What I've Learned By Chronicling Pain

Finding beauty while struggling with migraines.

I’ve written a few posts about my struggles with chronic pain — specifically chronic migraines. As I get older, the consequences of dealing with almost daily pain begin to become more and more obvious. For the first time in my life I’ve consciously made choices about my work life that take my migraines into consideration. In the past I’ve been determined not to let my pain impact my choices but it’s becoming too difficult to ignore that anymore. I found that if I don’t get a rest day every few days that my tolerance for my pain decreases. This has a negative impact on my mood and my ability to deal with stress. I found I was less patient with my kids and just felt like I was pushing through a day to get through it rather then living it.

I recently met with a new neurologist who put me on a new injectable medication — the first prophylactic medication made specifically for migraines.

Since starting this new medication and eliminating the hormone I’ve noticed a huge difference. I’ve found that I have days where I haven’t needed ANY break-through headache medication like Tylenol or a triptan. I think it has been YEARS since I’ve made it through a day without needing some kind of pain management.

This is obviously great news on my pain journey, but what I am going to say next might sound a bit backwards — so please hang in there as I write. It’s made me sad to see how happy, patient and energetic I’ve been. Certainly NOT because I am more happy, patient or energetic, but I’m sad because it has shown me the impact that my chronic pain has had on me and how therefore it has impacted my family. It makes me sad to think that I’ve wasted days just trying to “get through them” and not really trying to live in them.

As you’ve probably read in the past, my determination and resilience to ride through my pain is admirable, but I am starting to question what my life would have looked like without all that pain. This is obviously not a question worth asking as I can’t change the past and certainly never asked to suffer in pain almost daily.

I am however grateful I’ve been given the break in my pain for now. I try and live it day by day as my past has certainly shown me that my pain free days are much fewer than my painful days. There’s a small part of me that hopes for a pain free future but the realistic side is 100% aware that that is unlikely. I have found purpose in my pain in the past and will again. I will enjoy what I’ve been given for now.

If you liked what you read, please give me a clap or send me a note!

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Pamela is a nurse practitioner in Canada. This essay originally appeared on the Beautiful Voyager Medium publication. Want to share your own story? Here’s how.

The Link Between Chronic Pain and Depression

By Steven Booth, Founder and CEO, Elevation Behavioral Health

 In my role as the owner of a residential mental health program I have witnessed firsthand the debilitating effects of chronic pain-related depression in clients. Visibly hurting, both physically and psychologically, these individuals are desperate for relief from the suffering.

It isn’t hard to understand how suffering from chronic pain might lead to depression. Chronic pain, the persistent physical pain that lasts three months or longer, is exhausting to the brain and the body. Pain places a tremendous burden on one’s energy reserves, wearing the person down over time. Is it any wonder that one of the symptoms of chronic pain is depression?

Chronic pain and depression appear to be intrinsically linked through brain functioning. According to an article published in Neural Plasticity, “The Link Between Depression and Chronic Pain: Neural Mechanisms in the Brain,” the authors conclude that both depression and chronic pain share common brain regions that are involved in mood regulation. In addition, they conclude that there are, “overlaps in the pain and depression-induced neuroplasticity changes and neurobiological mechanism changes.”

Indeed, chronic pain and depression can set up a vicious cycle, with each condition worsening the symptoms of the other. The result can be debilitating pain-induced depression that severely impairs daily functioning. Unfortunately, many who relay their symptoms of physical pain and discomfort with their physician do not mention their depression symptoms. Doctors are beginning to be more proactive in asking pointed questions of their patients regarding potential coexisting depression. 

Treatment for a chronic pain patient with co-occurring depression should reflect both conditions. This will translate to the pain management program combined with psychiatric support, as well as other therapies or activities that will help alleviate suffering.

The Connection Between Chronic Pain and Depression

 Chronic pain refers to the physical pain that results from an injury, a degenerative condition, or a disease that persists for more than three months. It is estimated that nearly half the population is living with chronic pain. Living with pain on a daily basis is disheartening and can result in other symptoms such as sleep problems, fatigue, and physical weakness. Chronic pain can also lead to depression as its limitations to fully enjoying life begin to accrue.

Individuals struggling with both comorbid depression and pain may suffer major impairment in daily functioning, only deepening the depressive disorder. Disruptions in relationships and work performance due to the coexisting disorders can lead to serious consequences. In fact, among those with both chronic abdominal pain and depression there is a 2 to 3 times higher likelihood of suicide ideation or suicide attempts.  

Symptoms of Depression

While it may seem natural to focus primarily on the chronic pain and assume that any symptoms experienced are directly related to the pain, in many cases a co-occurring depressive disorder is the cause for many of the symptoms. By understanding what the symptoms of depression look like, individuals being treated for chronic pain are better prepared to identify them as attributable to depression and can then obtain necessary treatment for the depressive disorder. 

The DSM-5 has identified nine basic symptoms of major depressive disorder. While it must be taken into considerations that some medications cause depressive symptoms, as do some illnesses, it is helpful to consider the diagnostic criteria for depression. When five or more of these symptoms occur over a two-week period, it is pointing to a co-occurring depression diagnosis: 

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. 

2. Markedly diminished interest or pleasure in all, or almost all, activities more of the day, nearly every day.

3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day.

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Management of Co-Occurring Chronic Pain and Depression

Once a clinical diagnosis of depression is arrived at, it is essential for the individual to begin treatment for the depression in tandem with the pain management. Many doctors will refer the individual to a psychotherapist or a psychiatrist where the mental health disorder can be effectively managed.

To treat the depression, outpatient mental health services are usually the initial course of treatment. With the goal of improving overall quality of life, the prescribing doctor will likely include a combination strategy of psychotherapy and antidepressants. The most effective psychotherapy for depression patients is cognitive behavioral therapy (CBT), where negative thought patterns are challenged and reframed into more productive, positive self-messaging. CBT teaches patients how to shift out of negative territory when triggering thoughts occur, employing the newly acquired coping skills. 

