Exams

I don’t know how many times I’ve had this dream, or something like it. It’s 5.30pm on Saturday afternoon. My final Year 12 exam starts in 3 hours and I’m absolutely not ready. Why an exam is scheduled for 8.30pm on a Saturday is never made very clear to me! I don’t have a cheat sheet ready, I haven’t studied all semester, I know nothing and I’m in a despairing panic. Or I’m in the last class of the term doing trial exams and unable to answer a single question. Or I’m studying at home and don’t even know where to start. Or I’m in a group study session and the others know everything and I’m absolutely lost, up the creek without a paddle! The subject of the exam is never one that you can cram overnight like biology or history; it’s always physics, maths, or chemistry where you have to understand the equations and be able to manipulate them in the exam to show your understanding. Or lack thereof in this case. There is no way that I can shove enough knowledge into my brain in time to pull it back out again in time for the exam. In other words, I’m doomed! Can you imagine the panic, stress, anxiety, despair, terror, the feeling of utter failure and of the future being bleak? In the middle of the night in my sleep it’s very real and very upsetting! Wishing I’d done better, afraid of the moment my teachers find out I’ve failed them, fearing my peers finding out I’m dumb and incompetent. Cheery stuff!

The thing is, I passed my Year 12 exams. I received my Victorian Certificate of Education in 2005. I did well in fact. I was in the top 10 of my year level, number 6 I think. I achieved 94.55 out of 99.99. This isn’t a brag. It’s an attempt to make my brain remember that actually I have finished this part of my life, and finished it well. I no longer need to fret, stress, despair, panic, etc about facing exams. I mean for goodness sake, it’s 11 years since Year 12! It’s 7 years since I finished my Bachelor of Pharmacy, a lot less academically brilliantly but still. Those years are done, finished; there’s nothing that can be done to change any of it. I can’t go back and do it again. And after all I did those exams and passed them. But these dreams, largely about Year 12 exams, persist! And it’s tiring to spend so much emotion in my sleep during the night on a situation that would never occur to me to think about during the day. But during the night, my brain can’t rationalise. It’s susceptible to the strangest things. And never more so than since I’ve been on antidepressants. Prior to starting antidepressants in mid 2013 I may have had this dream, but I can’t remember. I never dreamed that much and I remembered even less of what I did dream. I’d wake up and any dream would rapidly fade and become a vague thought, or just drift away. But then.

SSRIs, selective serotonin reuptake inhibitors, are the first class of antidepressant that you get to know if you experience your own battle with anxiety, or depression. They are the first line of treatment. Lexapro, Prozac and Zoloft are some brand names you may have heard of. I prefer the generic names because they never change: escitalopram, fluoxetine, sertraline plus paroxetine, citalopram and fluvoxamine. These medications can have a side effect of strange, or even frightening dreams or nightmares (NPS), otherwise described in some places as vivid dreams. Can, being the operative word. They don’t occur in all people, or all the time. I seem to go through phases then have a break for a while, then another series. I was amused at the beginning. I had these super realistic dreams of utter nonsense that were really quite entertaining. I just wished I could have hit the video button and recorded them; I’m sure my name would have gone down in history along with the famous movie directors. I could never write them down quick enough and in enough detail to really proper capture them; quite a shame. But then I started getting variations on this exam panic and it’s not anywhere near amusing; it’s very stressful and I wake up next morning entirely exhausted, as if I’ve hardly slept! It’s draining. And to what end? My psychiatrist doesn’t believe in finding the meaning in dreams, neither did my psychologist, nor does my GP. Rationally I know that dreams are just my subconscious processing data. But sometimes I’d just like a reason why I’m fighting with these emotions during the night. I mean I know why, in that it’s because of the medication. But why this kind of dream, why this stress about failing?

So. What to do about it? In my case, not a lot right now. I’m on an SSRI plus 3 mood stabilisers. Theoretically for bipolar patients, the antidepressant is no longer necessary once the mood stabilisers are in place. Theoretically. So in order to get rid of the dreams, and the sweating, my psychiatrist started slowly weaning my high dose of antidepressant. We got down to 375mg from 525mg, but when we went to 300mg, things started falling apart. It wasn’t worth it so we went back to the last dose that worked. We might try it again later, especially now that one of my mood stabilisers has been bumped up. But it’s a balancing act. Sometimes you have to accept some side effects for an otherwise good healthy life. That’s just reality.

