On Medication: Managing with Mental Illness - Part 1 of 3

(Note: This post contains some profanity)

Crisis

It’s late summer in upstate New York in 2006 and I’m sitting alone in a dimly lit room in a darkened building on top of a hill. The inky midnight outside streams in through large windows. My environment reflects my mood.

Illustration by Mink Ratcliff, www.hypercarnivore.com

I rub my eyes. They hurt from staring at a computer screen for 10 hours at a time for each of the past three nights. I’ve been churning out a 70-page Master’s thesis in grueling segments between the close of evening vet school study group and the start of morning lectures. (Technically, one is supposed to have completed one degree before starting another, but rules were made to be broken.)

The deadline for my thesis is days away and I’m not done with the first draft yet. Stress and lack of sleep trigger my migraines, so I’ve made reluctant friends with the thrumming pain in my brain that beats in time with my elevated heart rate. The migraines started when I was a freshman in high school, and I have yet to find a reliable therapy. At least this one isn't making me nauseated.

I can’t complain; I brought this on myself. This overnight cramming is only happening because of nine months of professional-grade procrastination. After college, I earned a Fulbright Scholarship to study sociology at the University of Amsterdam. My sociology Master’s program was one condensed year, the first half of which was classroom learning and study; the second half was self-directed time for performing an academic study and writing a thesis fit for publication in a professional journal. The magnitude of the task scared the shit out of me and I became paralyzed with anxiety.

In the 9 months leading up to veterinary school, I was able to perform the study - I observed a feral cat non-verbally interact with people and and manipulate them for food and care, thus proving a more complex inner life than sociology gives animals credit for. In the six months following data collection, I hadn’t written a page of the thesis. In the past three nights, I’ve completed about half.

I sit leaning forward, pressing the heels of my hands into my eye sockets. The pressure helps the migraine and shuts out the world for a moment. When I pull my hands away, I blink several times to refocus. The cursor on my computer screen blinks back at me, and I decide to pretend that it’s commiserating with me instead of mocking me. The muscles in my back have tightened themselves painfully, drawing my shoulder blades together and restricting my breathing. For weeks, they’ve remained cinched up despite every effort, giving me constant back and neck pain. As I lean back to stretch, I realize my foot is tapping a mile a minute.

Inside, my mind is racing, but not straight ahead. Instead, my attention flails from one unrelated worry to another. Underneath it all is an overwhelming, nonspecific sense that something terrible is about to happen, but I can't settle on what that might be. In a deranged effort to help identify the threat, my brain pulls up everything I've done or experienced and scans it for danger. The effect is that everything I've done or experienced feels dangerous. The sensation is especially odd because I see my worry from a distance, fully aware that it’s irrational and yet completely unable to stop it. It’s like having a dedicated bully inside my head at all times. That feeling right now is cranked up to 11.

I’m startled by the tears suddenly flowing down my face. I reach for my phone. Two rings. “Mom? I’m breaking. I’m fucked up. I can’t do this. I need help.”

                                      Illustration by Mink Ratcliff, www.hypercarnivore.com

My mother raised me and my brother on her own on government assistance. She’s all the parent I could ever need. Once I clarify that I’m not in physical danger, she turns pragmatic, “Derek, I’ve never heard you like this. Can you go somewhere?”

“What do you mean?”

“Like a clinic or something?”

“The emergency room, but that seems extreme.”

“Then call Dave,” she said. She’s right. Dave has been my counselor since middle school. By then, the clinical anxiety and depression I'd developed from a childhood of mental, emotional, and physical abuse from my father were longstanding. After the abuse, grades became my obsessive focus; they were a vain effort to prove my worth. I received one grade lower than an “A” in college, and it was in a graduate class I took as a junior. My self-image was so mangled that graduating with a 3.996 GPA, the highest in my college department, felt like barely passing. From the outside looking in, this looked like success. In truth, my good grades were as much a symptom as an achievement - they brought me no genuine fulfillment or sense of worth.

I’ve only sought Dave out a handful of times in the past few years because of a combination of progress and avoidance. I pull up his number and dial.

“Hello?”

“Hi, Dave, this is Derek Calhoon. I’m so sorry to bother you this late.”

“It’s okay. I know you wouldn’t call unless it was important. How can I help?”