For those patients whose depression is spiraling, particularly those who have increasing thoughts about death or suicide, a residential depression program is appropriate. This higher level of care provides a more intensive approach to treating the depression within a safe, supportive, and healing environment. During the stay, patients focus on learning new helpful coping strategies and practice these skills. Psychotherapy is provided daily, with both individual and group therapy sessions. In addition to the conventional psychotherapies, holistic therapies are often integrated into a residential mental health program.

Holistic Therapies that Benefit Both Chronic Pain and Depression

There are multiple holistic or experiential activities that address the mind-body-spirit connection. Many of these are of eastern origin; some are even ancient. Other holistic methods have become popular in the past decade as a natural way to enhance the treatment effects of traditional therapy. Some holistic activities that help improve the symptoms of depression include:

●      Mindfulness. Our minds can take us to dark places if we let them. Mindfulness helps teach individuals how to focus on the present moment, to acknowledge the emotions, and offer a sense of control.

●      Regular exercise. Something as simple as a 20-minute daily walk can produce endorphins and increase serotonin levels, improving mood, sleep quality, and energy level.

●      Yoga. Yoga utilizes purposeful poses that can increase strength and flexibility while calming the mind.

●      Improve sleep. Sleep quality can greatly impact mood, one way or another. By committing to better pre-bedtime habits, such as no caffeine after mid-afternoon, avoiding heavy meals, and eliminating screen time one hour before bed, can improve mood, concentration, and cognitive functioning.

About the Author

My name is Steven Booth, the CEO and Founder of Elevation Behavioral Health in Agoura Hills, CA. I’ve earned my B.A. from the University of California, Santa Barbara in Economics. Before helping to co-found Elevation Behavioral Health I worked in both private and public accounting. Like many others, I have seen firsthand the destruction that addiction can inflict on family and friends. I have also witnessed the extraordinary changes that can be made when addicts receive the necessary treatment. My passion is providing outstanding mental health care through Elevation Behavioral Health. 

What Are "Integrated Interventions" in Mental Healthcare?

Photo by Vadim Bogulov

A mental health industry professional shares his perspective.

New lingo pops up in the mental health industry, so it’s useful to learn more about what terms mean as you search for approaches that will work for you. I’ve worked in in the mental health industry for just three years, and even in that short time, here have been developments and changes that have happened. The biggest change I’ve seen is the growth and sophistication of a holistic approach to psychological well-being.

When people ask, “what are integrated interventions?” this is what I tell them: Integrated interventions in mental health care include 3 essential elements.

1. Medication

2. Psychotherapy

3. Alternative treatments

I also always try to debunk the common misconception that ‘integrated interventions’ or ‘alternative treatments’ are against the medication. It’s not true! Integrated interventions actually mean a holistic approach to mental health care. They include medications, psychotherapy, alternative treatments, and cutting-edge technologies for improving the quality of mental health care.

Let’s talk about each and every element in detail so that we can understand what integrated interventions in mental health care actually imply.

Medication

Undoubtedly, medications have a big role to play in mental health treatment. Medications are a must for patients with chronic mental illness symptoms. They help to alleviate the symptoms and prevent relapse of a mental health disorder like:

• Panic disorder

• Anxiety disorder

• Post-traumatic stress disorder

• Schizophrenia

• Bipolar disorder

• Depression

• OCD

• ADHD

• Insomnia

• Dementia

• Psychosis

The most common types of medicines used for mental health treatments are:

Antidepressants: These are usually used for patients suffering from depression, anxiety disorders, and other behavioral issues. They help to alleviate the symptoms like hopelessness, sadness, lack of concentration, lethargy, and lack of interest in any kind of activity. Antidepressants like selective serotonin reuptake inhibitors (SSRIs) can help to cut down depression symptoms between 30% and 60%. They may also lead to a complete recovery of the patients.

Antipsychotic medications: These medicines are usually used for schizophrenic patients. They can also be used to treat people with bipolar disorder.

Mood-stabilizing medications: These medicines are best for people with bipolar disorder. Bipolar disorders are usually characterized by alternative episodes of mania and depression. Mood-stabilizers help to combat mood fluctuations. Sometimes, they are used with antidepressants to reduce the symptoms of depression.

Anti-anxiety medications: These medicines are used for curing panic disorder or anxiety disorder. They help to reduce anxiety, aggression and sleep disorders. Some medicines give short-term relief whereas others give long-term relief. Sometimes, psychiatrists don’t prescribe fast-acting anti-anxiety medicines to avoid causing dependency. Sometimes, patients become addicted to these medicines. Psychiatrists try to avoid that.

To get the best results out of medications, people must make informed choices. They need to take the right dosage and the right type of medications. For instance, if a patient with anxiety disorder takes medicines that have been developed for schizophrenic patients, then that would create a huge problem. The wrong medicines would destroy the mental balance of the patient.

Psychotherapy

Is medication the best way to promote mental health recovery? Urgh! No.

Many psychiatrists and psychologists say that the most effective way to cure mental illness is to use psychotherapy along with medications. Some of the most popular psychotherapies include:

• Cognitive Behavioral Therapy

• Play Therapy

• Talk Therapy

• Exposure Therapy

• Dialectical Behavior Therapy

• Somatic Therapy

• Narrative Therapy

• Interpersonal Therapy

• Psychoanalytic

• Psychodynamic

• Parent-child-interaction Therapy

• Solution-focused brief Therapy

Alternative treatments

While a combination of medicines and psychotherapy are an effective way to help people suffering from mental problems, some individuals are using alternative methods of treatments. In 2007, people spent almost $33.9 billion on alternative methods of treatment.

If you think that alternative treatments are anti-medical, you’re dead wrong. They are just a few natural ways to treat people suffering from depression, anxiety disorders, and other types of psychiatric disorders. Some people resort to alternative methods of treatments just to avoid the side-effects of medications. But that is a wrong concept. An individual can feel better only when medications, psychotherapy, and alternative methods of treatments are used simultaneously. An experienced psychiatrist is the best person to suggest how to use all the 3 elements judiciously.

Alternative methods of treatments for anxiety

• Yoga

• Kava

• Biofeedback

Layering alternative methods on top of more traditional approaches can open up new areas of anxiety relief.

