Mania, Anxiety, and Panic, oh my!!
December 27, 2014 5:57 AM   Subscribe

How do I know when what I'm feeling is simple anxiety, when it's an oncoming panic attack, or when it's becoming a manic episode, as it's coming on, rather than looking back with 20/20 hindsight and going, "Well, duh"? Blizzard inside.

I am under the care of a psychiatrist and a therapist both. I will not see either of them until the second week of January, so I turn to you, the great hive mind, with this question.

I recently moved in with my best friend and his family, since me living alone right now would be a bad idea, medically and psychologically (and since the health issues have made it nigh on impossible for me to work, earn money, pay rent, you get the idea). I have multiple chronic pain conditions, multiple neurological conditions, and tend to fall over a lot. Psychiatrically, I have new diagnoses that I believe to finally be the right ones, after 25+ years of being treated for the wrong ones. Mood disorder, NOS (as my therapist puts it, I have both the long cycles of Bipolar I, and the short cycles of Bipolar II, but I don't get to add them together and get Bipolar III), Panic disorder with agoraphobia, and OCD.

So far, I have only been able to identify a manic episode in hindsight. I can look back on certain times and go, "Oh, yeah, that was definitely a manic episode." Like the time I worked for 8 months straight at 80+ hours per week, taking no days off. That was a manic episode. Or when I dropped out of college, where I had a very nice academic scholarship and my parents were paying the rest, to move across the country to marry a guy I met online 3 months before I dropped out. Definitely manic episode. Or a shorter one, like a few weeks ago on the two days my bff and I moved me out of my apartment, into his place, when I wanted to leave the apartment immaculate, and packed and cleaned and organized and packed and cleaned and loaded into vehicles and cleaned and cleaned and cleaned until body parts started giving out and I wound up on the immaculately vacuumed bedroom floor unable to move. Definitely mania there.

What I'm feeling now feels in some ways like what I felt during the cleaning manic episode I described last....but that could just be because I'm unpacking and cleaning and organizing and unpacking and cleaning and organizing get the idea. In some ways, it feels like a panic attack coming on, because I'm not unpacked and organized yet, and there's no way I'm going to be able to work if I'm not unpacked and organized yet, and I don't want to live here like a leech so I have to work so I have to unpack and organize and my blood pressure and heart rate are high and panic attack. Or it could just be anxiety over the whole situation, my health, or lack thereof, money, suddenly having 5 loud roommates while I'm squishing my 400 sq ft apartment worth of stuff into 81 sq ft, looking like a torture victim from all the IV and blood draw bruises on my hands and arms from ER visits and hospitalizations over the last two weeks, etc.

Meds I take on a regular schedule to try to prevent things: Gabapentin (prescribed for trigeminal neuralgia, also works on fibromyalgia, also a mood stabilizer for bipolar), Trileptal (prescribed for TN, also a mood stabilizer for bipolar), Elavil (prescribed for atypical migraine, also an antidepressant). Meds I take for panic attacks: Atarax, as needed.

A few weeks ago, I had a combo of manic episode and panic attack that had my blood pressure at 219/193, accompanied by visual hallucinations, that landed me in the ER and almost in an inpatient treatment program, which is one of my biggest fears. How do I know what's going on in this head of mine as it's happening so I can medicate, meditate, react, and respond appropriately to not let things get out of control like that again? Please, MeFi, you're my only hope!
posted by The Almighty Mommy Goddess to Health & Fitness (10 answers total) 5 users marked this as a favorite
Part of the illness is that it's VERY difficult to figure out when episodes are coming on. Enlist your BFF to help you by suggesting if it's getting out of hand.

Decide on a daily basis how much is enough and report it to your BFF. So say, "I'm going to do the closet today, I plan to spend about 4 hours on it. Please come in and get me when I reach that point."

Force yourself to stop and re-focus.

