Distress tolerance and crisis survival

I haven't written much recently as I have been very busy at work and at home, and very stressed. My brain feels like it's been scrambled up and on overload. I've been having a lot of trouble staying regulated and working really hard on my crisis and distress tolerance strategies.

It's the busy season at work and because this coincides with winter (not my best months) and winter sickness, I often end up pretty depressed and off balance during this time of year. For me, the combination of working longer hours, less daylight, colder temperatures, more rain/grey days, and the occasional virus mean I really struggle every winter. This winter started better than most - it's the first one in about 3 years where my daughter and I have stayed in our house all winter by ourselves. Usually I have an episode in May or June which ends up with the two of us spending a month to six weeks staying at my parent's place till I get myself sorted out again. But this winter I was determined to try and head that off before it started, and concentrated on using all my distress tolerance strategies I've learnt in therapy to stay well.

I feel like I am finally making some progress in learning how to tolerate and work through my emotions. I see my primary illness (BPD) in simplified terms as being emotionally immature. Meaning that I have these intense emotions and instead of accepting that everyone has emotions and letting myself feel them, I panic and try to push them away by distracting myself or using other crutches (food, alcohol, etc) so I don't have to feel anything. In the past I have massively over committed myself, or taken on huge projects, trained for endurance sport, over scheduled myself, worked large amounts of overtime etc in order to distract myself from thinking or feeling anything. Whenever something that made me upset or uncomfortable happened I would just fill my life with more stuff to get done so I didn't have to think about it. This worked about as well as trying to hold a beach ball under water. You can only do it for so long and then the ball shoots up, often hitting you in the face as it pops up.

One of the major parts of my therapy has been to admit that I have feelings just like everyone else, and try to tune in to what the physical sensations are in my body, and let them come. At some point in my past I have absorbed the idea that emotion (and showing emotion) is bad and weak and wrong, and have spent so long denying I have emotions I had become unaware of what they felt like. This is not to say I did not know sadness or anger, but that every time I had those emotions I subconsciously told myself there was something wrong with me and I must get rid of them, and did everything I could to do this. With my history of depression stretching back to late childhood, it is easy to see how every sad feeling might cause some panic in case it was a sign the depression was back. And in suppressing my anger I turned it in on myself, told myself I was unlovable and the cause of everything bad and wrong, thus causing myself to become depressed. 

This is an extremely simplified version of some of what probably caused me to become the way I am. A sort of extraordinary response (due to genetics most likely) to things which for most kids would have been water off a duck's back. Like 'harden up' and 'don't be a cry baby' and countless other less than empathetic responses to a variety of situations.

It's taken me years to begin to unlearn my subconscious responses. First I had to start with recognising when I was being triggered. What sorts of things would trigger me. And then my body's physical reaction to being triggered. The problem with this though is that when you start to tune in to what triggers you, you then become hyper aware of when you are triggered. And that's where learning distress tolerance and crisis strategies come in. Once you have been triggered and you want to deal with your emotions instead of stuffing them back down, you've got to try and work out what to do with those emotions. Pages 10 - 30 of this workbook have a comprehensive guide to all the different strategies. There's a huge range of activities and strategies that you can try, and therein lies one of the problems. You've got to try them to see what will and won't work for you.

The thing with distress tolerance strategies is that you can't expect to feel better when you are doing them. You may not feeling better at all. The purpose is just to stop you from doing the self destructive or self harming behaviour you have been using to deal with your emotions up to this point. If you'd normally drink lots of alcohol every single night because you feel like crap, then distress tolerance will give you something else to do instead of drinking, but it doesn't remove the reason why you were drinking in the first place. It took me a long time to figure that out. The strategies that work are the ones that help you deal  with your emotions in a more positive way, not take them away entirely.

For me mindfulness is probably my number one go to strategy. It's too big of a topic to cover right here right now but suffice to say that I find most of the other distress tolerance strategies work ok if I have just had a one off bad day, or have one or two things bothering me, but if things have built up and I'm having a particularly tough few days I need mindfulness first before anything else.

Crisis survival strategies kick in when I am so strongly triggered I want to cut myself, or am thinking about death/suicidal ideation. This for me looks like putting one foot in front of the other, just coping with each moment, each minute, each hour. It's focusing on the big four each day - eating, sleeping, exercise, hydration. If I don't eat healthy food, get enough to drink, get enough sleep or do at least a little exercise then I will feel worse and am more likely to make self destructive decisions. This is pretty hard when I'm unwell, but essential to focus on.