Alternative methods of treatments for depression

• Magnesium supplements

• Hypnosis

• Acupunture

Alternative methods of treatments for personality disorder

• Homeopathy

• Ayurveda

• Reflexology

A few other alternative methods of treatments include music therapy, wilderness therapy, and nutrition therapy.

Alternative methods of treatments are a great solution for mental health patients. However, these treatments should always be used along with the clinical treatment as prescribed by psychiatrists. When both are used together, they give incredible results.

Caution:

Alternative methods of treatment shouldn’t be used without consulting a psychiatrist. Most of these remedies come from plants and animals. But that doesn’t mean that they are absolutely safe. They have some bad side-effects, and that can clash with medications. Just think what will happen to your body if you take anti-depressants and marijuana simultaneously? Your mental health will be in terrible condition. If someone asks you to try alternative treatments, talk to your psychiatrist first.

Buyer beware when it comes to plant-based alternative medicines.

There is yet another thing that you have to keep in mind. Most of these herbal products are not under FDA oversight. So there is no guarantee that the amount of active ingredients is the same in all the products, even if the brand is the same. Some products may have USP-DSVP (U.S. Pharmacopeia Dietary Supplement Verification Program) mark. Those products can be safe. Now the choice is yours.

What integrated interventions can tell you in your own therapist search?

Integrated interventions can tell you a lot about a potential health provider. For instance, it can tell you how the potential mental health provider will treat your psychiatric disorders. Like I said before, integrated interventions are a ‘holistic’ symbiosis of medication, psychotherapy, and alternative treatments. So, you can find out the treatment orientation of a psychiatrist/therapist.

Technology is a big part of ‘integrated interventions’. Some mental health providers who have expertise in treating psychiatric disorders through an integrative approach to psychological well-being use technologies to track your mental health progress. For instance, a face tracking software can tell if you’re sad, angry, happy or surprised. Likewise, there are tools to track a patient’s anxiety level across time and help the psychiatrist/therapist to make a proper diagnosis. You can learn about these things in your own therapist search.

Conclusion

Apart from medication, psychotherapy, and alternative methods of treatment, the integrated interventions in mental health care also take into account another important element, and that is cutting-edge technologies. You can use medications, psychotherapies, and alternative methods of treatment as much as you want. But how can you be sure that your mental health condition has improved? How can you track your progress across medications and across time? Nowadays, good mental health clinics are using technologies so that people can detect an oncoming mental health episode. This helps both patients and psychiatrists to take preventive measures and avoid another depressive episode in the near future.

My point of view

Integrated interventions can help to re-instill happiness in the lives of patients. They can help to drive away negative forces and heal all the self-inflicted wounds that disrupt one’s behavior. Also, it’s extremely important to track one’s mental health progress because without that it’s difficult to make a proper diagnosis. Just like doctors measure blood pressure and then prescribe medicines, psychiatrists should also think about the treatment orientation after checking the anxiety level.

Medication can help to reduce symptoms of depression, anxiety, schizophrenia, and other mental disorders. But psychotherapy and alternative treatments can help to bring tranquility in a patient’s life when used together with medication.

The biggest problem in behavioral health treatment is that doctors don’t know technology and tech-guys don’t understand medicines. Integrated interventions help to solve this problem. 

How I Avoid Panic Attacks When Talking to Strangers

Advice from One Overthinker to Another

Have you ever found yourself stuck in an airport and needing a pen, but the thought of talking to a stranger would falsely persuade you that you don’t need it? In these situations doubts tend to take over and drag people into the state of discomfort, shyness or even a shame for considering the idea of asking. In order to avoid or even getting rid of social anxiety, it is good to always have a complete protocol of actions for this unexpected, unwanted but very possible and almost inevitable scenario of our everyday life. Here are lessons I learned from my own experiences. Use the advice if you find yourself in a similar situation!

Don’t Make a Face of a Cat from Shrek

Sure, it can work if it’s a kind stranger. But if it is a bossy character who likes to be flattered by others, your chances of getting what you want may dramatically decrease. Simply because this person is extremely likely to start to feel a certain level of disrespect towards you, for applying this insincere technique. If you want to do things this way, you risk to become disliked even if you received the item after all. It is important to remember, that if you are classified as someone who tries to outsmart an individual in this primitive way, the process of begging for a material item will turn into a begging for a rejection.

Humor is the Best Weapon

Before you start a conversation with a complete stranger, you got to look for ways to make that person smile and laugh afterwards. Let’s say you run out of the internet and you need someone’s 3g. The person is using a phone a few feet away from you. Don’t approach from behind. S/he has to see you first, at least with peripheral vision. If the stranger wears earplugs – wave to make an eye contact.

Let’s compare your further actions to the process of building a house of cards. Yes, you can construct it fast. But if you allow yourself a bit of clumsiness you increase an additional risks. That is why it is a good idea to take your time. But you may not always have it. So let’s break down both scenarios: when you do have some extra seconds and when you don’t.

Scenario A: In the Hurry

Every responsible hiker has a first-aid kit in the bag. Yes, it cannot save from everything. But it will make that traveler more likely to get to the point B than the one who doesn’t have these things. That is why you should be guided by the same principle and have your go-to phrase for an emergency. It’s like always carrying a little bit of glue so that you could make the process of building the house of cards easier.

It has to be your original line. But if you don’t want to exercise your creative muscle you can use this one: “You see the internet is like a water in a desert. I’m not ‘thirsty’. I’m ‘dehydrated’. Could you please save my life by giving me a ‘drink’?”.

This phrase cannot be universal, as it may not always apply to the object you need. But only if you don’t think outside of the box. If you’re armed with a good phrase for an “internet need”, you may still use it when you need a pen. You just say that you know only how to persuasively to ask for internet. Use that line that has no connection to the item you need and finish it with “...so can I have your pen for a minute?”.

There’s an alternative method that you can use. But it requires you to have a specific skill. If you’re good at speed tongue-twisters, you can apply it in pretty much any situation. You can patter a long detailed and super informative explanation of why you need it.

Example: “Hi. Due to cosmic but yet not enough high speed of technological progress, the surface of the Earth still has not been fully covered with free internet. Since currently, I’m not at the space-time where my device can detect it, would you mind if I ask you to please share your 3g with me?”

