly checking and prodding and trying to reassure myself, but it was only after the appointment, when I received the results of my latest scan, explained to my in details that I could understand, that I realized that the pains in my flank had actually disappeared completely. I had previously been told that the kidney on that side was enlarged, but this scan showed that wasn’t apparently the case. Only I now have pains elsewhere in my back, and in my joints too. Logically I know that the pains are worse when my mood is low, as I would have predicted; made worse by my level of anxiety. I focus on things I have reason to worry about due to my family history: such as heart disease and arthritis. I do have chronic kidney disease and now associated hypertension, hypothyroidism, irritable bowel syndrome, early signs of cataracts (yes my optician helpfully added that to the list this week) and a long-standing mood disorder. And now I have started to monitor my body just in the way (though not quite as obsessively) as one of my patients who used to chart the progression of unexplained spots across his body in his diary.

Reassurance doesn’t work. I’m worried about my health. The last thing I need to do is to watch or listen to my body. I really need to be distracted from it in a major way. I know that even if I am feeling tired if I don’t get out there and keep getting on with life, setting myself (achievable) goals, life will pass me by while I’m still checking my pulse!

I just have to keep reminding myself just as I used to remind my own patients of that…and keep going.

So that’s the plan then.

Fear of flying

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Last week I had one of the most frightening journeys I’ve ever experienced in my life. I flew back into Orkney in the middle of the ‘weather bomb’ that hit Northern Scotland. Despite the forecast, it was surprising calm as the Loganair flight left Aberdeen, but after we had been served the customary tea and Tunnock’s caramel wafer I always look forward to, the wind began to buffet the plane violently, not only from side to side but also up and down. As we came out of the clouds towards the islands we turned on dipped wing into a curve that I soon recognised as the familiar holding pattern.

“Sorry about this,” came the calm voice of the female co-pilot, “there’s a snowstorm at the airport in Kirkwall so it’s going to be a little while before we can land.”

For the next fifteen minutes or so, it may have been longer I lost track of time, we jerked through troughs and peaks of stormy shades of grey, occasionally illuminated by a flash of lightning. My hands, cold and clammy by now, gripped the armrests. My stomach rose up into my throat as I shared false smiles with a woman seated across the aisle. Behind me, another passenger lost the contents of her stomach. As I caught occasional glimpses of the flinty sea just below I began to have those familiar thoughts: ‘is this where it will end, after all?’

A few days before I had been working with fear of a different kind as novice therapists I was teaching about suicide talked about the anxiety which comes with not knowing how to cope when you, as a mental health worker, are faced with someone who might want to end their life.

From my early days in psychiatry I had to try and learn how to cope with uncertainty. I often meet doctors, nurses and other health professionals who quiz me about what is the ‘right’ thing to say or do in a particular situation; as though we can always be prepared for whatever we have to face in a consultation, and handle it ‘properly’. As if, by some magic, we can always find out exactly what the chances are of a person seriously harming themselves by asking them the ‘right’ questions, and manage any situation by being ‘ready’ with the ‘correct’ words and interventions. So that they will be safe…and we will of course not be criticised.

The problem is that it simply isn’t possible for any of us, therapists, doctors, patients or service users, to be sufficiently primed to deal with everything in work (or life) beforehand. There are too many different permutations possible. You have to learn how to use the knowledge, skills and particular talents you have and the information you can glean at that particular moment, to do the best you can to help someone in the time available. In talking to a patient, a mental health worker has to work hard to gain a person’s trust so that the answers to his or her questions will be at the very least some reliable refection of how they are feeling. In order to achieve this the worker has to be able to contain their own anxieties; about their own performance, the safety of the patient, what might or might not happen, in order to help the patient contain theirs. If the worker is struggling to deal with their own fears, such as being simply overwhelmed by the enormity of the person’s problems, the person seeking help will not feel safe enough at that moment to share how they feel- and the worker probably will not obtain an emotionally accurate sense of what is happening for them.