Take your BP a few times a day, I find that my physical symptoms precede my anxiety attacks, so if I get a fast heartbeat or elevated BP, it would make sense to pop a Xanax, to head it off.

I take Celexa, usually early in the morning, before work. Since I lost my job (anxiety provoking in the extreme) I take my meds later in the morning now. My anxiety attacks happen at night, and I find that watching mindless TV really helps calm me down, but if it's 2:00 am, I don't want to turn on the TV and disrupt my sleep get the idea. So since the Celexa starts to wear off in the middle of the night, moving the dosage to later in the day really helps. Sure I wake pretty early, but I can turn on the mindless TV and sort of snooze and rest, which really helps me ride it out.

Just think about it, and keep asking yourself, "Is this behavior productive?" Ask for help and assessment from others.

Moving is very stressful and triggering for anxiety and manic episodes. It lends itself to manic behavior, even among those of those of us who don't suffer with it.
posted by Ruthless Bunny at 6:42 AM on December 27, 2014 [2 favorites]

I think you keep a detailed log and use it to find early clues and triggers. Then you will start to be able to see patterns a lot earlier in the process. Some things to log would be sleep, blood pressure, and mood. There are some good online trackers out there if you want to start there.
posted by dawkins_7 at 8:01 AM on December 27, 2014 [1 favorite]

First of all, are you taking the Atarax as prescribed for your anxiety? Because the thought that you have to unpack and get organized and find a job, after what you've just been through, may not be realistic, but sounds like anxiety talking. I have a 'scrip for generic Atarax that is 25 mg every 6 hours as needed (so, up to 100 a day). What does yours say and are you taking it? Because even taking one dose in the evening, I am kind of chill the entire next day. If your anxiety is super high, which is understandable given the circumstances, look at the bottle and see how much you are allowed to take. Don't go, "well, it makes me tired so I can't get as much done," say, "well, I need to chillax because of all the recent events so a few days of less activity will be healing for me."

Do a reality check with your friend and make sure no one is expecting you to compromise your health by trying to live up to these expectations of doing it all right now (are they your expectations? or did your friend actually tell you that you must get a job right away?). If possible, just only do a little per day, and tell yourself you will revisit these expectations after you see your doc and therapist. Make sure you and your friend are on the same level so you don't have to add that to your pile o' worries.

Sleep hygiene: are you sleeping 7 hours in a row? Dimming the lights in the evening, doing light things like watching relaxing shows, listening to calming music, taking a hot bath or hot shower? Use a sleep mask and a white noise machine, or a fan in your room. One difference between anxiety and mania is when you are anxious, you want to sleep but can't (monkey mind) and in mania, you aren't tired and feel like you don't need to sleep (or stay up very late and sleep at odd times, later on, wrecking your sleep patterns). Keeping track of your sleep patterns and being diligent about sleep hygiene is super important.

If taking your Atarax as prescribed is not getting your anxiety levels down to a manageable level, call your pdoc on Monday and let them know. Don't try to ride it out until your appointment. Sometimes you can get something temporarily if you are in crisis (i.e., just moved, etc.) or maybe someone else can see you, such as a prescribing nurse, if your pdoc is not available.

Not sure how long you have been on this particular blend of meds, but please discuss with your pdoc when you seen him/her, in case they want to adjust or try something else that may be more effective for your symptoms. Sometimes it takes a period of adjusting. Keeping notes or a log is a great idea, aim for a note in the morning, one at noon, and one at bedtime, no need for hour by hour, but just a general check-in that you can bring with you to your therapist and pdoc appointments.
posted by Marie Mon Dieu at 8:38 AM on December 27, 2014 [2 favorites]

Mood charts are the generally recommended way to get a handle on your bipolar cycles. The one I've linked is just an example, but most are similar to this. Some people find it useful to customize their own chart if they have certain behaviors that are generally indicative of a manic or depressive episode. For instance, when I was charting I kept track of *when* I slept as well as how long I slept. During manic phases I tend to sleep less but also in strange patterns--2 hours here, 3 hours there, with no long rest. I also kept track of my spending because sudden interests in new activities would also be indicative of a new manic episode coming along.