If you manage to clearly(!) ramble it in about 4 seconds it will crack up most of the people. Whichever method you’re going to use, consider that your decision should be based not only on your time, but on that person’s “index of a hurry” as well. If you can tell it is high – you know what to do. If it is low – apply the following strategy.

Scenario B: Easy does it

Going back to the house of card analogy, this option is like eliminating such factors as unnecessary wind and wobbliness of the table. And by the way, it doesn’t mean, that you should get rid of the phrase that was mentioned in previous scenario. This tempo should make your speech only a little bit slower. Don’t overdo with time. But also remember that you’re not in the hurry. So speed of energized yet relaxed telemarketer should do it.

Before starting a conversation, pay attention to everything that surrounds you. You can notice things that can inspire you to make a good joke. But if you don’t see any of the hints, you can build upon the phrase that was mentioned previously.

If you have plenty of time, by no means, don’t try to become friends in order to get the item. Even the kindest people may help you out with disgust if you give them a reason to suspect that your friendliness is just a trick.

Prepare to Offer Something in Return

If you made that stranger smile and you still don’t have what you need, you may receive a classical question “what’s in there for me?.” Your answer should be simple and preferably with notes of humor. Like “I will make you laugh even harder the next time” or “I won’t bother you with that question if we swap lives right now and you will need the same thing from me”

And if you do like that person you can go further. And hit back with: “you won’t have to worry about splitting a bill for our dinner. I’ll apply the same strategy of asking on the owner of the restaurant as I successfully did it on you.”

How I Use It

Once, when I needed a conference pass I was waiting for someone with badge card to exit the building where the event took its place. It was dedicated to hematology (branch of science about blood and its diseases). When I finally saw that person with badge leaving the territory of the building, I already had a plan with two objectives:

• Offer something in return

• Made that person smile

I came up with the opening line I’ve made specifically for that interaction while I was waiting. I’ve said the following:

“Hi! I really want to get to this conference. Could you please give me your badge card? In return I promise to donate you my blood if you get wounded”

Of course I received the pass because I got lucky with the person. But I also was able to use my luck by combining the two elements: humor and willingness to give something in return.

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About the Author

Zack Hargorve is a blogger and an editor of bookwormhub community. One of his missions is to notice interesting, unusual phenomenons and tendencies in the world of music and communication, and reporting it to a diverse scope of audience.

My Experiences with Clinical Drug Trials

And what I learned along the way.

Apparently the only way to slow me down at all was a serious chronic illness: I was diagnosed with Relapsing-Remitting Multiple Sclerosis on January 13, 2009—interestingly, also one of my brothers' birthday. I committed to a clinical trial for what became a drug called Ocrelizumab, but before that, I spent 6 months poking myself with an Avonex needle and learning to cope with side effects the first two months. Resilient in the extreme I am, but this tested everything the overintellectual overachiever in me had. 

Here I am in Puerto Rico. I’m not a person to be slowed down.

I probably have had MS for about 14 years, and was diagnosed at first with RA in 2007, summer. Luckily, in Nov 2008 I hit Vertigo City, and after asking for a pain management referral, got a neurologist who dared to give me valium and meclizine for vertigo and got me a MRI. I clearly remember he called me soon after the MRIs were taken, asked me to come in, and explained that the radiologist reading the MRI had panicked and called him, saying 'You have to get her back in!'. He was pretty sanguine, but also told me, "If you were my daughter, I would tell you to take this [MRI] disk and go to the emergency room at Barrow or go to San Diego." I looked at him and basically asked, "Really?" His contention, and I believed him, was that my little podunkia county could not get the team he thought it would take together in less than several months' time, whereas Barrow had everything in one place. He let me know he didn't think it was cancer, that maybe it could be MS, but oh, "you also have a disk protruding right... there." I wasn't worried really at that time, but I knew too many things were off for me not to listen. 

Long Story Short

Long story short, I drove to Phoenix the next day with my hubby-bear and proceeded to have every bit as exciting and frustrating a diagnosis process as the TV show "House" presents. I believe I had seven doctors in several specialties trying to diagnose me-- a neuroimmunologist, a neuroncologist, an infectious disease guy, a neurosurgeon, a rheumatologist, and at least two other neuros. Two wanted to biopsy my brain (AHHHH!!), and luckily my hero-MS-doc held them off while I was tested for every conceivable disease. Yes, including the rare, bizarre ones. I swear.

Hanging out with a wee friend.

In the end, after eight days in the hospital, I had one diskectomy in my neck, had given lots of blood, but went home for Xmas. I had to see them four weeks later, and two things happened-- my neurosurgeon said the neck was looking good, and my hero-MS-doc gave me my official diagnosis. Sis, hubby, and myself were there. Thus began the real drama in life.
MS has a frustrating unfolding, and many years off meds because of the long term effects of the clinical trial drug 2.5 years ago crashed with a relapse involving crutches and a wheelchair. I struggle not to make sense, but to make the best. At times, the best is actually sleeping well! But what option is better than persisting?

My Advice for Others

If I have any suggestions, it would be to not attempt this kind of ride alone. I'm beginning to understand how easy it is to care for everything but oneself, but also how, with the grace of insurance, I can find other tools to help me feel less abashed by my slow slide into a less-frenetic life. Go online. Go in person. But go find the things to make life not only bearable, but proactively possible.

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Sammy is a lover of the obscure, cats, and Texas. She says, “I overthink my way into drama entirely too often. My cats, dogs, and husbear are thankfully tolerant, and I know I'm blessed to have such love around me on the wild, MS-colored life.” Check out her lighthouse in San Antonio, Texas!

Does Generalized Anxiety Disorder Go Away?

In the years since my diagnosis, I've learned that anxiety is a physiological response involving hormones released in the body. If you have GAD, hormones will hit your system in a surge. They will also, however, draw back over time. Learning to feel the whole cycle—and appreciate the times when GAD is in remission—is an important part of living with anxiety. Though generalized anxiety disorder never goes away entirely, the more you understand the cycle, the better equipped you are to handle GAD symptoms.

How to Deal with Generalized Anxiety Disorder

1. Understand that anxiety will come and go throughout your life.

Anxiety is not a problem that offers any quick-fix solutions. When stressful things happen, I expect that my particular gremlin will poke his head out of the wave’s crest. Knowing what to do with him and that I’ve survived his visits before helps a lot.