Its not only novice mental health workers who find it hard to manage uncertainty. I meet some quite experienced professionals who are still very obviously struggling to cope with their own fears. For me, it indicates they need a time and place to share their worries about the job. Supervision is still sorely lacking for many workers. As a consultant psychiatrist I regularly shared my concerns with my closest colleagues but I had no formal arrangement for support and supervision. But I have seen how, if we don’t learn to cope successfully with the uncertainty and fear we face in our work, we manage it in other ways. By detaching ourselves from the pain and becoming less empathic; by trying to dissolve it in alcohol and other substances; or just trying to exert an even greater control over the world, searching for answers to those unanswerable questions I get asked at the end of lectures which always raise an uncomfortable laugh from the audience. Our fear is palpable to our colleagues as well as patients.

If we can acknowledge the limits of certainty we have a least a good chance of reaching out and helping a person to tolerate the fear they are experiencing when they begin to tell us about something awful- like their thoughts about dying or the abuse they faced in childhood. Then we can begin to give them some hope. The first step in this must be staying calm, and showing we can take it.

I used to be very afraid of flying. I suppose I’ve undergone a prolonged course of desensitization over the years, but my palms still sweat at every take off and landing. Last week they were wringing wet.

After one run at the airfield which was aborted because of a ‘build up of traffic waiting to get in’ we eventually landed at Kirkwall. I was emotionally drained and almost tearful. But I know that what helped me to contain my fear of dying in the storm was the reassuring commentary of the co-pilot. Her calm professionalism helped. There could have been panic in the cockpit. But it didn’t show.

“Ladies and gentlemen, I know it’s been a difficult flight but you’ll be pleased to know they have just checked the runway; it’s safe and we’ll have you on the ground in a few minutes now.”

I wanted to thank and hug her, but I didn’t…being British of course. So I just said ‘goodbye’ with a teary smile, and stepped onwards into the rain. Happy to still be alive.

Work

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I’m going to write about a topic I know nothing about, at least not from the viewpoint of an expert in the published research, but as that doesn’t generally stop many other people I don’t see why it should inhibit me. I have after all worked for most of my life so I’ve plenty of lived experience; and I’ve treated many people who have been struggling to get back into work, or suffering ill-health as a consequence of the toxic environment in which they work. Its eighteen months now since I retired from the University, and a year since I gave up my clinical work and drastically reduced my workload. I’ve been told that work is something that is good for our mental health, so I can only tell you that I feel better physically and mentally overall than I have for several years. People tell me I look younger. I regularly apologise for having thrown in the towel; but it has been something of a fight- to get to the point where I could be done with the job before it did for me.

Please don’t get me wrong, I always enjoyed the interactions with patients and service users, and if I miss anything, it’s the feeling of making a difference in a person’s life; connecting with them and helping them to achieve some change. However I do know that if I had stayed in the NHS rather than being able to move into an academic post quite early in my career I would have been forced into taking even earlier retirement many years ago. I didn’t find the health service to be a sympathetic employer, either in the face of my own episodic periods of depression, which sometimes required time off work, or that of my patients who worked in the system- doctors, nurses and allied professionals. Not only was the macho style of management one of the factors that made it difficult for people to return to work with some degree of flexibility, it was sometimes a key factor in a person becoming depressed or severely anxious in the first place. I personally experienced bullying on more than one occasion, which contributed to several months off work. I know I’m less resilient than I sometimes appear to be.

My patients in the private sector had very mixed experiences. I remember one man who was criticised at work for needing to take breaks to ensure he ate at regular times- he had type 1 diabetes. When he got depressed they sacked him. Another patient with longer-term mental health problems was a poster-girl for a supported back to work scheme. The supermarket who took her on were very keen to be involved, but after a few months, after the support had been withdrawn and a ‘success story’ publicised, expected her to ‘work like everyone else’. Her voices returned as she became increasingly stressed and paranoid. She lost the job. In contrast, a person who worked for a large multinational company was allowed to return to work gradually over an extended period of time, and the occupational health department regularly consulted with all of us to ensure we were all agreed with the plan. They viewed my patient as a valued employee with expertise and experience they did not want to lose. I wish I could say that the NHS generally responded in a similar way. But it didn’t.

