Monday, October 28, 2013

Zombies and Bipolar Depression




Updated October 2014 - BGE



It's been weeks since I've written anything of note. Well, anything period. But this actually segues well into what I want to talk about in this post. 

I've been stuck in mental molasses for weeks (actually make that months) and it appears to be worsening. Being in the depressive phase of manic depression (that is the classic definition of alternating between manic highs and depressive lows as opposed to the seemingly one size fits all definition of bipolar disorder which seems to cover a wide range of behavioural issues) is where I'm at these days. 

Few people, and that includes medical people, can comprehend what this means or what it's like. I am physically, emotionally and mentally gassed 98% of the time. Not even people who suffer from occasional bouts of depression understand what this is like (except for severe cases that end up in hospitals). The depressive phase of manic depression can be many things and I happen to think I'm winning the battle against a lot of those things (and I have no problem giving full credit to my positive difference making fundamentals ). I am no longer pummeled by negative self talk all the time (occasionally but nothing like before). It's not as dark and hopeless as it was before (though I still hit the suicidal darkness skids sometimes). It's not a lot of things you'd normally associate with depression. It's mostly an astonishing lack of energy (and motivation, passion, drive and other things but I want to focus on the energy component this week). 

And there's sweet tweet to be done about it. Honestly. Trust me. It's not a nutrition issue or an exercise issue or a not having a shiny happy people attitude issue. It's an unavoidable part of the cycle. And it is a cycle, a cycle that's as sure as the phases of the moon or the rise and fall of the tides; one will surely follow the other. And this is not a self fulfilling prophecy. I have moved mountains in the past in effort to ward it off and constructed super sonic levels of belief that surely the depression would not return. But it does. Every. Single. Time. That's kind of why it's considered a disorder - there's nothing you can do to stop it or make make it go away once it hits (alleviate it, perhaps, but not make it go away). Anyway, I'm not going to waste my time arguing about that (and believe me, many people try to). 

I keep telling myself that this is a normal phase of manic depression and that it'll pass. I tell myself that but the evidence is not stacking up very well. With the exception of my five week run of mania to kick off 2013 (five weeks to the day of almost zero sleep and off the charts mental energy) and about two months of something approaching "normal" energy, I've been in virtually a non-stop depressive state since spring of 2010 (much of that, I believe, induced by psychiatric drugs meant to "stabilize" me but I'll grind that ax another day). Throw in the manic phase that kicked off the eighteen month phase of "Photomania" (long story) late in 2007 along with the rapid cycling that took place during that time period and we're just not talking a whole lot of mental stability (AKA "normal", I guess) in recent years. 

This does not portend well. According to the book Taming Bipolar, as a fifty-four year old man who's lived with it all his life undiagnosed, I am in the worst category for "treatment resistant" bipolar (of course we must define "treatment" ... this is talking about traditional - and backwards - psychiatric treatment). There's a lot I disagree with in the book (traditional drug therapy for one, of course) but I think a lot of the basic research about the disorder is well founded and based on long term observations. Each cycle, the thought goes, that one goes through of mania and depression, the more entrenched the disorder becomes (and theories of neuroplasticity would support this. The more you go through it, the more "hard wired" it becomes). Also, rapid cyclers are thought to be harder hit. I'll put my hand up to support that. So, having gone through - what, close to twenty cycles? - and having done a lot of rapid cycling and living with it untamed for so long puts me in ... the shittiest of categories we'll say. 

But that's all water past the dam. Plus it's based on old models of understanding and treatment. I honestly believe I'm moving past that. This does not by any means mean I think I've got anything "beat" - far, far from it. I've got way too many been-there-done-that t-shirts for false flags of thinking this was in my past (like early this year for example when I boldly proclaimed myself free from mental illness and ready to conquer the world) but in relation to how bad the depressive phase can be (which Kay Jamison describes so well in her book An Unquiet Mind and about which I am well researched elsewhere), I think I am displaying remarkable improvement over that of the average sufferer and that of my own past. If it weren't for this energy shortage. This is definitely - and alarmingly - getting worse. An hour, two hours max is all I can go doing anything - light work, reading, writing, thinking, walking, socializing - and I'm thoroughly gassed. That's if I can do anything at all. Any kind of deep thinking and writing is almost out of the question. Hence the quiet blog of late. 