2. Practice riding the anxiety wave.

I've learned the shaky feeling many people experience after a stress response or panic attack is a sign of the hormone wave receding. It's actually a good thing! We often fear the strange shaky feeling. We should be looking forward its arrival. If we understand what the shakiness means, we can enjoy that another wave is over and our strength remains from our place on the beach.

3. Listen for your symptoms.

It took me 39 years to realize that the nausea, light sensitivity, and migraines I'd been experiencing were the ways my generalized anxiety disorder expressed itself. Learning how to tune in to your symptoms will allow you to sense when anxiety is affecting you, and take actions to take care of yourself.

4. Experiment with treatment that works for you.

No approach works for everyone. Experimentation means trying to figure out what works best for you. In my case, I use medication, meditation, a moderate amount of reading and learning (I have to stop myself from overdoing it), and communication. What works for you? Share ideas in the comments section below.

5. Accept that though anxiety is part of your life, it doesn't define you.

These days, when the hormones hit, or I feel a migraine coming on, I accept it. Can the beach fight the wave? Knowing that the answer is no helps. 

With treatment, you can bring your symptoms into check. But since you are predisposed to anxiety, when events happen in your life, you are more likely to have bigger anxiety responses than other people. 

Here's some other reading to keep going on your journey:

• The Hormone Wave

• Recommended Reading List for Anxiety Newbies

• Beautiful Voyager Anxiety Credo

Originally published Oct 29, 2017. Updated March 26, 2019.

I Was Proud of Quitting Antidepressants. Now I'm Back on Them.

Not the author, but the head-spinning confusion of SSRis catches the vibe.

My father, a rheumatologist, routinely prescribes drugs such as prednisone and methotrexate—he’s a believer in up-to-date medicine. Yet he’s skeptical of the fact that I have been on Celexa, a popular antidepressant and anti-anxiety medication, for 13 years. When a young relative of ours fled college two weeks into freshman year, undone by the anxiety that had plagued her all her life, he wasn’t impressed. “Why don’t they just tell her she has to stay?” he demanded. (Actually, he preceded it with “Jesus Christ!”)

The point is, even among doctors, there’s still a stigma about mental illness—and about the necessity of treating it with psychoactive drugs. The notion lingers that we all should be able to pick ourselves up by the proverbial bootstraps, that anyone who can’t hack life without a pill has a moral or character flaw. This, even though today in this country one in eight adults takes an SSRI (Prozac, Zoloft, Lexapro, Celexa) or a similar SNRI (Effexor, Cymbalta) or NDRI (Wellbutrin). The rates are almost double that for women in their forties and fifties.

Though I feel zero shame about my own reliance on SSRIs—maybe because so many of the smart, original artist types I know tend toward depression, and more than a few swear by these drugs—I worry I may have contributed to the stigma myself, with an article I wrote for this magazine nine years ago. So I’m here to set the record straight: to come clean about, well, not coming clean.

In my November 2008 piece, “Club Med,” I wrote about the backlash against SSRIs, which were then as now the most commonly used drugs to treat depression and anxiety, and the ones with the least—and least deleterious—side effects. Yet books with titles like Medication Madness and Comfortably Numb were arguing that Americans had medicated away normal emotions under the spell of evil-genius pharmaceutical marketers, that SSRIs increased the risk of suicide, and that the long-term risks of the drugs were unknown. I’d gone on a low dose of Celexa, 10milligrams, six years earlier for anxiety and insomnia and had been completely cured of both. As I wrote, “The white noise in my head vanished—poof!—and a feeling of calm came over me, the likes of which I hadn’t felt since childhood summer vacations, if ever. My anger at my husband, my annoyance about the mess of our house, my stress about public appearances, all quietly abated…. For the first time in a decade, I began to sleep deeply through the night.” I quit therapy, which no longer felt necessary; I cheerfully did a book tour I’d been fearing; I wrote a novel for the first time in years.

And then, after five years of taking Celexa, I stopped. My doctor had suggested it; with my life in a less taxing place, she said, I might not need it anymore. I respected my doctor, and I was secretly relieved to no longer “need” a drug for my head.

The withdrawal, however, was harrowing. “SSRI discontinuation syndrome” had been unheard-of when I’d started Celexa, which was initially marketed as dependence- and withdrawal-free, but by the time I went off, it was well known. A week after halving my dose to five milligrams, I woke up with what I thought was the flu: headache, dizziness, achiness, exhaustion. That lasted six weeks. I spent the next nine months tapering from five milligrams to zero.

I also adopted some classically “good” habits, practices recommended to people struggling with virtually any affliction: eating better, doing hot yoga a few times a week, returning to therapy. When I wrote the ELLE story, I’d been drugless for three months. Out of what I called “Pharma Nirvana,” I was “getting used to no longer hovering above myself watching myself live, but instead was actually living. Living and yelling and stressing, yes, and often anxious and angry and sad—but with the sadness came an awareness that I had not really experienced on the drug….Time was passing. My kids will be gone soon, I’d think, and tears would run down my face.”

If that sounds like a bit much, I can now tell you: It was. As the months passed, the old feelings and behaviors reemerged—all of them, like before, annoying and debilitating but not life-threatening—until one day, sitting in my therapist’s office alternately whining about my wonderful, chosen life and weeping because everything seemed just so sad, I begged her to affirm what I felt sure of: I was a tad, um, depressed, wasn’t I? When she agreed, I hightailed it back onto Celexa, felt worlds better soon after, and have been on it for the last seven years with no plans to ever abandon it again.

Since then, I’ve noticed that we read a lot of stories like mine, about people getting “free” of these drugs, but we rarely know what happens later. This makes sense; there’s a certain euphoria and nobility that comes with kicking a drug for the mind, something that, if you’re a writer, makes you want to, well, write about it. Two years ago, in a series of riveting essays for the New York Times called “Going Off,” Diana Spechler chronicled her decision to wean herself from a trio of psychiatric drugs because of their “grim, unbearable” side effects. The 11 columns spanned five months; by the final installment,she was “20 days med-free, eating only whole foods, stepping back into the world, a yoga mat strapped to my shoulder.”