So where does this take me? Well, now the end goal of Recovery seems to be to get into paid work. Indeed attendance at Recovery Colleges has been sanctioned in order to apparently assist people with mental health problems to do so. Aside from the fact that, if Recovery were so straightforward all we needed to do was attend a course in it (and I don’t believe it is for many people), I’m very concerned about what we are sending many people back into. Not everyone is an academic who can work flexibly and take time off without risking their employment, I know that. However many more people do jobs from which they gain little sense of self-worth or value beyond simply earning a living. I’m a working-class girl. My parents both clocked in at 7.30 every morning and neither of them would have described their jobs as particularly fulfilling. What they did get was company, an opportunity to use some of their skills at least and a pay-packet. As a student I worked on supermarket checkouts, served in a bar and waited on tables for employers who varied considerably in their attitudes to ill-health. I wouldn’t have coped with those jobs at all if I had been depressed- nor would I have been in any great hurry to return. I personally know people who would never be able to cope with the stresses of regular employment again, yet they are repeatedly reassessed with the constant threat of losing their benefits. This just acts as a further stressor- we all know its cruel and has led to suicide.

So I have doubts about paid employment being the right goal for everyone. Surely it isn’t just about ‘work’ but how we spend our day? Yes, I know we have to bring in an income, but I’ve personally met very few people who really didn’t want to work. What they wanted was a supportive plan to help them move towards employment. A plan which might also involve volunteering and further study or training to gradually help them rediscover a sense of who they were, where they were going, and what goals they could realistically achieve. Not a simple ‘course’ but a journey, which might end in a regular job, but might not if that wasn’t right or possible. A much more humane solution than we are presented with now.

So don’t tell me that work is always good for me, because I know it isn’t. If it was, I wouldn’t be sitting here, feeling quite relaxed, writing this blog. I’d be on call. Or writing another grant proposal.

Whew!

‘Misery’, moods and madness

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I find I learn what I think about something as I write about it. Composing words on a screen (I stopped writing by hand when I gave up clinical work- I have a writing corn from years of scribbling in notes) helps me to formulate what exactly it is that is troubling me. But for a few weeks I’ve had difficulty writing anything very creative other than a single blog. I’m well aware I’ve been grieving for my beloved cat; I was feeling very sad but I began to feel a little better again. Then I had a visit from a family member, which stirred up unwanted thoughts (and dreams) about the past.  I began to ruminate again about all sorts of other ‘stresses’ in my life although I’m still not sure how really threatening they actually are, and, for a couple of weeks, my mood plummeted downwards.

 

It’s become fashionable in some circles not to use the word ‘depression’ but to refer to ‘misery’ instead. ‘Depression’ is a contested concept and there is a powerful view that it is primarily a state that is socially determined, a natural response to life events that will respond to social and/or psychological intervention without the need for anything more. Particularly medication.

 

While I wholeheartedly agree that the DSM concept of a unitary ‘depression’ is simplistic and that there are, as the founder of the Black Dog Institute in Australia, Gordon Parker, has suggested, many different ‘depressions’, I really must draw the line at the increasing use of the word ‘misery’. To be described as ‘miserable’ not only means being constantly unhappy but also has connotations of wretchedness and being an awful burden to others. ‘Misery’ as an idea I can just about tolerate, but to be described as miserable because you feel down feels like yet another form of stigmatization of the ‘undeserving poor’ who are unable, or cannot be bothered, to help themselves.

 

And the question is should all experiences of depression now be lumped together as a result of social causes? This is as simplistic to me as suggesting its all down to incorrect or ‘faulty’ thinking or something wrong with the level of monoamines in the synapse. All of these are, for me, similarly discredited ideas. Surely our brains (and our experiences) are worthy of more complex theories than these?

 

What I’ve learned is that there are times when something really seems to shift in my mood, as though some unseen worker in my brain pulls a lever.  Usually this happens in response to a build up of life events (yes, social factors play a key part), and when these events are of a particular kind that holds an inherent threat to my sense of who I am (the psychological part), then my mood is much more likely to shift, and quite rapidly too. When I was working full time I could move from feeling anxious, but keeping my head above water, to quite a different state of mind, within a day. When I am there I feel quite different. I don’t only feel sad, I feel physically ‘changed’; heavy of limb, tired, unable to sleep yet also very agitated. I ruminate about things that at other times I would be able to cope with easily and I am full of ‘fear’. When I look in the mirror I am quite sure I can see it in my eyes. There are times when my fear can shift into frankly paranoid thoughts and feelings of wanting to end my life. It’s terrifying and yet oddly familiar at the same time. I’ve been there many times, and I’ve just been there, albeit fairly briefly this time, again.

