I figure effort level using heart rate. There’s a lot you can read about on the web about why that’s reasonable. The graph shows my best guess, based on experience, how my sustainable heart rate depends on ride duration, which is on a log time scale from 10 seconds to 100 hours (assuming I’m well warmed up for the short rides).
This being my history with the medical treatment of BPDII.
In summer 2003 I had been unemployed for more than a year. In October 2001, my employer, a high-tech equipment maker, went bankrupt after the investors lost their nerve the previous month. Every employee was laid off at a meeting in the cafeteria. This wasn’t a surprise but it was a new experience, as was unemployment. One has a lot more time when unemployed. With a full time job its hard to squeeze in all the things that are so much more interesting and relevant than either work or being at the office: reading books, practicing guitar, going to movies, clubs, concerts and gigs, playing games and sports, writing, collecting music, improving ones German, and maybe learning Spanish. But instead of thus deploying my unemployed time I just spent it being depressed.
In the second half of 2002, the absurd build-up to an outlaw violent US attack on Iraq was underway. I felt complicit in this war crime having subsidized it as a US tax payer and having failed to do anything much to stop it. A couple of friends managed to talk themselves into supporting the war — willful acceptance of a lie, as I saw it (still do). This was a betrayal I could not accept — a crushing blow. Then the war happened.
The next four months or so did not exist. Human memory is selective; it remembers only what is worth remembering, what’s new, not routine and literally memorable. I believe I managed to get out of bed every day, eat and wash myself. And I remember pain and self-hate from reliably failing at any of the tasks I set myself, no matter how simple and small. I’ve long known that ambitious goals when depressed are pointless but that getting something done, anything, no matter how small, was about the only thing that feels any better than really bad. But nothing happened.
In the summer I started to recover. It had been the worst depressed episode of my life. I had been through depressions often before, usually twice a year since mid-adolescence, but the evidence was that it was getting worse. I had wasted too much of my allotted time here being depressed. I went for help.
I consulted a private independent psychotherapist known to me for quick, effective results. I had a preconception that I wanted cognitive therapy to remedy the false cyclical logic of self-defeat and loathing in the depressed mind. I wanted to learn how to stop putting obstacles in the path of my own life.
After ruling out early life trauma or other subconscious motives for my illness and interviewing me about my symptoms he said he thinks I have manic depression should see a physician about drug therapy. Saying that he’s not a psychiatrist so he got out his copy of DSM-IV so we could read the diagnostic criteria of bipolar disorder together. We checked a few other conditions as differential and it seemed fairly clear that I was bipolar II, i.e. manic-depressive with mania that doesn’t reach the level of dysfunction.
Surprisingly, I was surprised. I had known that my behavior and moods were of a manic and depressive nature since I was an undergraduate student. I knew that there was a regular pattern of mania roughly every February and August followed by gradual onset of depression of increasing intensity until it flipped suddenly back to mania. I had learned to fear and prepare for the Manias. I could accurately and objectively characterize both the manias and the depressions. I also knew that these were the characteristic symptoms of manic-depressive illness and that it is also known as bipolar disorder. And I knew that manic-depressive people took lithium to control the symptoms; they used mood stabilizers. I had known all this for over twenty years but not made the connection that I was myself a manic-depressive, that is, I am a person with manic-depressive illness, bipolar disorder, and that needed psychiatric treatment.
So I sat in that psychotherapist’s chair (do any of them still use a chaise longue?) quite surprised, a little alarmed, trying to take the idea in. He encouraged me to take the view that the problem has a biological cause, that I shouldn’t feel responsible for my moods, and that I don’t need to tackle them alone. I roughly remember his words, “You don’t have to strap your balls on and go to fight this.” He suggested I think of myself as someone with congenital hypertension that no lifestyle adjustment can remedy. A blood-pressure-reducing drug may not be the most desirable solution but it’s better than nothing and it helps.