Twenty days isn’t a long time to be off an antidepressant; some of these drugs don’t completely exit your system for weeks. I wondered: How was Spechler coping now? And then there was Patricia Pearson, the author of the gorgeous and philosophical 2008 book A Brief History of Anxiety: Yours and Mine—which I’d referenced in my earlier piece. Her book, too, was written right after she’d stopped taking first Effexor and then Lexapro, which she’d used to help her cope with quitting Effexor. It ended as she hit her six-week drug-free anniversary. But again, what happened after the six weeks…or six years?

I got my answers. But first, I want to address some of the controversy and doubt about SSRIs—a shadow that hasn’t lifted appreciably since I last wrote about this.

First, it’s true that even though it’s been 30 years since Prozac hit the market, no one knows exactly how SSRIs and their cousins work, although that’s the case with medications for everything from penicillin for infections to acetaminophen for pain relief. One long-standing theory is that SSRIs recalibrate levels of neurotransmitters—dopamine, serotonin, norepinephrine—which brings relief to people with a supposed deficiency of them.

But depression is a complicated illness, with multiple causes—some mix of genetic, environmental, and psychological components—and different symptoms for different people (anxiety, sadness, apathy, hopelessness, irritability, fatigue, change in appetite, suicidal tendencies), not to mention different side effects from its medications. Treating it is as much art as science. “Even as I faithfully took my pills,” writes Daphne Merkin in her new memoir, This Close to Happy: A Reckoning With Depression, “I couldn’t help wondering: Was I medicating a bad childhood or a chemical irregularity?”

That said, we do know that SSRIs help a lot of people, whether alleviating chronic mild depression (dysthymia) or preventing attacks of the major, paralyzing variety. Here’s Merkin again, who’s taken psychiatric drugs for more than three decades: “It’s only when I begin to sink that I remember why I am on antidepressants to begin with, which is they seem to keep me from hitting rock bottom.”

Second, it’s also true that no one is sure of the long-term impact of these drugs. Some—among them Katherine Sharpe, who wrote Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are—believe that “the brain habituates to SSRIs,” so that when they’re withdrawn, depressive symptoms come sneaking back. The corollary to that, of course, is that once you start, you can never stop. I asked psychiatrist Peter Kramer—who wrote the landmark Listening to Prozac in 1993 and last year returned with Ordinarily Well, which is in large measure a defense of antidepressants—what he thought of Sharpe’s assertion. “If she means that there’s a higher likelihood of depression when you come off medicine than you would’ve had if you’d never been on medicine…it’s just very hard to research that question,” he said. In Ordinarily Well, he calls a theory like Sharpe’s the “nightmare scenario” and, ultimately, deems it implausible—partly because he’s seen patients give up SSRIs and do fine, and partly because there are shortcomings in the research that supposedly proves they’re doing harm.

Even Sharpe admitted, in a piece in the Atlantic, that “SSRIs have been around for 25 years, and anecdotal reports of catastrophic ill effects have yet to emerge.” (There is something called “Prozac poop-out,” a sudden return of depressive symptoms after sustained usage. Though he hasn’t encountered this in his own practice, Kramer, a professor emeritus at Brown University, doesn’t dismiss it outright, comparing antidepressants to insulin for diabetics. “It’s not that insulin fails at its job, it’s that it doesn’t do everything,” he writes. “Something comparable may occur with antidepressants in depression; they help whatever brain system they are helping, but the underlying illness will break through, so that more or different help is needed.”)

In contrast, the risks of not treating depression are considerable. Once the illness sets in, it’s harder and harder to interrupt—and the longer someone remains depressed, the more likely the illness will continue or recur, and with more virulence. Plus, persistent depression may, among other things, cause memory loss and increase the chance of Alzheimer’s, Kramer says.

Perhaps what has stoked the biggest suspicion about the value of SSRIs are studies that suggest they work no better than placebos. To be clear, few experts make this argument with regard to treating major depression—the drugs are widely judged effective for that. The controversy focuses on the milder manifestations of the disease. In his new book, Kramer documents myriad flaws in data collection and interpretation that undercut this conclusion; for just one persuasive example, he offers evidence that a significant swath of the subjects participating in SSRI trials aren’t actually depressed, so of course they improve on “dummy pills,” as he puts it.

For my part, I’m not sure I care whether or not it’s the placebo effect that’s responsible for the transformation SSRIs have wrought in my life. I don’t believe it for a minute, but then placebos have been shown to mitigate the symptoms of all kinds of physical illnesses,after all. Mind-body dualism is dead.

It came down to this: The amount of time,energy, and money I was spending in an effort to feel half as well off Celexa as on it seemed ridiculous—notwithstanding how much I vibed with high-flown thinking about the virtues of feeling one’s feelings. “It is necessary to go / through dark and deeper dark / and not to turn,” the poet StanleyKunitz wrote. Rumi: “You are the cure for your own sorrow.” And the chronically anxious philosopher Kierkegaard theorized extensively about the condition as a source of creativity and personal growth: “Who ever has learned to be anxious the right way has learned the ultimate.” (Today, anxiety disorders are the most diagnosed mental illnesses in the U.S., though anxiety and depression often overlap and are now considered essentially flip sides of the same coin.)

pills, pills, pills, pills, pills

I get all this—and I’m also disquieted that a record number of young people take SSRIs, for longer and longer periods. Will this interfere with their ability to fully experience,and thus learn from, the glories and rigors of growing up: finding love, discovering what you want and don’t want? Curbing negative emotions isn’t always ideal for artists, either. A writer I know told me she’d tried an SSRI and felt her lifelong anxiety dissipate, but with that, she had a sudden lack of need to do the thing that had quelled it—writing—which was also how she made a living. So she gave up the drug, and the writing came back.