 

I’m fortunate that I haven’t had depression severe enough to warrant admission to hospital but I’ve had several episodes in my life. Why does this happen to me, but not to so many others who seem to be much more resilient? If I’m just ‘miserable’ perhaps it’s because I’m just inherently weak? For me, this is the obvious conclusion I must draw.

 

What I do believe is that ‘depression’ is a complex, multidimensional experience incorporating everything from profound and painful unhappiness to suicidal thoughts and psychotic degrees of despair. As I’ve said before, ‘depression’ and ‘anxiety’ are also very closely linked to the degree that I don’t find the idea of diagnostic co-morbidity useful at all.

 

The only way I can explain why only some of us seem to become depressed in response to life events is by drawing on the concept of vulnerability. A combination of genetic factors, early life experiences and unremitting life stresses such as lack of support and long-term physical illness add to our vulnerability. Such that, when a torrent of life events come along, those of us who have the greatest vulnerability and lowest threshold for becoming depressed, will get washed away by the waves while those who are fortunately more resilient seem to remain standing.

 

I don’t find it difficult to identify all of those factors in my own life. I’ve used biological (medication), psychological (therapy) and social (retirement from a stressful job) strategies to overcome them. Most of the time now, it works for me.  But there are still likely to be times when my mood just seems to switch gear again and I begin to see an image of the world distorted through a glass, darkly. I’ve never been clinically high, but when I begin to feel better I do sometimes feel an odd surge of well-being to be back in tune with life again.

Just please don’t call me ‘miserable’.

Grief

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With so many people experiencing loss and hardship at the moment its not easy to admit the depth of grief I have been experiencing over the last month.  I’m sure I’ve glibly told many people over the years how ‘grief is a normal human experience,’ but that doesn’t make it any easier to bear. It may simply be an everyday kind of emotional pain, but it washes over me in waves of acute sadness and despair. One moment I’m fine, the next I’m in tears; and it hurts physically too. There is a pain my chest right above my heart. But this grief is not for a human being, but for an animal companion, my cat Sophie.

 

I’ve seen that wry smile on a colleague’s face when I tell them how it feels to lose a pet . Not that Soph was a ‘pet’, she was a fiercely beautiful but barely tamed Maine Coon cat who viewed the human race if not quite the enemy, certainly as all potential vivisectionists. But those who don’t understand how attached you can become to an animal are simply embarrassed by our tears; they don’t know what to say. Statements like ‘well you can always get another one can’t you?’ are unhelpful. Yes, I have another cat, but he isn’t her. He is different. I will probably have a few more in my life (or rather they will have me) but each one I have lost has left a unique shaped space behind in my heart that another will eventually fill- but not in quite the same way. Some colleagues of mine have written about the important part that animals play in providing support for people with long-term conditions. But we live in a society where older (and younger) people with mental health problems are regularly separated from their companions when they have to move into new rented accommodation due to the desperate state of our housing policy. I cannot imagine the pain of having to give up my companion animal. Perhaps I will have to one day.

 

Grief is something I know about. I treated many people in my career who were failing to grieve for someone, or something they had lost. It doesn’t have to be a person, it can be a career, a person, your health, or even your hopes for the future. The list is endless. The process IS normal but it can be frightening if you have never felt it before. It isn’t the same as depression although if a person fails to grieve properly depression may follow, and in the vulnerable, loss may trigger it. But it should not be medicalised as it has been in DSM-5 where two weeks of depressed mood following loss is taken to indicate depression. Two weeks? That’s crazy. Grief can take years, a lifetime to resolve. The key thing is the trajectory of the process and the severity of the symptoms. Is it gradually getting easier over time or unchanged in intensity? How low are you feeling? Have you had thoughts of suicide or wanting to join the dead person?  I failed to grieve successfully once when I lost someone very important.  I didn’t talk about it. I tried to work my way out of it at the hospital rather than go through it.  You cannot shut it out. You have to talk, remember …and weep.