Then I have the things I do when I'm right at the point of doing something really stupid and distress tolerance isn't enough. This is called TIP and for me it's holding ice against my skin, submerging my face in a sink of cold water, intense exercise in the gym (intervals). It's designed to try and change my body chemistry and turn on the survival mechanism in the body by stimulating the "dive reflex" and shutting down functions not essential for survival (more on this here). I'm not a big fan of progressive muscle relaxation (the 'P' of TIP), mostly because I am usually far too agitated when I am in this frame of mind to use it. I seem to be unable to sit down and focus when I'm in this state as I'm often pacing,  crying and muttering to myself. Other people seem to find it helpful though.

Anyway, enough from me for tonight. Ka Kite Ano!

Self harm and me

Trigger alert - today's post talks about self harm and it's causes. If self harm is a problem for you please get help from a professional. This post describes my experiences and is in no way designed to encourage anyone else to self harm. 

Just as an added note, I wrote the following post last weekend. I debated all week about whether to post it because the issue of self harm carries a huge amount of stigma. Many people know I have this problem because the scars are hard to hide, but no one (with the exception of my family and one other person) has ever raised the subject with me. 

The shame and stigma attached to self harm are overwhelming at times and it is perhaps one of the hardest aspects of mental illness to discuss. Many people can not understand why you would want to harm yourself, particularly using the method I do which is cutting. The following post describes what leads to this behaviour and the biological reasons why.

(Sunday)

Today....today was unfortunately one of those days that is so common for me as a person with BPD. A day where my moods changed with speed of the wind outside, sweeping away all traces of what I felt previously and hammering me again and again with intense emotion.

This morning I woke feeling motivated. Little G went off to her father's early, and then I got on with the washing and ate breakfast. I had decided to spend another hour or so in bed as it had been a long week and I was trying to take things easy so as not to get sick.

All morning my brain fought me. It was sunny outside and there was a war raging inside my head. One side telling me how lazy I was, and that I was wasting sunshine and time laying in bed reading. And the other side telling me I needed the rest, to give my body a chance to recharge and get ready for the next week. I recently found an article about boring self care and her drawings were the main reason I managed to stick to my guns this morning and try not to berate myself too much for resting and reading. She does cute little cartoons about the little things we can do to take care of ourselves, and today I knew that rest was what I needed. Didn't stop my brain from trying to take over with my normal pattern of non stop activity to fill a long day by myself though.

After lunch I stopped feeling like I should do something, and started feeling like I didn't want to do anything. This was particularly bad timing as this is when I'd actually planned to get moving and do chores and buy groceries. It took me several hours to force myself to have a shower and get lunch, put on shoes and go outside for a walk. My brain kept distracting me and I was having trouble focusing on what I should be doing. I wasn't actually doing anything during this time except wandering around pausing and looking at all the stuff I should have been doing. The thoughts in my head about me being useless and lazy were pretty loud, and were drowning out anything much else at that point.

I finally got outside and did about half an hour's walk. This week's goal is to be consistent with my exercise, and try and do 20-30 minutes on 5 or more days. I walked yesterday and today so was reasonably pleased by the time I got home. Off to the supermarket and for some inexplicable reason, the person in front of me drove at 35 km/h the whole way (speed limit is 50 km/h, I normally do more like 60!). The frustration and anger that overtook me was incredible, I was imagining setting up a punching bag and slamming my fists in to it over and over. After 5 minutes I was in full blown rage mode, though my rational/logical mind kept trying to tell me I wasn't in any hurry and that I should calm down.

Pull in to the supermarket car park and park the car in the far corner away from anyone else so I can have some deep breaths and calm down. Then on into the supermarket. After only a few minutes inside I start feeling really upset, then a sad song comes and I have tears in my eyes while I am picking out apples. After telling myself that I'm being ridiculous and have no reason for crying, I manage to pull myself together enough to continue with the shopping.

In the supermarket environment I'm overwhelmed by the number of people, the bright lights, tiredness and the music. My physical senses are often in overload in settings like that due to my autism.

My emotions have run the gauntlet from motivated to hyped up, to depressed, then to confused and distracted, happy after my walk, then tired, angry, full of rage, then to sad (complete with tears). I feel so overwhelmed by the large swings in my mood that my brain keeps trying to default to its standard method of taking the emotional pain away. 

All I can think about is drinking alcohol and cutting myself. I'm severely triggered walking past the wine and beer aisles. The craving for a drink is so strong that I can't stop myself from choosing a bottle of wine to take home, all the while knowing it is the first step on a disastrous path that only has one end.

I'm well aware of how destructive the drinking is, and how once I start drinking then what little control I have over my self harm urges subsides. This usually leaves me sitting in a pool of blood with a razor blade in my hand at some point.

I have to walk past the utility knives, don't need those as my house is littered with them, and anyway they don't provide the deep cuts that give me the relief. They have long since been replaced with razor blades.