But enough of that depressing talk. Or at least let's look at it a bit differently. Your intrepid mental health blogger-reporter has not let this opportunity go to waste. I have been faithfully observing and logging my depressed mental state and putting it under the microscope as it were. All the while wondering "why the hell does my brain do this to me?" and in a habit I picked up earlier this year, when I wonder "why?" about something to do with mental health, I demand answers and won't stop digging until I find them. 

I read, as you may have noticed, much about neuroscience. I follow the most superb blog Searching for the Mind by Dr. Jon Lieff and many other neuroscience blogs and websites. I read or have read several books put out by renowned neuroscientists and I hang out online with a small number of neuroscientists who, knowing what I'm up to, send me all kinds of research papers. It's not like I lack for resources (nor, I'll point out, the ability to understand a great deal of it). But there are not a lot of answers out there. I actually was in email contact with Dr. Lieff about this and this is what he told me: "There are literally thousands of scientists trying to understand the neuroscience of bipolar disorder. At this time in history, it is too complex for our present tools. Everything is currently speculation." Not exactly brimming with optimistic outlook for someone looking for answers, is it? 

But I am not to be deterred. One thing manic depressives have going for us is that we tend to think outside the box and we go in different directions from the mainstream. At least this manic depressive does (and I've interviewed others who do as well ... we'll get to this in more detail another time though) and that's what I do - I search outside of mainstream ideas for answers. After that long preamble, we finally get to the topic - zombies and bipolar depression. Which I'll tie into this mental and physical fatigue. 

There are several possible biological reasons for the fatigue that we won't explore at this time. These are hard to explore because they just don't appear to have found them or nailed them down (see Lieff's quote above). One area that looks interesting, however, is the critical role of glia cells in brain functioning (which Lieff touches on here). There is research to suggest (which I can't seem to find in my horror show of a filing "system") that sleep is essential to glia cells doing their thing. Not to mention sleep appearing to be critical for neuronal and synaptic housecleaning (yet more research for which I can't find the link which I was sure I'd saved ... sigh). 

During phases of mania we don't sleep. How much damage does this cause and how long does it take to "catch up"? Is this part of the reason for the depressive/low energy phase? Alas, clear answers are not currently forthcoming. But I have some other ideas I'd like to put forward for now, ideas that I strongly believe, based on my observations of my current depressive phase and current understandings of how brains work, have some merit. Which finally brings us to zombies - or more specifically, renowned neuroscientist David Eagleman's concept of "zombie systems"; the subconscious and automated brain functions that really drive who we are, what we do and how we do it. 

I touched on these two posts ago in my introduction of neuroscience 101 (<self-promote> which, by the way, got a big thumbs up from Jon Lieff and my Google+ neuroscience buddy </self-promote>) and I'd like to delve into them a bit more. It is, as I said before and which I'll repeat, critical to understand how little conscious control we have over our actions. Massive amounts of research shows that before an "idea" or "decision" hits our conscious mind - located in our frontal lobes - much deeper brain systems have already chewed on the data (key memories that the brain has stored unawares to "you") and presented it to "you". Chances are if you've had a "brilliant" idea that you think is "original" it's something (or various bits of thereof) your subconscious noted from somewhere else and filed away. In other words, you stole it from somewhere else (but don't worry, your subconscious will also create a story for you that it really is your idea). 

This is but one example. Your five senses are constantly testing the waters for anything that is of possible use to you or a danger to you (which is virtually everything from food to sex to rivals for those ... sorry, but yeah, we are that simple). All this runs mostly through our primitive lizard brains and limbic systems. Which, to remind, look roughly like this:



Our fancy-smancy mammalian neocortexes highlighted there in purple do lots of fancy stuff but that fancy stuff is mostly just adding and compiling and crunching more data that will also get run through the more basic hardware in green and pink - IE; simply running more sophisticated zombie systems (like math for example). And it's all this that "decides" what we do, not "we" (though we have no problem at all taking the credit). 

Zombie systems run most of what we do for a few reasons. One is because having automated programs that can run with no conscious input (and we do have some) is the most energy efficient way for the brain to operate (and energy efficiency is a super key driver of evolutionary progress - the more energy efficient, the better the chance of survival). 

Eagleman tells a fascinating story of the energy efficiency of chess master Gary Kasparov's brain (which they measured) during his famous chess match with the computer Big Blue. Big Blue may have been his equal on the chess board but it was no match for Kasparov's mental efficiency (he was humming along at about 20 watts while his machine counterpart was burning through thousands of watts and was almost literally melting down). 