 

Sophie was killed by a fox one night in August. She loved going out at night to hunt. She began her life as a pedigree puss and then heard the call of the wild. She escaped when she got very frightened as were taking her to a cattery and wriggled out of her harness. She would never travel in a cage. I missed her terribly but I always hoped she come back to us, and she did. She spent two years living rough before she finally trusted a lady enough to accept help, and was returned to us (due to her microchip) by the RSPCA. She would sit next to me on the sofa and purr loudly, demanding her share of my love. Her coat was soft and silky before she disappeared, but woolly and thick when she returned after two winters outside in Yorkshire. But she knew she was home and she embraced it with enthusiasm. She was a happy, healthy cat and she was only seven years old. It’s really hard to accept she could have survived so long on her own and then die now. But I couldn’t have kept her inside. That would have been unbelievably cruel.  Yet I still feel I should have been there to protect her. Grief isn’t just about sadness, but guilt and anger. And remembering.

I have some of her fur, and a library of pictures to remember her by. I can look at them now. It was very painful at first.

It’s getting a little easier each day.  That I’ve been able to write this is a sign I’m coming through it.

But I’ll always miss her.

 

On not being immortal

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When I was a medical student, I remember one ward round when we were gathered around the bed of a patient who was breathless and coughing up blood. She admitted to being a heavy smoker. The surgeon gave her his usual stern ticking off about the dangers of cigarettes, and then we all trooped back to the doctor’s office where he took the patient’s chest x-ray out of the envelope and pushed it up onto the light-box on the wall.

“Look at the mass there he said,” pointing to dense shadow in the left lung, “almost certainly a carcinoma.”

And then he calmly took a packet of Senior Service cigarettes out of the pocket of his white coat and lit one up, puffing away as we discussed the prognosis. You have to understand this was the Stone Age.  People did still smoke in hospitals, even doctors. But some things haven’t changed. I think many doctors still have a peculiar belief in their own immortality. That knowing all about disease not only gives you power over it but makes you immune to it. It begins at medical school. Many medical students aren’t even registered with a GP where they go to university. They alternate between being sure they have every disease they learn about and denial of their own susceptibility. And it carries on. Doctors generally don’t smoke now, but we still abuse ourselves in other ways, notably with alcohol. We are tough and macho, don’t admit to weakness, and rarely follow the advice we give our patients, yet expect them to wholeheartedly agree with us.

Last year I had to come to terms with the fact that I’m not going to be immortal after all. I don’t mean that in the sense of transcendence of my soul.  I’ll keep out of that argument for the moment.  Rather I am not going to live forever, and life might get quite a bit harder for me physically in the future than it is now. To add to the anxiety, depression and hypothyroidism, I was diagnosed with progressive kidney disease.

Okay, so I know I will not live forever. Of course I won’t. Indeed would I really want to? There have been times when I’ve been so depressed that I’ve wanted to end my life somewhat sooner. The thing about depression for me, unlike physical illness, is that it feels like if I were to die from it, it would be because I wanted to. I have control. Even though I know rationally, as a psychiatrist, that what I perceived I wanted would be strongly influenced by my mental state at the time.  But there is, I think, a part of all of us that secretly hopes we can cheat fate and carry on forever (only while enjoying of course the perfect health of youth). When I was a young child, the idea of dying seemed so impossibly far away as to be almost irrelevant to being alive. Then my grandfather died followed by my father, both at ages not so different from where I am now. When people close to you die, death became a real possibility for you too.

People who have chronic illness are more likely to experience depression and anxiety, and the more chronic illnesses you have the greater your risk. In the last research project I worked on in Manchester, we attempted to offer psychological therapy to people with diabetes and/or heart disease who were also depressed. What was striking was how few of these people were actively receiving help despite the fact that all them had been screened for depression on an annual basis as part of the payment incentive system for GPs in the UK. Some of them had never discussed their mood or suicidal ideas with their doctor. They didn’t want to, they were embarrassed or they didn’t see the point, so they suffered in silence. It can feel stigmatizing having chronic illness, and having a mental health problem as well just doubles the stigma.

