KEY 9: ACCEPT WHO YOU ARE

Not sure how to do this as I don't know who I am.

My midlife crisis has consisted of me trying to find out, first by working out my clothing style (yes, I know), then my personality type on MBTI. I am 18 months into this and still not very sure, although doing the exploring has been amazingly engaging and I have learned a lot about myself. 

I don't think of myself as obsessional (in fact I police any obsessional behaviour in myself quite carefully so maybe I am actually...See what I mean about not knowing myself?). I always avoided doing a blog because I knew I wouldn't be interested in one thing long enough to sustain one on a theme. But there is one theme with everlasting interest for me - this stuff that's happening to me - what does it mean?

A nice image of all the thoughts that go through your head all the time
from http://mindfulnessni.org/what-is-mindfulness/

RIGHT NOW what's happening to me is fatigue, and I am sorting through the reasons why I might be exhausted, in the way you do in order to work out how to get unexhausted, as the strategies I tried before didn't work. There are lots of explainations out there which apply to me to one degree or another. I think it's as much of a 'rabbit hole' as personality typing, so you could get lost in it, but there is perhaps something in all of the explanations which fit me, and it might be worth thinking about the explanation - where do they overlap and how does that help me?

So first, here are some syndromes which appear to apply to me now (although I have had no differential diagnosis of this kind from a professional):

CLINICAL DEPRESSION

where I got this from - WHO ICD 10

'In typical depressive episodes... the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity...(for at least 2 weeks). Marked tiredness after only slight effort is common. 

Other common symptoms are: 

(a)reduced concentration and attention; 

(b)reduced self-esteem and self-confidence; 

(c)ideas of guilt and unworthiness (even in a mild type of episode); 

(d)bleak and pessimistic views of the future; 

(e)ideas or acts of self-harm or suicide; 

(f)disturbed sleep 

(g)diminished appetite.'

'...characteristic features that are widely regarded as having special clinical significance. The most typical examples of these "somatic" symptoms are: 

loss of interest or pleasure in activities that are normally enjoyable; 

lack of emotional reactivity to normally pleasurable surroundings and events; 

waking in the morning 2 hours or more before the usual time; 

depression worse in the morning; 

objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people); 

marked loss of appetite; 

weight loss (often defined as 5% or more of body weight in the past month); 

marked loss of libido. 

Usually, this somatic syndrome is not regarded as present unless about four of these symptoms are definitely present. The categories of mild (F32.0), moderate (F32.1) and severe (F32.2 and F32.3) depressive 

According to this, as I have two of the three basic symptoms, 4 of the other common symptoms but only 3 somatic symptoms, I fit 'recurrent depressive disorder, currently moderate depressive episode without somatic symptoms'. 

On the other hand, the description doesn't really sound like me, and some of my problems are the opposite of these eg weight gain, mood best in the morning, and sleeping 12-15 hours a day. In particular I don't actually feel low in mood or lacking in enjoyment most of the time - only when I put myself into situations that I'm not up to coping with at that moment. When I can listen to my body, avoid difficult conversations, and rest when I need to, I feel quite positive, and can really enjoy things. In general I know this will pass and that it doesn't make me a bad person.

ATYPICAL DEPRESSION

ICD 10 does say that there is great individual variability in depression symptoms, but this seems to be a bit of a cop out, allowing practically anyone to be diagnosed with depressive syndrome if the doctor thinks they are depressed. There used to be a syndrome called atypical depression which seems to fit my problems more closely, but this has become part of the depressive syndrome in ICD and part of major depressive disorder in the American classification. It is still described in public-facing websites WebMD and NHS as follows: where I got this from

 'The main characteristic of atypical depression that distinguishes it from melancholic depression is mood reactivity. In other words, the person with atypical depression will see his or her mood improve if something positive happens. In melancholic depression, positive changes will seldom bring on a change in mood. In addition, diagnostic criteria call for at least two of the following symptoms to accompany the mood reactivity:

• Sleeping too much (hypersomnia)
• Increased appetite or weight gain
• Having a more intense reaction or increased sensitivity to rejection, resulting in problems with social and work relationships
• Having a feeling of being weighed down, paralyzed, or "leaden" '

I certainly feel more cheerful if someone seems to be caring about me, or for example when I saw a particularly high quality production, and I have all four of the additional symptoms. 

Any depression diagnosis requires physical cause to be excluded, which it has not yet. I have low iron, and H pylori, but I don't think these are enough to explain the degree of tiredness and upset I am suffering.

So, so far it looks as if my problems are described fully by atypical depression.

Treatment for this is antidepressants (which don't work so well for atypical) & psychotherapy. Self-help includes regular exercise, and a diet with vits A,C,E; wholegrains; low fat proteins; B12 and folate; vit D; selenium; omega 3 fatty acids.

And reduced use of drugs, alcohol and caffeine.

SOMATISATION DISORDER

from ICD10 as above

'A definite diagnosis requires the presence of all of the following: 

(a)at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found; 

(b)persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms; 

(c)some degree of impairment of social and family functioning attributable to the nature of the disorder...

Exclude physical illness, anxiety and depressive disorders, hypochondriacal disorder, delusional disorder.'

a/and c/ are true for me. b/ not so much - I do go away when they tell me it's not serious. Physical illness is not yet completely excluded, and I am depressed according to this classification. I don't have an idea I've got cancer or something, and I am not in a good position to judge whether I have a delusional disorder, but I think not!