I'm not buying blades today. My hands are shaking on the trolley as I walk past but I try and tell myself that if I don't buy them then all I'll do is drink. Unfortunately, this has not proved true in the past. I know full well how to take a razor apart when I'm drunk and in the grip of my compulsion. 

In situations like this in the past I've gone straight home after the supermarket, opened the bottle, sat down and cried about what I'm about to do. I'm normally a spirits girl and a shot is all it takes to release the flood gates. That is when the blades come out and I promise myself it will just be one or two cuts. That I'll see the blood and feel a bit better and then I'll stop. However, it usually takes 8 - 10 shots with small chasers of coke before I've cut myself enough to be able to control it enough to stop.

It's hard to describe the relief the cutting provides, and it can be different depending on the circumstances at the time I have the urge to self harm. For me, self harm is a compulsion. I've used it so many times in the past that my brain is wired up to want to complete acts of self harm to relieve my emotional pain. 

Part of the reason for this is because at some stage I accidentally tapped into the brain's ability to use it's natural painkiller, endorphins, to relieve my emotional pain. Our human brains are wired up to sense both physical and emotional pain using the same two areas: the anterior insula and anterior cingulate cortex. When you get hurt physically, your brain registers the pain in these two areas and prompts the production of endorphins, which is the brain's own natural morphine. Wikipedia says "The principal function of endorphins is to inhibit the transmission of pain signals; they may also produce a feeling of euphoria very similar to that produced by other opioids.^[3]   

Basically this means that if you cause yourself physical pain, the body produces endorphins which then act on your emotional pain as well. In terms of self harm, this is why it can be so addictive - create enough physical pain and your emotional pain will be relieved with endorphins your body has produced to get rid of physical pain. Unfortunately there is no way to stimulate an endorphin response to emotional pain without causing yourself physical pain. And it seems (though more research is being done on this) that you can not relieve emotional pain with painkillers made for physical pain.

The upshot of all this is that every time I create physical pain in response to my emotional pain, I force my body to produce endorphins which relieves both types of pain. This creates a feedback loop - emotional pain leads to physical pain which causes endorphins which relieves the pain. And every single time I use that response to my emotions, the feedback loop is reinforced, making that connection stronger and stronger. This makes the urge to harm myself become a compulsion when faced with situations that trigger overwhelming emotions.

This is not the only reason people self harm. Sometimes for me it is about punishing myself, causing myself pain because I believe I deserve it. Sometimes it is more about the scars and pain on the outside matching the black deadness you have on the inside. Often it is a combination of things - a triggering event may cause the compulsion but may also cause me shame because I'm not living up to my own expectations. I can spiral down as thoughts about what a terrible person and waste of space I am go around and around in my head. 

The therapy I'm doing, which is a combination of acceptance and commitment therapy and dialectical behavioural therapy with a few other things thrown in, is teaching me to recognise my triggers, to try and prevent them, and what to do when I am in this situation. In order to remove my self harm behaviour I have to have something to replace it with.  Not only do I need to recognise when I'm having thoughts that lead to overwhelm, I have to self care skills, triggers, be able to tune in to myself and my surroundings (mindfulness), and a range of coping skills to suit all sorts of situations.

So, last Sunday, despite the fact that I brought the wine, I came home and I did not drink it. I put it away at the back of the cupboard, then I ate dinner. I had forgotten to eat much during the day and it wasn't until I did some mindfulness on the way home from the supermarket I realised I was hungry. I switched on Netflix and watched a funny movie, with my soft sensory blanket on my knee and the cat on my lap. Then I got on here and wrote about my day. I did some other writing which was a bit of homework for my therapist and finally sat down to read. Crisis averted, till next time.

You might think, reading what I did to cope with that overwhelming urge to self harm, that the things I did were nothing special so how could they possibly have helped if I was really that bad. The answer to that is two fold. One, the whole time I did the things I outlined above my body was craving endorphins. The thoughts don't leave my mind, I just try and distract myself from acting on them. Two, it's taken a lot (a lot a lot) of hard work over the last two years to get this far. I have crisis strategies like holding cubes of ice (either in my hands or against my arms), submerging my face in cold water, intense exercise (like short sprints), and paced breathing. But first I try distraction and soothing my senses with things I know work for me (a really good link explaining this is here.

Things are slowly getting better but sometimes I fail, and sometimes I fall. I am always going to have to be mindful not to fall back in to old patterns. At times the amount of work I need to do to get and remain mentally healthy looks like an enormous burden. But I have learnt that there is a time to look at the big picture and a time to look only a little way in front of you. Sometimes it's best to try and deal with today and plan just for tomorrow rather than get too tangled up in what the future might hold. 