So it turns out I have a genetic disorder of the kidneys that I’ve had for many years, but didn’t know about before, and which is going to get worse as I get older, at a rate as yet undetermined. There is a good chance I will eventually need to have dialysis. Despite feeling fitter than I have for years, it is as though my body has let me down. Something is happening inside me over which I have no right of determination. Like many people with chronic illness I feel my useful life has now become shorter, so I’m beginning to speed up my rate of travel, picking up again those things I started to do many years ago but dropped because of my career, and aiming to achieve a few of them while I’m still quite healthy. Not quite a bucket list but something similar. It has increased my level of anxiety but I don’t feel depressed about it yet because I’m still in control, trying to keep myself fitter than I have since – well ever.

Or maybe it’s because I’m just being tough…. and I still believe I can win.

A diagnosis of anxiety

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On one of those occasions when I peep around the screen at what my GP is typing I see a diagnosis of ‘anxiety with depression’ at the top of the screen. I’m not sure how I feel about that. I suppose I’ve always thought about my problems as being more to do with depression than anxiety. But regardless of the idiosyncrasies of the recording system that GPs use (for the uninitiated, the Reed codes used in British General Practice don’t much conform to DSM or ICD), I think it’s probably right. In my life, low mood comes and goes, while anxiety has been pretty pervasive at the times when it hasn’t progressed to frank agitation.

This all comes to mind recently because the National Institute for Health and Care Excellence (NICE) just published its quality standard for anxiety disorders. It has information on all the different disorders neatly laid out- with specific pathways for Generalised Anxiety disorder, Panic disorder, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder etc. At the same time there has been the usual and continuing debate about the validity of diagnosis in psychiatry in the twitter sphere, in which I occasionally participate.

My problem with NICE guidance is that there are so many different pathways for the different diagnostic categories of what are called Common Mental Health Disorders– which consist of all the anxiety disorders plus depression. Some mental health professionals disparaging call these ‘minor’ mental health problems and the people who suffer with them the ‘worried well’. I’ve unfortunately heard psychiatric trainees use those terms.

Warning: don’t ever use these terms in my presence, I can’t be responsible for the consequences.

If you add in the other common mental health problems in the community, use of drugs and alcohol which many use to self-medicate for these ‘minor’ problems, you have a complex bundle of guidelines for a large section of the community (around 15%) who mostly get their mental health care from primary care. In common with the main classification systems, NICE treat all these as distinct diagnoses. If only life were so simple.

The problem is that in the real world they all overlap, co-occur and change around over time much in the way that my own symptoms have done since adolescence. ‘Anxiety and depression’ is the commonest mental health problem that GPs see. Mixed in with that may be some phobic symptoms, panic attacks, obsessional symptoms along with other features which suggest post-traumatic stress such as hypervigilance. Add to this the common ‘co-morbidity’ with drugs and alcohol, and the difficulty some people with these problems additionally have in social relationships which equates to some degree of personality difficulty, we have the potential to label a person with multiple diagnoses. At the other extreme we could say, these ‘disorders’ are all part of the same problem. You are suffering from something called ‘life’.

My view is somewhere in the middle, but I struggle with it. I’m a supporter of the need for psychiatric diagnosis and anyone who doubts the need for it should first read Robert Kendell’s classic book The Role of Diagnosis in Psychiatry. But to say that doesn’t mean we’ve got it right, or that the same system is appropriate in all settings. In my work with WHO, I’ve helped towards developing the ICD-11 system for primary care, which is a good deal simpler than anything DSM can ever think up. However what is key for me is that a diagnosis is only a construct,

as Kendell puts it:

‘thoughtful clinicians are aware that diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organising and explaining the complexity of clinical experience in order to provide predictions about outcome and to guide decisions about treatment.’

Clinically I have found the NICE stepped care model useful: severity of symptoms is the key to what intervention is likely to be helpful. But my approach to helping people has been to start with their life, their problems and hopes and concerns and help them to work out goals for how they would like it to be different. To work towards this by both finding out exactly what they are experiencing, and have been through, and then use a range of therapeutic tools from medication, psychological and social interventions in an essentially transdiagnostic way according to what is likely to help, both from the evidence base and their own past experience and preferences. This has been how I’ve supervised step 2 workers in Improving Access to Psychological Therapy (IAPT) in Salford where I worked for several years, to deliver care for people who might have ‘anxiety and depression’ in some kind of admixture, but had complex life problems. I’ve utilised a very simple set of ‘working’ diagnoses which can easily change over time.