All of this is in the past tense because I'm not currently in treatment for bipolar, and charting is essentially useless without someone to share it with. That's the other half of charting. Sometimes you can convince yourself that everything is fine even though you've lost weight and are sleeping less. Someone with a more objective outlook will be able to point things out on your chart that you're not noticing. That person can be your therapist/psychiatrist, depending on what type of relationship you have with each of them.
posted by xyzzy at 9:12 AM on December 27, 2014 [2 favorites]

Any time you're excited/under stress, your blood pressure will be up - it could be up in any of the 3 scenarios, so that's not a good measure of which problem it is. I'm not a psychiatrist nor do I have anxiety, but my impression from dealing with many people having both ongoing anxiety and panic attacks is that anxiety does cause you to have intrusive thoughts about what you're worried about and/or to do behaviors that are motivated by the anxiety, while panic attacks are quite debilitating but short in duration, and you can't accomplish very much during them because you physically and emotionally are in a state of panic - many people refer to the sensation as a feeling like they are going to die. That seems to be a good way to differentiate the two. I think some people might use 'panic attack' to mean just a somewhat more intense period of anxiety that could last longer, but the classic panic attack lasts a short time with very high intensity.
posted by treehorn+bunny at 9:57 AM on December 27, 2014 [2 favorites]

I have heard psychiatrists who are experts on bipolar disorder say that it is very common for people with bipolar disorder to have a hard time recognizing mania, even after the fact, and this is one reason why diagnosis of bipolar disorder is so difficult. Even if the psychiatrist asks careful questions, and the patient answers honestly, it may be hard identify episodes of mania. This particular expert was recommending that psychiatrists seek information from friends or relatives, with the patient's permission, of course.

You can recognize mania after the fact, so that's good. You're ahead of a lot of people. But maybe you should do what this psychiatrist suggested, and rely on the judgment of friends you trust, as well as your own insight.
posted by islandeady at 10:46 AM on December 27, 2014

Response by poster: To answer a couple of questions posed: Atarax is 20 mg up to 3x/day as needed. I'm taking 20 mg 3x/day and still going in a hundred directions wanting to get everything done RIGHT NOW.

My friend (and his family) have absolutely no expectations of me beyond taking care of myself so I can get health conditions under control. The cleaning and unpacking and wanting to work is all me. 100%. They frequently tell me to slow down, take it easy, nothing I'm doing is urgent, take care of myself. In fact, BFF is reading this post as I'm writing this comment, and had this to say: " If you like, make it known to posters that this stress is NOT because of friend expecting you to do things. Just the opposite, BFF doesn't expect you to do anything but get rest and try to get relaxed and get your health back. "

Sleep: Sleep is weird. I'll sleep 10 hours, or I'll sleep 2. Night before last, 9.5 hours. Last night, 2.5 hours, then an hour nap this morning. If it's a big sleep night, I'm exhausted, I want to sleep, I need to sleep, oh thank god sleep. If it's a little sleep night, I'm not tired in the slightest, but I know I need to sleep, so I'll lay in bed for an hour or so before I give up and do something else. Then after an hour of something else, I'll try again. When I do fall asleep, I wake up 2-3 hours later, wide awake and ready to rumble.

Thank you for all the comments so far. I'll try to not threadsit!!
posted by The Almighty Mommy Goddess at 12:00 PM on December 27, 2014

It's awesome that you are in a safe place and your friend is helping you out.

I would cautiously say that anxiety is more internal, thoughts rolling around and physical symptoms like muscle tension, that aren't visible to others. Panic, you might be outwardly upset, trouble breathing, heavy feeling in chest.