While chess strategy is in the domain of our neocortex (reptiles can't play chess after all!), Kasparov's real mastery was of internalizing thousands of moves and counter moves into zombie programs so that his brain could run them automatically and thus very energy efficiently (and this is why many young chess prodigies eventually burn out out - they don't master this). Please make careful note of this because energy efficiency is an extremely major underlying functionality of the brain that will be my key point today.

Two is that this is simply how brains run - automated functions. This is how fruit fly neural circuitry runs, this is how round worm neural circuitry runs, this is how reptile circuitry runs, this is how more advanced mammal circuitry runs, this is how all creatures' neuronal circuitry runs, including that of homo sapiens. We're just further up the evolutionary scale. The underlying basics, however, are essentially the same. This is why neuroscience finds so much to learn about how our brain functions by studying simpler animal forms (I, in my initial ignorance, used to scoff at this but we do indeed have things in common with such simple things as fruit flies and there is much to learn, for another example, from studying the "connectome" (the wiring) of the simple round worm). 

A good deal of the programming comes "pre-installed" (basic organ functions such as breathing and pumping blood for example but, it turns out, also more "advanced" things such as human facial recognition) but the majority is learned "behaviour" (and "behaviour" is really just these subconsciously generated and run automated systems). The average human has hundreds if not thousands of programmed automated systems that guide the conscious you through your life. These would include virtually everything about what you do physically, what you "think", "decide", avoid, strive for, your "morality", philosophy about life and so on and so on. 

Even what you believe to be big life changing "decisions" were probably just barfed up by a complex combination of various subconscious zombie systems that may have been chewing on the problem for weeks, months or even years that are designed to nudge you this way or that through life. In other words, how well your life is going is completely controlled by forces mostly beyond your conscious awareness or control and depend entirely on how well your various autonomous systems were formed through genetics and environmental factors. 

Three is the simplest and most obvious. There isn't a living creature on earth that could get through any day if it had to actually "think" about what it did. And so it is for humans; it's far better to leave all the daily functions - large and small - to the three pound mass of tens of billions of neurons and more synaptic connections in one square centimeter of cortex tissue than there are stars in the Milky Way. 

That machine of yours contains awesome (in the true meaning of the word) amounts of computing and processing power and it's far better for conscious "you" to just stay out of its way and let it do the job that evolution brilliantly designed it to do (well, there do seem to be endless examples of brains that seem not so brilliantly designed to guide their hosts through survival but lets leave that aside for now). 

So what does all this about zombie systems - AKA, automated neuronal circuitry - have to do with bipolar depression? Well, a lot I believe. If how well your life is going, or has gone, depends entirely on subconscious automated systems, then by golly you'd better hope those systems are working well. And what working well is depends on two basic things: one, is some semblance of routine from day to day and two, and perhaps more critically, is how well and consistently your brain constructs your "reality". It doesn't really matter how "normal" either of these are, only that they are relatively consistent from day to day. And a bad case of long running bipolar disorder - like mine for example - decimates a) routine and b) your concepts of "reality". 

Bipolar disorder will, in true cases anyway (there are exceptions we'll get to another day), disrupt your life. Internal disruptions will lead to external disruptions which will lead to more internal disruptions which will lead to more external disruptions and on and on in a vicious cycle. I wrote some months ago a three part series about realities and the minds of bipolars and schizophrenics starting here

Between the various states of bipolar - mania, depression and mixed episodes - your brain will construct entirely different realities. In other words, when in these vastly differing states you will see the world in vastly differing ways. "Reality" one day might be to become the coach of a professional hockey team (as I once believed I would do) or "reality" might be that it's perfectly sensible to put a gun to your head and blow your brains out (as a particularly bad episode of psychosis was driving me to do or other self termination options presented as "reality" during episodes of mixed episode mania). It might be to be the most agreeable and seemingly nicest person in the world or it might be an almost unstoppable drive to punch the shit out of the guy in the car next to you. I've often said, roll the roulette wheel that day and get a different reality. 

The brain does not like this. It likes routine. This is why we call people "creatures of habit". It's because brains - AKA "us" - like it that way (as do all creatures of course). Even if it's a bad habit it's better than having your realities scrambled every second day. By saying your brain doesn't like it what I really mean is your zombie systems don't like it. Automated systems - even actual machine ones - need routine. And when your zombie systems start running amok, you start running amok. And because these are deep systems well, well beyond your conscious control, there's sweet tweet you can do about it. Fun, what?! It's not, of course, and this is where we get to the horrors - and they are horrors - of bipolar depression. 