CHRONIC FATIGUE SYNDROME CFS /ME myalgic encephalomyelitis

where I got this from

'Most patients seeing a GP in the UK today are diagnosed using the criteria outlined in the NICE Clinical Guideline of 2007 (read the Guideline and supporting documentation here). This Guideline makes clear that the illness is recognised on clinical grounds alone (i.e. that there is no specific ‘test’ for the illness) and that healthcare professionals should consider the possibility of ME/CFS if a person has:

a) Fatigue with all of the following features:

• new or had a specific onset (that is, it is not lifelong),
• persistent and/or recurrent,
• unexplained by other conditions,
• has resulted in a substantial reduction in activity level,
• characterised by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days).

and

b) one or more of the following symptoms:

• difficulty with sleeping, such as insomnia, hypersomnia,
• unrefreshing sleep, a disturbed sleep–wake cycle,
• muscle and/or joint pain that is multi-site and without evidence of inflammation,
• headaches,
• painful lymph nodes without pathological enlargement sore throat,
• cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts and information processing,
• physical or mental exertion makes symptoms worse,
• general malaise or ‘flu-like’ symptoms,
• dizziness and/or nausea,
• palpitations in the absence of identified cardiac pathology.

It is important to stress, however, that ME/CFS, whether defined by NICE or using another definition, remains a “diagnosis of exclusion”, which means that other possible causes of a patient’s symptoms should be excluded, often by testing, before this diagnosis is given. As the NICE Guideline says, “A diagnosis should be made after other possible diagnoses have been excluded and the symptoms have persisted for 4 months in an adult [and] 3 months in a child.”'

I have all of a/ and 6 of b/. But I don't think I have this for several reasons. The more dramatic symptoms and limitations do not relate to me. I would say that my tiredness has been lifelong, although it's much worse at the moment than it usually is. Cardiac causes of my palpitations and pains have been excluded but I am still under investigation for stomach symptoms.

Canadian consensus document on ME/CFS

This one seems authoritative and has more detail on the symptoms and treatments for this syndrome. It also has a useful section on differentiating it from mental health problems. Which gets quite annoyed with people who don't get the difference! I don't know whether that is because sufferers won't engage with doctors who think it's 'all in the mind', or because they have the idea that mental illnesses don't have accompanying physiological changes (neither of which I necessarily go along with).

Again, I don't relate to the perspective here, and the relationship between activity and fatigue is more on a minute to minute than day to day basis. However, I do relate to the stuff about thinking being as fatiguing as exercise. So I am going to stop doing this now. and have a proper rest.

That said, it has some helpful ideas about how to help yourself. In summary these are - learn to listen to your body, adapt your life to your fluctuating capacity rather than the other way round, relaxation, sleep hygiene, healthy diet + multivitamin, exercise only within your capacity. This is what I have started doing for myself recently.

THERE WERE MORE BUT I CAN'T THINK OF THEM RIGHT NOW. SEE YOU LATER.

OK, 13 hours sleep later...

NEURASTHENIA  - excluded because of the severity

HYPERMOBILITY SYNDROME - don't quite fit the profile

AUTOIMMUNE DISEASE - test for inflammation negative

more and more and more
MENOPAUSE - well almost anything can be a symptom of this apparently. The treatment is...there is no real 'treatment' as it's normal. Exercise, healthy diet, supplements. Time will tell.

MY ANALYSIS OF THIS LIST:

Having done this (in an uncharacteristically precise way) I have a new perspective on why people are dismissive about psychiatric disorders as not illnesses. They are descriptions of symptoms which are almost all very common ie extensions of normal. These are all extensions of normal, and there are no clear signs that I have one rather than the other. I could almost have them all. (Except the ones which explicitly exclude themselves if there is another one, like neurasthenia and depression, presumably to serve the classification system rather than the patient).

There are presumably so many because doctors are (by their training and inclination) not interested in non-fatal syndromes and so people with disabilities due to them are left having to work it out for themselves. Like me. Depression is the exception, as doctors do diagnose depression which is not severe and life threatening, which has probably been driven by the drug companies (see Prozac Nation).

So officially (on my sick note) I have depression. But what do I really think is going on for me? And do I think something needs to be done about the way doctors think about this? If so, in what direction? Step back and let it be normal? Or prescribe more non-medicine solutions?

Right now I don't really care about that. What I care about is what is really going on for me, and what will help me recover quickly and never ever ever get to this point again.

WHAT IS REALLY GOING ON FOR ME? & HOW DID I GET HERE?

I drove myself to a standstill.

I have an image in my head of a donkey being beaten even though it is on it's knees.

https://uk.pinterest.com/pin/540502392750733374/

Would you haul this donkey up and send it back to the same work? Seriously not.
I don't do physical labour, but my work and my 'self-discipline' have done this to me. Again.
Radical rethink time. 

This one isn't down yet, just resisting a bit. As I was in 1982. And 1996, and 2001, and 2002, and 2003...etc
That would have been a better time to rethink my strategy.
http://www.newser.com/story/163485/new-meat-scandal-donkey-in-south-africa-burgers.html