In the meantime, my energy is going to trying to wake myself up out of these dreams and remind myself that although I did have some close calls with studying at the last minute during my university years, that’s long gone! It’s in the past and it needn’t bother me anymore. What’s weird is that it was my years at uni when I was less studious, but the dreams are always about high school. I guess that’s just proof that this is an irrational thing, and to just let it go as much as possible, let it pass, let it slide. Breathe in, 2, 3, 4, out, 2, 3, 4. Ahhh.

Advertisements

Tales of a missed dose

[Written 16th June 2015]

This is a story of what happens when I miss a dose of medication.

What happens depends whether I miss a morning dose or an evening dose. As I write this I’m suffering from missing an evening dose so let’s go with that.

At night I take several tablets: quetiapine, lithium, valproate, rosuvastatin, pantoprazole. Mood stabiliser, mood stabiliser, mood stabiliser, anti-cholesterol, antacid. Yes, it takes that many stabilisers to keep me going!

In the morning I take thyroxine, venlafaxine, Levlen, valproate, lithium. Thyroid hormone replacement, antidepressant, contraceptive, mood stabiliser, mood stabiliser.

All done! Hopefully...I'll still count the tablets out every morning and night to double triple check

In terms of missing a dose, lithium and valproate aren’t the worst to miss as a patient because I’ll be taking some again soon. This is not an official pharmacist, GP or psychiatrist recommendation! Lithium and valproate should ALWAYS be taken twice a day, as close as possible to 12 hours apart for the best effect! And I repeat! This is because for lithium a healthy person’s kidneys clear it out of you in that time frame so to keep a steady level you should take it consistently. And for valproate it’s your liver. That’s why you should respect these two organs very highly! They are very important. But what I’m meaning is its not the worst in terms of the adverse effect of missing a dose. If I miss taking lithium at bedtime, I take it first thing the next morning which gets it back in my system before I physically notice that it even left. My overall level will be a bit lower for a few days which isn’t ideal, but it will work back up to speed soon enough. And I do have a level at least.

Whereas for medications that I take once a day, I’ll miss the effect for 24 hours. Which sucks. Plainly and simply!

boxes, bottles, tablets, capsules

Quetiapine is one of the once a day tablets. It is prescribed to me to prevent mood swings, reduce my anxiety and has the handy effect of giving me a good night’s sleep. It was doing this a bit too well for some months there and I was doped out all of the time, but my awesome psychiatrist recommended a change in the times I take it and we’re back up to speed. Yes!

So, do I get a mood swing if I miss one dose? No. Really not. The chemistry isn’t that reactive. In the same way that it takes weeks of first taking the medication to get the benefit, it takes longer than one day to mess up the whole thing. But I do have a rough day afterward, and a rough night too! It’s a bit like I’m sitting in my car going along nicely and I know where I am and where I’m going and how I am and suddenly another car rear ends me, or bumps into the side of my car at a right angle. Slowly of course, not fast. So my mood just takes a hit, a bump and suddenly I’ve jumped along or across and I find myself somewhere other than where I just was, a bit disorientated about how I got there and sort of catching up with what just happened and where am I now and how I am and are we still okay? That following day I may be in quite a different mood from the one before, either peppy and edgy and anxious and manic, or slow, and silent, and flat and a bit away with the fairies. But that doesn’t qualify as a mood swing, just a sudden small change that affects my day.

After missing a dose here and there I have now gotten the side effects of missing my nightly dose of quetiapine down in a pretty clear timeline. Yes, there are side effects from NOT taking your tablets, as much as taking them. Something to consider.

So here’s the quetiapine absence timeline.

strips, tablets, capsules

10 to 11pm: I can’t get to sleep.

This is a terrible thing. I need my sleep. Always have, and always will I guess, but especially since I’ve been sick. So does everyone, I realise. If I don’t get a good night’s sleep the next day is a struggle, emotionally. So I toss, and I turn, and I turn, and I toss. After an hour of this, if I’m alert enough, I’ll think to myself, self, why can’t I get to sleep? I usually go straight to sleep! Then I’ll look in my pill box, see my tablets, mentally or physically hit myself in the head, take them and all is good in the world. Just like that. If I’m not thinking too clearly, I might think to take a Valium and at least get some sleep. If I’m dull-witted, which is at least half of the time, I’ll eventually wrestle myself to sleep. It sounds funny to say, but I’ve become very good at putting myself to sleep. I nap most days from necessity, and there is a skill involved in going from activity to sleep in a short space of time. I guess shift workers eventually excel at this sort of thing. So I’m quite adept at getting myself in a comfortable position, getting the temperature right (cannot sleep well unless it is right!), darkening the room, doing a conscious relaxation of as many muscles as I can, and stilling my mind into sleep.

Say I managed that. Next time check?