As I said, the most fundamental problem with the depressive phase of manic depression is the complete and utter loss of energy. There are, I think is obvious, biological reasons for this (IE: actual brain damage (more later on this, I promise)). But a large part of the problem, I am now quite convinced, is discombobulated zombie systems thrown into complete disarray by constantly shifting routines and realities. Now let's go back to the paragraph about zombie systems and mental energy efficiency. If those systems aren't running smoothly then you will be burning a lot of energy just trying to do the most simple of things. 

Myself, when I started to think about them, I realized I have so many zombie systems that have been completely thrown off the rails, that I have almost nothing running smoothly and energy efficiently. And here's another thing about the brain. What starts to run amok in one place can cascade through others (Norman Doidge touches on this in The Brain That Changes Itself - it can go both ways, for good or for bad; it's part of neuroplasticity). 

One of our most fundamental zombie systems is our belief system; what we believe about ourselves and the world around us. Another is our system of thought. It is absolutely 100% critical to have confidence in these. For me, my last six years of bipolar zaniness has decimated these (the previous twenty to thirty years also are in the mix but it's mostly the most recent six years). Take my thoughts for example. Bipolar brains become very disordered. We will be presented with a constant barrage of what are known as "cognitive distortions" (part of what I mean by constantly alternating "realities"). These run from moderate to extreme paranoia to thinking it perfectly reasonable to prematurely terminate one's life to extreme grandiose thoughts and so on. 

I cannot trust a single thought in my head. Literally. Honestly. A single seemingly innocent incident (to you) can kick in some kind of discombobulated zombie system that will have me down by train tracks desperately waiting for a train to come along. Just. Like. That. <snaps fingers> Or that I'm the greatest thing since sliced bread and should run for PM of Canada. I am not in the least exaggerating. Or throw in frequent hallucinations, hearing voices, psychotic episodes and you no longer have any idea what "reality" "is". And it is these inner "realities" that generate your "thoughts". That's just what brains do - they generate a reality for you (yes, you ... all of our realities are internally generated by our brains). So I cannot allow my thoughts to run, as you can, on auto-pilot. I have to examine Every. Single. One. It is - excuse my French - utterly fucking exhausting. 

And this is just one example. Almost nothing runs automatically for me anymore. Not driving a car (something I've done since I was fourteen with almost no effort at all), not doing simple carpentry work, not socializing, nothing. I can be plucking away at seemingly the most simple thing in the world and suddenly hit overwhelm Just. Like. That. <again snaps fingers> Whatever I'm doing wherever I am I simply have to just stop and run my meditation program to try and empty my mind and let it reboot. This is utterly fucking exhausting. I wrote earlier about ego defense systems. These are yet more zombie systems (Eagleman touches on some of them - the stories we tell ourselves - in his book, Incognito) that are in complete disarray in me. I don't even know where to begin to put them back together again. Ego defense systems are designed to protect us from the big bad world out there (yours work so well that you are 99% unlikely to even be aware of their existence and what they do for you) and this I have to pick through one by one to try make sense of. This is exhausting. 

Oh, and then there's the little fact that all this disorder and mental chaos becomes a zombie system in itself. So you have to, once you learn awareness, fight all that. This is super deep hard wired stuff that you don't exactly just spin around on a dime. This is exhausting. 

There are, as I've said, other reasons for the well documented (for those of us who've researched it) exhaustion of the depressive cycle. Why, for example, when manic do we have nuclear amounts of off the charts energy? What generates that and how does that just "turn off" (or burn out more likely)? Why does the energy level slide so badly in the other direction? Many questions, almost no answers. But I firmly believe that having our deep and critical subconscious automated operating systems so messed up and their energy efficiency go out the window with that is a big part of the puzzle. And there are many, many days when it feels like all the king's horses and all the king's men can't put Humpty Dumpty back together again. 


Update, October, 2014

I can't believe it's been a year since I wrote this nor can I believe that I am still battling the relentless fatigue. But I must say that I've done enormous amounts of (exhausting) work to move past many of the issues I've described here. I think I have mental and physical routines down better and the mind scrambling (and exhausting) inner chaos settled down to a great degree. So things are improving. 