So I went to see a psychiatrist at the same hospital where my GP works. The meeting was farcical. She became obviously irritated with me when I said that I had taken myself to a psychotherapist privately. I became irritated at that and defended the therapist, a man I greatly respect, and my decision to see him. She became very angry that the therapist had offered a psychiatric diagnosis and she immediately disagreed. She decided that my depressions had not met the diagnostic criteria for major depression and therefore I wasn’t bipolar II. That I had managed to never lose my job as a consequence of depression was the key — if I had managed to hold down a job then I must be functioning. She really did nothing to hide her contempt for me and my friend the therapist or that she was professionally insulted that either of us, both equally unqualified, should have been so bold as to wield the DSM-IV or had the temerity to deploy technical terminology such as “bipolar II disorder” that we do not fully understand. But she offered me a consolation prize. She could, with more examination and after due consideration, perhaps offer me a diagnosis of cyclothymia. But why bother? All she could do with that diagnosis is offer a mood stabilizer like valporate, something I didn’t really want and that a mild disease like cyclothymia didn’t really need. I decided not to waste any more of her important time with my malingering or return to insult her professionalism again.
That absurd and pointless interview set my treatment back about three years.
I made an appointment to see a social worker for talk therapy. But by the time of the appointment I had found a job (a fairly good one, surprisingly enough, after two full years unemployed), I was hypomanic (a bit off schedule) and consequently arrogant enough to regard the therapy as unnecessary. So I stopped after only one or two visits.
But the cycles of the disease continued and when depressed I would fear for my job. My productivity was so poor that I could go for weeks without any real progress on any project. I managed to hide this, somehow I always have, but it’s really not a swell feeling to have to do so.
In early spring 2005 my mother, who lived in Scotland, was diagnosed with AILD, a bizarre and rare lymphoma. Her treatment with steroids caused psychosis and acute confusional episodes severe enough for hospitalization, once for two weeks against her will. (She was “sectioned”, as they say in the UK, which is when the police arrive with the ambulance.) Her subsequent treatment with antipsyhotics and thalidomide caused depression. It seemed like a cruel way to treat a woman in her late 60s.
I became tense, irritable and unhappy. It was a dramatically new. I clearly remember when I first noticed it, sitting with my legs wound tight around the office chair at my desk, back arched, leaning over the keyboard with a frown and restless fingers. It was perfectly persistent. It didn’t go away for over two years and after my mother’s death in August 2007.
During 2005 and 2006 my moods were still episodic but different. I did not experience euphoric hypomania, only dysphoric. I also learned what agitated depression was like. I was perpetually tense and irritable. It was exhausting.
In summer 2006 I returned apologetically to the social worker I had disdained the fall of 2003. I was in a tense, irritable remission when we met and for quite a while we didn’t have that much to talk about but I wanted to maintain regular contact in case something happened with my mood, which at some point was sure to happen. When in December it did, she suggested my GP prescribe an antidepressant (unlike the psychaitrist in 2003, the social worker didn’t regard my depression as subsyndromal, but then that psychaitrist would surly regard this social worker as unqualified to judge) but he refused saying I should see a psychiatrist and citing the risk that if I am indeed bipolar then an antidepressant could be dangerous.
I got an appointment very quickly and bipolar II diagnosis within half an hour. I was cagey about the somewhat paranoid and delusional thoughts featured in some of my youthful manic episodes. Seeing as the treatments are no different, I’d rather live without bipolar I on my medical records. I’ve never been ravingly psychotic but I’ve definitely walked on the perimeter of neurotic.
I was given lamotrigine and quickly developed a persistent low-level dysphoric hypomania: reduced sleep, fast thoughts, energy, ideas, arrogance, spending, irritability, cynicism, pessimism and I was unable to relax. I was given Seroquel as well and that helped me relax and sleep better. Eventually in the summer I asked to be taken off lamotrigine to see if the tension and irritability would go away. The doctor strongly resisted taking me off a mood stabilizer. We compromised on a lower dose, which didn’t help. In September, after my mother’s death, I switched to taking lithium and sertroline. The nine-month-old dysphoric hypomania dissipated but I was left with persistent fatigue and muscle weakness. Those side effects, and how I handled them, are the subject of another post in this blog
the fsb 
