Limping through emotional pain

Notes From the Mowed Down, part two.

In my prior blog, I wrote about getting hit by a distracted driver as I was crossing the road with my family to get ice cream. Instead of a small cup of strawberry with chocolate sprinkles, I ended up with a fragmented leg and ten excruciating nights in the hospital. Definitely a downgrade. When people think of trauma and accidents, the first thing that comes to mind is the physical pain the person must be suffering. What is more challenging to discuss is the subtle onset of emotional pain this experience has caused, the losses, the isolation, the grieving, and the roiling anger, all ultimately giving way to gratitude.

In my experience, initially, physical pain predominated over emotional pain in its sheer intensity and in its immediate all-encompassing totality. There was only my right leg – the rest of me entirely dissolved in the face of such agony. Once the physical pain was medicated to tolerable levels, as they heaved narcotics at it, there was a grace period during which a dense flurry of friends and relatives visited, empathized, hung out, helped out, fed me, and generally tried to cheer me up. This was profoundly sustaining, and I will never forget the visits, emails, texts, meals, letters, and calls.

My twin brother Josh, an attorney, who has lost a daughter, told me that he was warned, grieving-wise, to watch out for the “once the casseroles stop arriving” phase, as people organically return to managing their own stressful and overstuffed lives. The initial tragedy flashes brightly onto everyone’s radar screen, but the more subtle suffering that comes later can go undetected.  

True to this, after a few weeks, I found that I had a lot more time to be alone with my feelings. I’ve spent about half my life specifically trying to avoid my feelings. This is, in large part, what my addiction to prescription opioids was all about, documented in my memoir, ‘Free Refills: A Doctor Confronts His Addiction’

Once it was just me and my feelings, often alone, sitting in a chair all day, unable to walk, an emotional pain starts to seep in, like a thin autumnal fog, distributing itself throughout every cell. This usually occurs in the early evening which, unhelpfully, in the fall, comes a few minutes sooner each day. By this time, I have usually exhausted all of my distraction techniques, and my leg is too sore to do much more limping around on crutches.

I can sense my mood starting to sink, a balloon slowly losing altitude, and, despite having been a primary care doctor for a quarter century, treating thousands of patients for depression, there is very little I know to do to retard this process in myself.

There is a complex, intricate interplay between my physical and my emotional pain. They are two sides of the same coin, inseparable and inextricably linked. They reinforce each other – a dire negative feedback loop. The way in which our moods, attitudes, and beliefs can increase or lessen our pain has been written about voluminously and has critical relevance to the fifty million Americans who suffer from chronic pain. If my leg hurts more, I can’t really do anything, except sit in a chair, which undermines my mood, because I’m just sitting by myself in a chair. If my mood is depressed, I have less ‘fight’ in me to push against this pain.

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As my mood follows the sun below the horizon, darkening the world, my blood gradually starts to feel like it’s poisoned, sluggish, and thicker than usual. In the area where my heart is, I feel a dull lethargy which saps my motivation to do anything that could help snap me out of this funk.

I asked Chat GPT what was happening, and it responded, “Depression is like a stubborn weed that infiltrates your heart.” (I should have followed with “What do you know about it, you’re just a mindless, heartless pattern recognition algorithm”?) Consistent with Chat’s pronouncement, my experiences and interactions can feel as if I were viewing the world from behind a dirty and slightly tinted window.  

Another thing that happens when feeling depressed, is that I want to sleep all the time. Sleep is like a drug, specifically a narcotic that drags me under, into a realm where I don’t feel anything at all, sort of like I imagine being dead would feel like (or would not feel like). I can relate to Thomas De Quincey in ‘Confessions of an English Opium Eater’ yet here sleep is the drug, not opium. I’ve been taught that the ‘vegetative signs of depression’ include not sleeping and not eating or oversleeping and overeating.

I didn’t eat much – notable for someone who has been overweight for most of their life (until Wegovy), but I did sleep, which helps pass the time – another challenge when I am feeling depressed. Time slows down, sort of like when I’ve been high on cannabis, but instead of everything being magical, interesting, and fun – I want the day to end as quickly as possible so that I can narcotize myself again with sleep.