As well, thanks to a tip from Jon Lieff (mentioned and linked to above), I learned much about the physiology of the depressive phase fatigue which I summarized in a brilliant three part series. You can access them by clicking on the links below:

The Neuroscience of Bipolar and Major Depression Fatigue - Part One

Part Two

Part Three


Saturday, October 26, 2013

Stories From the Inside






I'm working on the next blog post in the more science bases series that I started but in the meantime I'd like to start a series of stories about people I met while staying on psychiatric wards. Part of the purpose of this blog is to educate others about the world of mental illness and this is part of that education. 



Weird Scenes Inside the Goldmine 

- Jim Morrison, 1970



"Z”

Z was about twenty-one or twenty-two years of age in March of 2011. She had the beautiful high, hooked nose that many people of her native Afghanistan have, along with high cheekbones and eyes of a pretty hue of brown that were so deep you swear you could swim in them. She was small and frail. If her five foot frame weighed ninety pounds I'd be surprised. If I'm not mistaken, she was the youngest or one of the youngest in her family. She may have had a younger brother, I can't remember now. She did have, I know from her family's visits and through Z's stories, lots of older siblings, about evenly divided between brothers and sisters.

Z and her family were from one of the more southern areas of Afghanistan. I can't recall the name of the area. I think, though, that it was a suburb of Kabul. Nor can I recall Z's family's exact religious affiliation. I didn't get the impression that it was important to her. It didn't seem to be to any of her siblings when they came to visit either. Z and all of her family dressed and acted very progressively and with modern sophistication and style. Her father had been a gold merchant (not bulk gold but of the jewelry variety, something very important in Afghani culture). Her family was not rich but of upper middle class well off means. Z and her family lived well. Their family was well known and respected in their neighbourhood. Z told of her father being a generous man, one who didn't mind rubbing shoulders and sharing tea with anyone. The life of Z's family was good. They had everything they needed and were all ambitious as far as education goes, they were expected to gain a higher education and become doctors or other such gentrified positions.

Then one day the Taliban came.

One day Z's family was “in”, the next day it was “out”. The Taliban, as Z told it, had targeted her kind of family as “out”. I don't know what your knowledge of the Taliban is but at that period in Afghanistan's history, you did not want to be “out” with the Taliban. So, as with tens of thousands of other similar people at that time, they were left with little choice but to flee. Z would have been about eight at this time. Her life went from one of sheltered upper middle class with everything she and her family needed to one on the road with whatever possessions they could carry.

For weeks they traveled over dirty and barren roads through scorching hot valleys and harrowing mountain passes. All this while her family and those that they were traveling with had to keep an eye out for the Taliban and their sympathizers and to look out for bands of thieves. Much of the gold they'd brought along had to be bartered away for their safe passage. Several months later, they had crossed the Pakistan border and had found a refugee camp. As refugee camps go, it was no different than any such camp around the world. Relief organizations had done their best to erect tent cities and provide as much as they could. It was dirty, water was rare and precious, there was little food and there wasn't a speck of shade outside of the tents to give any relief to the daily 40C temperatures that seared down on them in summer. Nor was there much protection from the harsh mountain winds that sent temperatures plunging in winter. From playing with beautiful dolls in air-conditioned rooms, Z went to playing with sticks and rocks and balls of rags in ad-hoc games played with other children in small, barren, stone strewn patches of hard, sun baked soil. From being taken care of by a nanny, she went to having daily chores of scrounging for food and water. She went from having the finest clothes to wearing nothing more than whatever rags were left from what they could bring and what they could now find. Everywhere you looked, there were tents and other large families like hers. No one had much of anything.

This was to be Z's home for the next eleven years.

Z's family were cut from sturdy cloth, however. Somehow through all of this, they not only survived, but somehow managed to relatively thrive. And through relatives who'd long ago emigrated to other countries, connections were made, money saved, refugee relief procedures navigated. And Z, her mother and father, and most of her siblings found themselves in Vancouver, BC. Z didn't really know how all of this happened. She was young and unconcerned with such things. She just knew her father, mother and family had made it happen. As she was expected to, Z was entered immediately in school, in a school in an strange English speaking world where she barely knew a single word of English.

But, as immigrants have done for centuries in sink or swim situations in new lands, in new cultures and among strange people and a new language, she learned and she learned fast. Within a year she had a part time job at McDonald's. Within six months, she had mastered everything there was to know about working in that McDonald's and all of the English needed to boot. She was promoted to an assistant manager position. At the same time, she'd graduated high school and had been enrolled in college.