Ka kite ano

On BPD, anger and depression

Things haven't been going too well for me mental health wise in the last couple of weeks. Having BPD makes it hard for me to control my emotions, and my highs and lows tend to be much greater. Couple that with a tendency towards depression, and an Aspie brain, and you can see why my mental health seems to be a roller coaster ride most of the time.

I refer to my lows as episodes, much like someone with bipolar probably would do. During a low I can be extremely depressed, suicidal, indulge in various self harming behaviours, angry, emotional, belligerent, argumentative, manipulative....you get the idea. It's not pleasant for me or for anyone around me and it does a whole lot of damage to my life which I have to try and repair when I am well again. It's also very frustrating for me, because often I am aware I am acting badly but lack the skills to do anything but react.

One of the things I have been struggling with most during this particular low is anger. Often having a low with strong anger as the dominant feeling means a depressive episode is on the way. This is because as the anger or rage causes me to do things that I regret, I start hating myself for being like this. This begins a cycle of thought about how I am not trying hard enough, people would be better off without me, I'm not good enough, I'm a horrible parent/family member/friend/person in general. Then leads on to thoughts of death and finally suicidal ideation. Occasionally I hallucinate if I get really emotionally fraught - I have gone for bush walks and thought I have seen bodies hanging in the trees. 

So the anger I have been feeling this time has scared me. I have had several severe major episodes in the last 3.5 years and every time it is a long hard journey to climb out of that hole and keep living. My daughter has been and continues to be my reason for living, for climbing out of bed every day even when things were at their worst. But returning to a place where you can see a future again and have a little hope takes a lot of hard work. Severe depression is unlike mild and moderate depression in that the traditional things that doctors recommend don't work, at least initially. No matter how much exercise, good food, quality sleep, social connection etc you get, your whole life basically falls into a pit of doom and you become unable to do the most basic of things for yourself. At my worst I couldn't read or watch TV because there was too much effort involved in concentrating and trying to understand the plot, and my ability to speak was severely impaired because I had trouble following conversation and forming opinion.

I think what I also find hard about anger as a dominant symptom of a low is that it makes me inclined to be extremely difficult to deal with as a patient. As much as I need help I will take offence to suggestions or instructions from my nursing case manager and my psychologist. I will feel like nothing anyone suggests is good enough and I will interpret attempts to help me as "people interfering" or them "telling me what to do". I vocalise this opinion to the people involved and I have been effectively fired as a patient by several psychiatrists and one psychologist for becoming angry and verbally agressive in appointments (just to clarify - I've never hurt anyone, just damaged the patient/therapist relationship).

I am currently receiving DBT therapy for my BPD and have made huge improvement in a number of areas. But anger still remains one of the emotions I find hardest to control. 

For whatever reason, this morning I woke feeling better than I have done in a while. Work was busy but not as stressful as it usually is, and after work Little G and I went to a local swimming pool. We bumped into friends and she played with their girls while I chatted to the mums, then Little G and I swam laps together. After dinner her and I walked to the dairy for an ice cream and sat in the park to eat them. Her and I sat in companionable silence and I tried to just be in the moment, enjoying the last of the evening sun and the taste of the ice cream and the company of my child. I think my peace is slowly starting to return. I am hoping that I hit the bottom of the low and because I am getting better at resisting self harming urges and limiting angry outbursts, it hasn't lasted as long as it normally would.

I'll leave you with the lyrics from one of my favourite Six60 songs, and in their words "Ain't it good to be alive?"  That might be a strange thing to say when I've just spent this post telling you the difficulties of mental illness, but I believe that I wouldn't be the person I was if I was not forced to face these challenges.

SIX60 LYRICS

"Only To Be"

Only to be, I live in expectancy
No wonder it feels like this wasn't meant for me
Though my mind is so confined
That there ain't no point in reasoning,
Now that it's clear to see,
It was all in front of me
And I'm right where I'm supposed to be

Yeah yea, I'll live just turning pages
Yeah, well I know that it's worth the ride
Ain't it good to be alive?

So what will it be?
My dreams are my company
To lose what is me,
I follow the path I see.
My mind is so confined
That I don't even know where to begin.
But it took me so long to find
That I can leave it all behind.
Cause I don't got everything I'd ever need

Yeah yea, I'll live just turning pages
Yeah, well I know that it's worth the ride
Ain't it good to be alive?

Cause only to be,
Was all that you've got from me
You told me it's real,
And nothing comes easily.
Cause that was the truth, I was losing all my youth
To a world that's fit for someone else

Yeah, I'll live just turning pages
Yeah, well I know that it's worth the ride
Yeah, I'll live just turning pages, yeah
Yeah, but I know it was worth the ride
Ain't it good to be alive?