The human warmth in his reply immediately blunts the cutting edge of my anxiety. He asks me to tell him about what’s been going on since we last spoke. I mention the thesis and months of procrastination, the looming deadline, my recent breakup, the crushing stress of my first term in veterinary school, my quick transition from Amsterdam directly to Cornell - I feel like the list goes on and on and on. Dave waits silently for my rambling to exhaust itself. He lets a momentary pause hang between us, then replies serenely, “Wow. That sounds like more than one person can handle.”

I’m instantly overcome. His tone and his words cut through the capsule I’d built around my internal experience. Wrapped tightly inside my private cycle of self-reinforcing anxiety, it hadn’t occurred to me that it might be reasonable to feel overwhelmed. For a moment, I see my stressors and my responses to them from the outside, and I’m so sad about the layers of shame I’ve piled on top of my anxiety.

Illustration by Mink Ratcliff, www.hypercarnivore.com

Seeing myself as just a person struggling - poorly - under a heavy load calms me. My tornado of anxiety subsides into a mere storm. I answer the standard questions - I’m not having thoughts of harming myself or others, and I’ve been exercising and eating well. Sleep, obviously, has been in short supply. Next, Dave asks what the consequences will be if I fail to meet my thesis deadline - I’m unable to think the thought; it simply does not compute. He persists and coaxes out of me that missing the deadline, though a crummy option, is a possibility that both exists and could be manageable.

Next, we work through a few of the strategies we've developed for acute anxiety episodes, but it becomes clear that I won’t be able to breathing-exercise or self-talk my way out of this one.  

“Derek, I'm concerned about you. It it sounds like you’re having a serious mental health crisis. You need to see someone first thing tomorrow. You need medication, at least for the short-term.”

Illustration by Mink Ratcliff, www.hypercarnivore.com

This stuns me. Dave’s never recommended medication before. He considers it a tool of last resort, and I’m sobered to think that my current mental state qualifies. My lifelong companion, shame, venomously whispers at me anew. Am I the kind of person who needs brain medication? Am I incapable of functioning “normally”? (Spoiler alert: Yep.) I start re-negotiating my identity as we wrap up and say goodnight. I stop writing for the night and head home. Strained like an overheated computer, my brain clicks off and all is black as soon as my head hits the pillow.

Short-term Meds

Cornell’s main campus is situated atop stone bluffs in Ithaca, New York. This tiny town in the Finger Lakes region of Upstate New York swells with students each academic year to become the largest town within an hour’s drive. Its isolation is celebrated in its unofficial slogan, “10 square miles surrounded by reality.” Cornell’s vet school and teaching hospital sit on the far western edge of campus, at the terminus of Tower Road. Three quarters of a mile in the opposite direction is  the famous Cornell bell tower, which sits among the older buildings and quads on campus.

Illustration by Mink Ratcliff, www.hypercarnivore.com

Some of these buildings date back to the founding of the school in 1865, including the one that originally housed the vet school but now trains students in a different discipline. At the time of Cornell's founding, horses were essential to the economy, doing the same work cars, transport trucks, and heavy equipment do today. Legend has it that when Andrew Dickson White, one of Cornell’s founders, set off to hire the original faculty, his co-founder and the school’s namesake, Ezra Cornell, told him, “Don’t forget the horse doctor!” Thus began the veterinary school that will define much of my life.

The current vet school occupies a whole complex. At its heart is a building characterized by some of the more unfortunate institutional design elements of the mid-20th century. (Think yellowing tile and black-and-white reel-to-reel films of men - they were nearly all men then - in horn-rimmed glasses and lab coats carrying very important-looking clipboards.) This building holds the anatomy lab, which stinks of preservatives, and the meeting room I’ve been sequestering myself in to write my thesis. More elegant buildings have been tacked on, but the cloistered complex feels physically and aesthetically removed from the prettier Ivy League parts of campus between here and the Tower.

In the break between morning lectures and afternoon anatomy lab, I drive west on Tower Road toward the older part of campus, surrounded increasingly by the past. I feel disconnected and adrift. It occurs to me that as I drive west I’m getting closer to home - Oakland, California - than I’ve been for a year. Staring down the barrel of four more years of isolation in this environment makes me hunch in my seat.