To be sure, there are many “cures” to try before going the medication route, as long as you’re not suffering from major depression or anxiety: therapy (psycho- or cognitive behavioral), regular exercise, even various diets. I know someone who eliminated her depression by going gluten-free. ABC anchor Dan Harris, the author of 10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-HelpThat Actually Works—A True Story, trained himself to meditate after having a panic attack on air. And some people decide they need their dreary emotional state, at least for a while. I begged a friend who couldn’t get out of bed after the 9/11 attacks to try an SSRI, but she refused. Later, she told me she’d had “a strong visceral feeling that my depression was caused by something I could change. I suspected that taking Prozac or Celexa would allow me to manage my feelings better—lift me out of them, even—but I wanted to grapple with them and fix what needed fixing.” And she did. She left her frustrating marriage, which was painful, but is now married to a man with whom she’s much more compatible. When she feels depressed, she quits drinking for a while, which so far has worked to set her straight again.

But I have another good friend—another talented woman—who never could settle into a career. She was always insecure or dissatisfied or just plain miserable. For years, I urged her to try an SSRI, but she worried that a drug would “change” her. I try to respect this; every person’s life is her own banana peel to slip on and all that. Still, I can’t help but think that she missed the opportunity to reach her potential and live a better, brighter life. “There are people who want to be the way they are,” Kramer told me. “But there are other people who suffer emotional pain every day who think they have to live with the way they are. And they sometimes need a friend to say, you know, you think this is your fate because you’re in this state right now, but there are ways for you to feel relief, to gain perspective.”

Celexa never made me feel like I was a different person, just a more contented version of me. And it didn’t make me feel drugged or high, just less dissatisfied, easier to be around…a more patient person, mother, and wife. With the mild filter the drug put between events and my emotions, I could step back beforeI reacted—which I deeply appreciated.

I’m lucky, and this is key, that a low dose is enough to give me benefits without many side effects. The few I do have are minor. I’m woozy in the morning. I can’t drink, because more than a few sips of alcohol bring an instant headache. I am “lazier” medicated—but for me, “lazy” just means not shooting around like the Road Runner, making everyone in my orbit want to stab themselves in the face. I exercise daily, but I have no interest in the intense workouts I used to do. Maybe this is bad for my bones; I’m a tiny, thin person,and perhaps at 70, I’ll suffer some consequences from having chosen a drug and a walk (or reading a novel) over lifting weights or training for a marathon or suffering through a hot yoga class. I used to feel great after those classes, like I’d sweated out all the stress, but I remember thinking, Is spending 8 or 10 hours a week in this wildly overheated room just to be able to be at peace…is that really much better than popping a cheap, legal pill for the same or better result?

Which brings me back to Diana Spechler and Patricia Pearson, my fellow “going off” authors. How are they now?

Spechler is writing a book that stemmed from her column, so she wouldn’t say too much, but she shared this: “I didn’t go back on meds in any official capacity, though I did have a brief reunion/romance with benzos around election time.” She made other big changes, though—including moving from the East Coast to somewhere much warmer and sunnier. In other words, she made the sort of dramatic change that alters your life and can alter your depression.

Pearson was more forthcoming. At the end of her book, at six weeks without meds, she was a regular at both the gym and cognitive behavioral therapy, savoring her children and even going to church. Healthy stuff, for sure—but not, she admitted, enough to keep her med-free forever; she resumed Lexapro before the book even came out. First, it was because of anxiety over her hypothyroidism. Then, on the day of the book’s release, her father died suddenly of a heart attack. In short, her life got more stressful, as lives do, and she needed more than exercise and church to get by. The Lexapro eventually made her gain weight, however, so after another year, with her life back on track, she jettisoned it. But, she told me, “I hopped on and off a couple of times between 2008 and 2014.”

I reminded her that her convincing and sophisticated book was largely about how we’re using pills to vanquish anxiety that we might be better off living through. “I was mad at that time,” she admitted. “Mad at Effexor and mad at the pharmaceutical companies. Since then, I’ve become more moderate: When something’s of use to me, great, and when I don’t need it, fine.” She’s not taking anything now, but “if I got anxious again, to the point where I’m almost paralyzed with anxiety, then I’d have no trouble…getting a prescription for 20 milligrams of Lexapro.” She still believes that doctors and especially drug companies should be more honest about the side effects of SSRIs and the difficulty of getting off them. Other than probably Big Pharma itself, who could disagree with that?

My own biggest worry with Celexa is not what eventual damage it might cause—I’ll cross that bridge if I ever come to it—but that someday I won’t be able to get it and I’ll have to go off it cold turkey. The worry is irrational. I do still wonder on occasion, If I’d never found my wonder drug, would I somehow be more “interesting,” the person I was “meant to be”? What might I have written without Celexa? And what about the great artists who were famously depressed? If Van Gogh had been able to pop an SSRI with his morning OJ, would we have all his paintings?

Then I remember: I wrote three books taking Celexa and three not taking it, and of the latter, only two got published—because the third was so depressing no one would buy it. And while it’s true that we might not have all of Van Gogh’s paintings if he’d taken an antidepressant, I have a feeling we’d still have some—and he might not have taken his own life.

As for my young relative who left college because of anxiety, she went into therapy, started on an SSRI, and picked herself up off the floor. She returned to school the next fall and is now thriving. She’d like to eliminate the drugs—she’s had some side effects and chafes at the idea of being on them indefinitely—so she sometimes lowers her dosage (with a doctor’s help) and is learning to meditate. But in the meantime, thanks in large part to antidepressants, she’s making her way in the world, taking advantage of her rights: life, liberty, and the pursuit of happiness.

I relate.

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Cathi Hanauer is the New York Times bestselling author of three acclaimed novels—“Gone,” “Sweet Ruin,” and “My Sister’s Bones”—and two essay anthologies, The Bitch in the House and The Bitch is Back, which was an NPR Best Book of 2016. She’s contributed articles, essays, and criticism to The New York Times, Elle, O, Real Simple, and many other publications, and is a co-founder of the New York Times “Modern Love” column. Find her at her site or watch her Ted Talk. 

The original piece that Cathi refers to here was published in 2007 in Elle Magazine, and this piece appeared originally in Elle Magazine in 2017.