3am. Yep, wide awake, fresh as a daisy, ready to go at 3am. I toss, and turn, and can’t get comfortable, and I’m restless and my poor husband is rocking and rolling every time I turn and I’m messing with his sheets, and he has to go to work tomorrow even if I don’t, so I try to lay still and physically can’t! Why am I awake, I’m usually asleep, what is happening, oh….ahhhh! Tablets! I forgot them! Duhh! I hate that moment! I try to do my utmost to prevent it, but it still happens and it does feel like a failure every time I somehow mess it up! So, should I take them now? The dilemma! It’s 7 out of 12 or 24 hours through the medication time period. So I can’t take all of them. Maybe just some of them. Can’t take quetiapine, I’ve missed the boat on that one otherwise I’ll sleep all day. And I’ll be taking lithium and valproate soon anyway, and can’t double dose. What about the rest? Which are nothing really, in the scheme of me being wide awake at 3am! Cholesterol and stomach medication. Sure I can take them, they should be taken regularly but it’s too late for my sleep. The next dilemma then: try to force myself to sleep again, or just get up, take my laptop to the spare room and do something else? Who knows? Depends what I’ve got on the next day really. I can never decide!

medication list

8am: I’ve finally given up the ghost on sleep so I’m up and peppy and full of life and only just partially anxious and ever so slightly manic and energetic and going to run the world! If I haven’t already taken one to sleep, now is the time for a Valium to wind back the jets on being super woman and achieving all my life goals in one sweet day! And talking my husband’s ear off and planning one hundred chores like a complete going through of the entire kitchen plus 3 loads of washing on a rainy day and lunch with girlfriends and all kinds of magical things. ‘Woah, says my husband, that’s too many things for today. No do that another day, you’ve got enough things for today. How about you sit down for a minute, what about some mindfulness? I think you should do some mindfulness…how about you go and do that now?’ At around about this point I have now blown my nose for literally the THIRTIETH time since waking for the final time. THIRTY. You just can’t blow you nose till it feels empty; there’s always residual. And it’s pretty much like a tap. The medical term is rhinorrhea, like diarrhea but your nose is melting and there is a constant liquid dripping, dripping, dripping!! Quetiapine dries you out like anything so you get dry mouth (and want to drink Coke all the time!), dry nose which leads to sores and blood noses, some degree of constipation which no one wants to know about and some urine retention. The last one isn’t noticeable on any other day, until the missed dose day and then I realise that yes I really have been holding back! TMI I know, but you wanted the whole story right?

But the nose thing really gets me! If I notice nothing else in the middle of the night, I do notice my nose dripping incessantly! It’s an instant giveaway! It’s different to regular waking up in the morning and blowing your nose. It’s more like hay fever without the sneezing but the medication to stop it cannot be taken til nighttime!!! Cue fierce under breath bursts of ‘idiot’!

And then it’s just getting through the day like usual, but bearing well in mind that you’re a bit high today, a bit edgy, a bit fiddly, a bit anxious, a bit overstrung so remembering to breath, relax, calm, easy, gently does it. And I should mention that the other things ease off too, just not in such an obvious diagnostic way. I have the right amount of saliva in my mouth (who knew that was a thing!) and going to the toilet is a breeze, like really easy, like maybe a bit too much and too many times! So happy thoughts!

medication box, tablets

Now the morning lot and venlafaxine. Anyone who is involved in the prescribing, dispensing, and before too long taking venlafaxine knows about the withdrawals. It’s described in the textbooks and it happens like the textbooks. Exactly like. I used to think this was pretty cool. I still do theoretically, but in practice I either love or hate that they’re so reliable and unavoidable. I love them if I notice it before I’ve left the house for a work day because I immediately fix the shortcoming. I hate them if I notice once I’m already on the way to the bus stop and I don’t have time to turn back, or I’m on the bus, on the train, on the tram, in the building. Then it sucks because I know what’s coming and I can’t do a thing about it! Unless I can get to my doctor for an emergency script but that means paying full price, and after all it’s nothing life threatening. Not bad enough to pay three times the normal price! And believe it or not borrowing stock from the shelves is not strongly encouraged by my employers nor is it in any way legal!

What the symptoms/adverse effects of missing venlafaxine are: electric shocks/tingling in your fingers, light headedness/feeling like my head is spinning/wondering if I’ll faint, nausea. Nothing fun. Nothing dangerous. They don’t make for a good day, and I have to wait til the next morning to fix it! More banging of palm to forehead and severe muttering to oneself!

So that the what. The why is a whole other adventure and I don’t have time today, but hang in there and soon we’ll have another chat and look at the other part of the problem. Chat soon!