The campus health center sits in the Tower’s afternoon shadow. I leave my car in the tiny parking lot and head inside to meet with a physician. We discuss my recent symptoms and she makes a talk therapy referral and prescribes alprazolam, better known to many as Xanax. It’s a common prescription choice for short-term use in acute-anxiety crises like mine. It’s in the benzodiazepine (ben-zo-die-AYZ-eh-peen) class of medications, which are also used for depression and other mood disorders.

The mechanism for benzodiazepines isn’t fully understood, but they appear to function by changing the way neurons talk to each other. Neurons carry electrical signals from one part of the body or brain to another, and they communicate with each other using chemicals called neurotransmitters. Each neurotransmitter tells the neighboring neuron to activate or stay quiet. Since most brain neurons connect to many others throughout the central and peripheral nervous systems (CNS and PNS), activation or non-activation depends on how loud those competing messages are and how long each message lasts. Benzodiazepines like Xanax mimic the neurotransmitter GABAa, which sends “be quiet” signals. My doctor and I intend for the Xanax to quiet the over-active anxiety pathways in my brain for a few hours at a time.

That evening, I sit at my computer, gearing up for my fourth night of marathon thesis-writing. I’m exhausted and tense. My back and neck ache, my muscles are taut. My thoughts are racing, soaked like uncooked French toast in fear and anxiety. The effects of Xanax typically begin within a few minutes of dosing, peak one or two hours later, and last for a few hours total. Lacking any experience with CNS-active substances - no booze, medications, or other drugs - I have no frame of reference for how this is going to feel. I pick up the bottle and pop my first pill.

Less than five minutes later, I’m thrilled and troubled by the massive changes in my brain and body. My mind quiets. I’d honestly forgotten what it felt like to think a full thought without the next butting in. My thoughts are suddenly my own instead of intrusive strangers. My self-bullying fades. I’m shocked at the sudden relaxation of my muscles; my back and neck pain fall away and breathing becomes easier. It feels like someone grabbed the anxiety knob in my brain and turned down the volume until I could hear myself. If I was at an eleven before, I’m at a three now. The looming deadline now feels motivating. I’m ready to work.

                                                                                 Illustration by Mink Ratcliff, www.hypercarnivore.com

I’m grateful for these changes, but they scare me. I’m surprised by the impact of my mental state on my physical symptoms. I’m afraid of the idea that I’m at the mercy of my brain chemistry. I’m frightened to think that I’ve been unable to work or will my way out of a lifelong struggle in part because my computer was malfunctioning. Am I really incapable of doing this without meds? Am I the kind of person who’s unable to overcome not only external challenges, but also structural, biological ones? (Spoiler alert: Yep.)

Illustration by Mink Ratcliff, www.hypercarnivore.com

The Xanax is helpful in temporarily reducing my mental and emotional distractions, so the thesis progresses and I finish on time. Summa cum laude, even. That hurdle handled, I pivot immediately to the next: my first vet school exam.

I go in feeling less than confident, but what’s new? Waiting for the result is torture, and I when it's finally available, I stare blankly at a “C.” I’m pulled into my chair by the gravity of getting such a low grade. I’m so...relieved. Thank God. I resolve at that moment to divorce my sense of worth from my grades, which is lucky timing, because the next two months are hell.

The first term of veterinary school at Cornell, called Block I, is an intense crash course in comparative anatomy. Over a couple months, we learn the detailed anatomy of dogs, cats, horses, cows, pigs, sheep, goats, alpacas, birds, and reptiles. We bouey ourselves by joking that “real doctors” treat more than one species, but the experience feels like hazing in its intensity. When I mention this to one of my professors, he replies, “That’s not entirely off base. We want to shock you guys, give you an idea of how hard this will be, and hopefully instill that if you can make it through this, you can make it through the rest of the curriculum.”

“That doesn’t seem productive,” I argue. “All of us are just cramming and forgetting. Most of us can’t pass the tests we’ve taken after a few weeks. Very little of this is staying in our heads.”

“That’s okay, you won’t need most of it,” he explains. “What you will need’ll keep coming up in other courses.”

I’m infuriated. I have so much to say, but I have to go study...

Part 2 of 3 out next week!