Ordinarily, I never have the opportunity to ‘pass the time’ because I’m busily contending with the fact that time is passing me by. I need 27 hours in the day to accomplish all that I set out to do. Time is scarce. Time is precious - a commodity to be stingy about. Time only happens once.

When depressed, it all gets flipped on its head. Like an endless road that extends into an eternity - alluded to in Nietzsche’s ‘Thus Spake Zarathustra’, each day seems as if it is going to last forever. This is daunting, as it can feel as if I am going to be sitting in this same chair, in the same position, in the same lonely state, with the same broken leg, until time ends, if it ever does.

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My brother David, an incredibly brilliant Astrobiologist and writer, pointed out that high-achieving people can enter another negative feedback loop. This one is especially true if you happen to be one of us who has fragile self-esteem and who needs to see yourself in print all the time to feel validated. In a depressed mood, it is more difficult to get my regular things done, like writing, posting on social media, corresponding, collaborating, and educating. I chip away at it, but inefficiently, due to strong psychic headwinds. It’s like walking on a treadmill set to the steepest slope. At some point, you just get tired. As I’m less productive, there’s less positive reinforcement – fewer articles, fewer quotes, fewer invitations, and fewer friendly and inquiring emails – which deflates my mood even further.  

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Where do we go for help under these circumstances, to reinfuse joy and meaning into our lives, or at least to staunch the hemorrhage? I am one of the rare, lucky patients to have a psychiatrist who is empathic, open-minded, and who, over more than a decade, has come to know me. She listens to my ideas but certainly isn’t afraid to say no. For example, she would shoot it down if I were to ask her to treat me with ketamine (which I haven’t yet). She is, I suspect, somewhat suspicious that I have a tendency toward bipolar disorder and is concerned that I could potentially loft into a manic state if given an antidepressant (which is what I originally asked for).

Bipolar does run in my family and my psychiatrist believes that, under normal circumstances, I have every single positive aspect of being hypomanic – the generative energy, the motivation, the ability to burn the candle on both ends - without getting into difficulty with actual mania or reckless behavior. It’s called being ‘hyper-thymic’. In essence, I don’t have bipolar unless I take the wrong medication – an antidepressant - and then I might have bipolar. I guess I have, making this up, ‘potential bipolar’.

Hence, I end up on Lamictal (lamotrigine), one of the antiepileptic drugs, also used to treat bipolar (which I only have potentially), and now used, off-label, for general mood stabilization. Once I had been prescribed Lamictal, it seemed like a good time to learn about the drug. I have prescribed it before, because we primary care doctors are now forced to prescribe Lamictal and other obscure psychiatric drugs, as there aren’t nearly enough functioning psychiatrists to do so, even though we know little about them.  The utter collapse of primary care, which I have had a front-row seat to for the last twenty-five years, is the subject of a future blog. The main side effect of Lamictal is a rash, which hasn’t yet occurred, so…so far so good. It is too early to tell if it is helping my mood. (Ketamine would work right away though it could precipitate mania.) Check out my blog on ketamine for Harvard Health:

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Depression is not the only emotion that can overwhelm my system when my attempts to distract, outlimp, or escape my negative moods flounder. The feelings can run the gamut. Anxiety is a ferocious competitor to sadness for my attention, presenting as a general dread that eludes any specific concern. I’m not anxious about anything specific that I could fix or at least address, such as a test, a speech, or another effective pay cut from my job; rather it is free-floating, nebulous, and difficult to grapple with, as it isn’t tethered to anything real.

What are the things that don’t help my anxiety? Not exercising doesn’t help the anxiety. The glacial and uncertain pace of my recovery doesn’t help. Not being able to take a walk in the pristine fall weather doesn’t help. Not working doesn’t help. Sitting in this same chair doesn’t help. Not knowing if my bone is truly healing (until an upcoming x-ray) doesn’t help. Missing out on social events, academic conferences, plays, concerts (I had Peter Gabriel tickets…), trainings (such as a MAPS psychedelic therapy training), on dinners – all of this does not help with the sadness or the anxiety. Sitting and ruminating doesn’t help either, but it’s difficult to tune out the negative Siren songs of misery.  