I think we do underestimate the importance of anxiety, but it’s not just that we fail to recognise anxiety disorders. Anxiety pervades all of the common mental health problems except for in those people who experience depression without it. There is a significant genetic component which I can easily identify in my own family. Anxious symptoms in the presence of both bipolar and unipolar depression tend to make the outlook worse and suicide more likely.

Recently, since I gave up the day job, I’ve been feeling much less anxious. This was (unhelpfully) commented on by a colleague whom I hadn’t seen for a while who decided to mime how agitated I used to be at times. I have to admit that I was (strangely) usually worse when in his company. However this coming week I have to have more investigations for my physical health and the familiar churning stomach, sweating and tension have returned once more. Hopefully, after tomorrow, I will be able to return to the combination of exercise and mindfulness which I have recently found helpful in managing my ‘anxiety’.

Fingers crossed.

The healing power of the sea

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I’m on the coast of North Yorkshire this week weathering a storm. I can hear the waves lashing the sea wall below my window. It’s different from the storm I would be facing if I were still at work, having to face the reality of providing care for people with mental health problems when services are being so constrained. While I listen to the windows rattling and watch the water rising up the slipway at high tide I find myself dipping into twitter every now and then. I can sense my blood pressure rising as I follow the debate about whether it is actually possible to achieve parity of esteem with physical care for people with mental health problems when everything is being cut. In some ways I miss work, particularly for the sense of being able to make a difference and for the contact with my patients. In other ways, for the constant anxiety it evoked in me for so many years, I don’t miss it at all. I’m still writing, and involved in research and teaching but I have control over what I do each day. That sense of having control over your life is important when you experience depression.

The sea can be both a source of fear, and of great comfort. I grew up next to it, and it evokes powerful memories of my childhood. My father was an excellent swimmer, but however hard he tried he never succeeded in teaching me. I was simply too anxious to take my feet off the bottom. I didn’t entirely trust he would not let go of me, yet now those times when I sat on the beach and watched him powerfully crawling through the waves off the Lincolnshire coast are some of the fondest memories I have of him.  I was born a couple of years after the great flood, which devastated the East of England. Since then I’ve travelled all over the world but have always felt the need to dip my toes in the water of whatever ocean I find myself beside. It’s like touching base with the past.

I cannot begin to imagine what it is like to be swept away in a tsunami, have your home battered by tidal waves or lose your husband when a fishing boat goes down with all hands. I’ve stood in the waves on Copacabana beach in Rio, and felt the warm tropical current try and drag me down into the depths. I’ve been unable to go into the shallows in Queensland for fear of being attacked by box jellyfish and sharks. The ocean is immense, merciless and can be so destructive, and yet it connects us all together. It has a power over which we can have no control; we have to accept it.

When times are bad the sea has a way of helping me to get my problems into perspective. I came here once, to the place I am now in Yorkshire, when an intense relationship that meant everything to me had broken down. Listening to the sound of the waves pounding the walls below as I lay in bed, with only the moonlight shining through the curtains illuminating the room, both resonated with my mood and helped me to understand how life goes on whatever happens.

Some years ago when I was on a beach in the Pacific Rim Park on Vancouver Island in Canada, I saw a woman meditating whilst sitting on a driftwood log next to the ocean. Since then, I’ve always taken the opportunity to use the sound of the waves to help me to clear my mind and relax whenever I am in earshot of the sea.  Next time you are there, whatever the weather happens to be, find somewhere to stand or sit awhile that is sheltered from the wind (or rain). Focus on your breathing as you would in any kind of meditative practice, but listen intently, with your eyes closed, to the sound of the waves ebbing and flowing and crashing to the shore. Try and carry on for at least ten minutes or longer if you can. When I make time to do this, it gives me a wonderful sense of wellbeing. For me it’s a kind of meditation in which I connect directly with nature. I suspect it’s a similar feeling to that achieved by mindfulness practice, but I am only just making time now to learn more about that. I will write more on that topic soon. In the meantime I am returning home with the sound of the sea, not in a shell in my pocket as I did as a child, but in my soul instead.