Mania, talking rapidly, irritability, acting on impulse (i.e., meeting someone in the street and bringing them home to visit, or extreme road rage, the above-mentioned spending sprees). Some things can trigger a manic episode, stressful events, certain meds, SAD lights, and lack of sleep is one of them. But it can be the chicken or the egg with that.

Would I would do is call the doctor on Monday and tell them what you've been going through and see what they say. Tell them you've been feeling anxious and have had insomnia/wakefullness every other night and are worried about tipping into a manic episode. Maybe they'll just tell you to increase on one of your current meds. Make sure to tell them the Atarax isn't hitting your anxiety.

With a new diagnosis you don't want to mess around in guessing or what if's, but err on the side of caution. Maybe all it will take is an increase in the one or adding a mood stabilizer specific to your condition. Some of those you are taking for other things may work for some folks with bipolar but not for you.
posted by Marie Mon Dieu at 1:18 PM on December 27, 2014 [1 favorite]

You need a doc to help you since you've exhausted your medicine cabinet. I would talk to a doc about doing away with antidepressant and finding something else for migraine relief, adding some thing else to knock down mania (eg atypical anti psychotic), upping the trileptal or augmenting with additional mood stabilizer, etc. All of this needs to be done in coordination with people handling your physical medical condition.

Honestly, for someone in your situation, inpatient might not be so bad. The side effects of your new meds will likely worsen a pain condition or migraine and odds are you'll land in the ER again anyway while adjusting to new meds. At least inpatient you have a bed, a fixed IV line, and access to painkillers while you stabilize. Plus you don't have to look at a mess of boxes.

Sorry to hear you are in bad shape right now, I hope things will turn around soon.
posted by crazycanuck at 2:55 PM on December 27, 2014 [1 favorite]

It sounds like, from your question and follow-up, that there are currently minimal external pressures on you that would require high-stress activities. You can choose to do them if you wish, but they are not required. It also sounds like you are looking for tools you can use every day in conjunction with health care and medication. (I emphasize that last point, because proper medical care is really the most important thing, and I don't want to imply otherwise at all.)

With that in mind, do you respond well to schedules and regimentation? If so, I'd suggest setting an alarm for every 3 hours, starting at the time you wake up and continuing for every moment that you are not in bed, in the dark, with your eyes closed. This means that if you wake up and get out of bed at 2am, you have to set an alarm for 5am. If you go back to bed at 4am, turn it off.

Every time the alarm rings, you have to stop what you're doing immediately and meditate for 7 minutes. Set a timer for that too. Then you have to check in with yourself for 3 minutes. This could be a mood/pain board, a quick journal entry on how you spent the last three hours, checking your financial statements if you're prone to impulse spending, etc. You also have to do this as soon as you wake up, no matter what time it is. If you're pooing or showering, you have to start this as soon as you're done. The parameters of the set up can be altered based on your pain level and/or physical abilities.

This will serve three functions: 1) a soft reset button every 3 hours, if you're engaged in a manic/OCD activity, 2) active mindfulness (which it sounds like you're on board with), and 3) a way to track your mental state on an ongoing basis. Right now, you don't have the tools to identify what's happening as it's happening, and your brain chemistry can trick you into believing you're stable when you're not. You can try to bypass that problem by enforcing an alarm break no matter how you think you're feeling. Think of it as medication -- it doesn't matter whether you're feeling well or not, you still have to do it in order to heal. If you miss a session, do it like normal at the next scheduled time.

You might also consider sharing your mood board or journal with your therapist or a friend.

I did this when I was in a similar crisis situation in the immediate aftermath of my lowest mental health point (for me, it was acute anxiety and situational depression), when I was lucky enough to be able to focus on my health with no other major responsibilities. This technique is not a magic bullet, and again, it won't replace proper health care and medication. It's a tool, and it helped me get through some rough times.
posted by Ragini at 11:27 PM on December 27, 2014 [1 favorite]

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