All we can do is…try to tolerate these feelings, practice healthy mental habits, and drug ourselves with medications when that doesn’t work. I do my best not to succumb to negative cognitive distortions which can make everything worse, which I have described in one of my Harvard Health blogs.

There is also a roiling fury, that descends, from time to time, against the unpleasant circumstance I abruptly find myself in.  The oblivious psychiatrist who took away, essentially, a half year of my life, reigns supreme on the top of my shit list. Why wasn’t she watching the road? It’s weird to be so angry at someone you have never met.

Another question is why were the police in my hometown of Newton, Mass. so weirdly passive? They didn’t do a breathalyzer on a Saturday evening – that’s utterly insane. They didn’t even bother to look at her cell phone.

To cope with this anger, I continually remind myself of something I learned in my recovery from addiction: resentments keep you sick and it’s far healthier to let them go if you can bring yourself to do so.

A final issue is how my mood affects the people around me. This always puts me in a bind. On the one hand, I am a true believer in being open and honest about one’s feelings, not repressing them, or you get a Freudian “return of the repressed” and they tend to run amok. You can’t just stuff sadness into a psychic closet somewhere. I learned this the hard way during my decade of opioid addiction. I can’t just withhold information when I am feeling depressed - this is a recipe for disaster, especially as I interact with a ton of different people on some days. Yet, if I am outwardly miserable every single day, that saddens those closest to me, such as my wonderful partner Lizzie, who I desperately need to not be sad so that she can uplift, or at least palliate, my spirits. I haven’t found a solution to this or figured out how much disclosure is helpful to myself and others. I am open to suggestions.

Gratitude

The final emotion to discuss is the most essential of all: gratitude. This is what has enabled me to continue to put one crutch in front of the other, despite how uphill or slippery the path may appear. I couldn’t be more grateful that I didn’t start my walk toward my elusive cup of strawberry ice cream a fraction of a second sooner. If I had, I would have been several inches further along on my ill-fated journey. I would have been hit full-on, not just a glancing blow to my right leg.

There’s no way my hospital, one of the best in the world, would have been able to stitch me together again. Instead, I’d now be a decomposing, distributed mass of ashes drifting in the Nauset Inlet in Orleans, Mass., along with those of my brother Danny, whose ashes we scattered there a half-century ago after he succumbed to childhood leukemia.

Next on my gratitude list, which I try to revisit every day, comes my partner Lizzie, who has walked with me every limp of the way. With her dexterous and loving wound care, she helped me avoid two excruciating surgeries on my skin. Not bad for a Data Engineer (whatever on Earth that is…). She did everything a person could do to help sustain my mood – inviting people over, listening to my concerns, getting me out of the house, procuring tasty treats when I was blue – and supporting my care. I am eager to repay the favor, though hopefully she won’t need it for many decades to come.

I am grateful for the doctors and nurses who not only put me back together – a complex task with an open fracture - but who also controlled my pain, my infections, my anxiety, and who helped address all the other myriad discomforts and indignities that come with spending ten unexpected, traumatized nights in the hospital.

From the personable Orthopedic resident Trevor who rounded, with good cheer, at 4:30 am every morning, to the diverse cohort of nurses who changed my I.V.s in the middle of the night, and who chatted with me about anything and everything - they were all professional and compassionate. It is infinitely appreciated, and it inspires me to be a better caregiver.

Above all, I am grateful to have such an interconnected network of loving people surrounding me. Once my kids had left for college, I started thinking about how essential adult friendships are and, also, how important it is to truly connect with family. These relationships require nurturing, initiative, and effort. They don’t happen by themselves. The communities that we fashion are essentially what define us. We don’t exist, in any meaningful sense, on our own. Community comprises the background fabric of our everyday lives, and this becomes particularly apparent when life deals us a cruel, unexpected blow.

I can’t thank enough the people who reached out. We gorged on a ton of home-cooked food, sent over with love. In truth, just a brief visit can cheer someone up. If someone is suffering an injury or an illness, you simply don’t know how long they’ve been sitting there or what their mental state is. I implore you reach out to those around you who are suffering. Visit. Call. Text. Connect in any way possible. We don’t know how someone is doing if we don’t ask.

We can make someone’s emotional load a bit lighter, and possibly even save a life, just by maintaining simple contact with someone who is ailing.