Try Throwing Some Clay to Find Some Peace

Like most folks who come here to Beautifully Voyage, I’m a chronic overthinker. I’ve learned to compensate for the brain buzz by staying preoccupied most of my life. Until about 10 years ago, my main outlet for keeping myself busy was baking. Measuring the ingredients with a scale (like most serious bakers, I am OCD about measurements), following linear instructions, and producing something that gives pleasure quiets my brain from obsessing about, for instance, how in third grade I was waiting in line for recess and told my friend that I was going to die by the age of 45, and how I turn 45 next year, and, you know, what if that somehow comes true? 

But then I transitioned my career from graphic designer (also detail obsessed) into baking and developing recipes. I founded my blog Eat the Love, then wrote a baking cookbook called Marbled, Swirled, and Layered. And I started to find that the kitchen was no longer a place for me relax; now it was a place to work. Fun and satisfying work, but work nonetheless. My former space to get out of my head was suddenly a cause of stress. I needed a new hobby.

In this age of social media, hobbies for the sake of private fulfillment are becoming a thing of the past. What used to be fun for the sake of fun has now become a public display of people who want you to know they are trying to #BeAuthentic, #LivingTheirBestLife, and #LivingTheDream. Also, Instagram and Etsy have made it possible to make hobbies into careers. That is wonderful for the few who bubble up to the top and actually make money. But it also means there’s pressure to both excel in your hobby and to make money from it. If you aren’t getting hundreds and thousands of likes on social media and money from Google Ads then why bother? There is no longer space for mediocrity and that’s unfortunate. Because sometimes, doing something for the sake of doing something is the whole point. 

About three years ago, I signed up to take a continuing education class in ceramics on a whim. I thought it would be fun to make my own plates and props for my food photography. I had taken a ceramics class many years in high school and I figured it wouldn’t be too difficult to pick up again. I figured wrong. Every piece I created was garbage. But a funny thing happened as I made my clunky ceramic pieces—I fell in love with making pottery.

Here’s the thing about clay as a medium: it is both one of the easiest mediums to work with in the sculpture space as well as one of the most difficult ones. There is no other medium that allows you to immediately create a shape with minimal skill. If you want to create a dent in your piece, you just place your thumb into the clay and push. Every other medium has you carving, hammering or chipping away to get that dent. With clay, you just push and you have it. No other medium allows for this immediate result.

But unlike other mediums, the process to make that shape permanent, is fraught with potential mishaps. Drying the piece improperly can cause cracks in the clay. The dried, unfired clay (called greenware) is fragile, and be ruined if dropped or roughly handed. The clay can explode in the kiln for a number of reasons, including improper preparation of the clay, not properly drying it, or having air holes in the clay. Then, assuming you even get to the next step, glazing the piece poorly can result in in shards of glaze (which is basically glass) falling off. And if you work on the wheel throwing pots, the chances for error become exponentially larger as you try to center and pull each lump of clay into a perfectly symmetrical (good luck!) functional item. Even seasoned ceramic artists know that there is an element of surprise and magic in the outcome. Some of the best potters exploit that, creating unique pieces that are impossible to replicate. It’s a humbling experience and that’s exactly why I love it.

I’m not the only person who feels this way about ceramics. A few years ago the New York Times wrote about how ceramics was the new pilates and last year Vogue declared it the new yoga! Ceramics not only requires an attention and focus on detail but it is also a way physically be in the moment, almost a form of mediation. Nearly everyone interviewed for the article talked about it as a form a therapy, as if the clay somehow is able to absorb your stress and emotions, while those quoted in the Vogue article refer to ceramics as a “holistic antidepressant.”

I’ve spent the last three years trying to master the potter’s wheel and I’m still learning. I recently started using porcelain, a type of clay that is notorious for its exacting nature, and I feel like I’m starting at square one again. It’s challenging and rewarding work though, as throwing porcelain clay will just make me a better, more refined potter.

I imagine working with clay will be a lifelong pursuit, as every time I learn something (or think I learn something) there are five more things for me to learn or deal with. I talk to potters and ceramic artists with 15 or 20 years experience and they say the same thing--at every turn, every step, something comes up that is potentially problematic. You can invest days, weeks and even months working on a piece, only to have it fall apart in the end. But when it does turn out how you expected--or even better--it’s a wonderful feeling. My professor likens opening the kiln doors to Christmas morning. You never know exactly what to expect but you’ll get something, even if it resembles a lump of coal.

Working with clay is so absorbing for me that I can’t obsess about anything else. I can’t worry that I didn’t wash my hands after using my iPhone and then ate a handful of potato chips, which will surely give me a severe foodborne illness, because in my mind the iPhone is one of the dirtiest surfaces on the planet. I can’t fret that I inadvertently insulted a friend because I still haven’t written about her cookbook on my blog even though she totally wrote about my cookbook on her blog. All I can do is concentrate on the clay in my hands, especially when I use the wheel. I concentrate on wedging the clay, centering it, creating a hole in the middle then pulling the clay up into a cylinder; that’s it, but that’s everything. Any time my thoughts waver, the clay wavers too, so it takes all my concentration. And since my hands are dirty with wet mud, if the phone vibrates I have to make a choice between getting up and to wash and dirty my hands, or continue what I’m doing. I rarely choose to get up. For the entire period of my three-hour class I am usually unreachable and completely focused on the process. It’s a glorious thing.

But the biggest learning experience in clay is that sometimes (ok, often) the end result isn’t quite what you expect it to be. So instead of making that the most important part, I focus on the joy of the process and get lost in that, which many would argue is a good rule for how to approach life in general. That’s what I’m trying to do.

But it’s hard. Up until this point, I’ve avoided selling my work and turning my hobby into something that creates money. I don’t want the pressure! But I also have so much pottery in my house, it’s getting a bit ridiculous. So I’ve started up an Instagram account dedicated to my pottery, but I know it’s risky. I can feel the old allure with each like and each follower I get. I’m trying to hold on to my love of clay and working without distraction in the studio. I don’t want to be the guy that has to check his Instagram posts every 15 minutes. I’ve been down that road before and I never want to go back.

For now, I’m just going to enjoy the soothing feelings of the mud slipping through my fingers on the wheel and remind myself I have plenty of time to figure out the rest. Right?

About the Author 

You can follow Irvin’s ceramic adventures on his Instagram account or follow him on his main Instagram account or his food blog Eat the Love to see his ceramics pieces in use.