Throughout those eleven years in the refugee camp and the ensuing several years adjusting to Canada, Z's family's expectations for their children had never faltered. They were still expected to get the highest education possible and the best careers possible. Not jobs, but careers. Z's expectations were no different.

All of her siblings had done well and Z loved and admired them all but she had special love and admiration for an older sister, “M”. M had not, for reasons I can't recall, fled with the rest of the family when the Taliban arrived. I believe she may had already left for university and been well into her education and that that part of Afghanistan perhaps had remained in more liberal hands. At any rate, she stayed there, had become a doctor and in the now more liberated post-Taliban Afghanistan was practicing medicine specializing in women's needs (which was in very, very sore need among Afghanistan women). M was Z's hero and when Z spoke of M, her voice and beautiful deep brown eyes made this abundantly clear. Z said that they spoke often on the phone or through Skype. Z wanted very much to be like M.

She therefore put on herself, aside from the pressure her family put on her, a enormous amount of pressure to live up to the standard set by M. But she struggled with school. College was not like the simple courses of high school. The vocabulary and demands were much higher. In college she wasn't sheltered in an ESL program like she had been in high school. The stakes were higher. The workload to keep up with normal homework and to continue learning English at ever higher levels and to hold down her part time job at McDonald's was knee buckling. Delicate and frail Z was having a very hard time keeping up with it all. She began to suffer anxiety and couldn't sleep. She saw a doctor and was put on medications to ease her anxiety and help her sleep.

Then one day, while suffering from exhaustion, Z had failed a critical test at college. Utterly distraught and humiliated, she returned home and wept in despair. And then, and she couldn't clearly remember why or explain it at all, she took her freshly renewed prescription bottles and downed their entire contents, about a hundred pills in all. It was not long before she collapsed. One hundred pills in a body as slight and tiny as Z's will go to work fast and when her mother and sister found her, the toxins were already well within her system and were shutting organs down. She was already incoherent and lapsing into a coma. Her right hand had already frozen into a death grip around the bottle of pills she'd emptied. 911 was called, she was rushed to hospital and put on life support. Through some sort of miracle she survived. She spent several weeks in ICU.

And this is what brought Z to the chair next to mine to where our very disparate paths met in the TV room of the psyche ward of Royal Columbian Hospital where she had been telling me all of this in snatches of time in the long, boring, pointless days that we had to pass. She told her story with such humility, with such lack of self-pity and with such utter charm and humour, that at times my eyes stung with tears. The only times her voice showed much emotion was when she told of how fast she'd risen in McDonald's and had learned English. She was very proud of that and rightfully so. I've taught English to many, many people in the last twenty years and the level of English with which she was speaking to me was astonishing for the short amount of time that she'd been using it. She scarcely even betrayed a trace of an accent. For all I knew, she'd grown up here. The other time was when she spoke of M. It's not that her voice was flat otherwise, it wasn't, it was very animated (and of course it would be ... she comes from country with a thousands of years old tradition of oral story telling). It's just that there were those times that her voice told of a special emotion.


It was in the TV room that we'd met and we had become bosom buddies over the Vancouver Canucks of whom she was an avid and passionate fan (the Canucks are Vancouver's professional hockey team). The Canucks were on what would be a special run that season and the city was really fired up and the psyche ward of RCH was no different. Z and several of us gathered each night of a Canucks broadcast in the TV room and raucously cheered on our boys.


Z was therefore in the psychiatric wing of Royal Columbian Hospital because of a suicide attempt. She hadn't been depressed. There wasn't a trace of depression or of feeling sorry for herself when I talked with her. She had told me a lot of detail of what had been a very difficult life and had never shown a speck of sorrow or of self-pity. Talking to her, she was as vibrant, humorous and joyful a human being as you could want to meet. Positive life force verily radiated from her. She had been under a lot of recent pressure and stress however. I have no idea what her “diagnosis” might have been. She had been, however, obviously under a great deal of stress. 

The story of Z is one of several I'd like to tell of people I met "on the inside". I'd like to tell these stories for a number of reasons but chiefly to give an idea of the kind of people one will find on a typical psychiatric ward. I met dozens of people in my four stays in psychiatric wards no two of them alike. Readers of this blog also will know that I have a particular interest in suicide and the reasons behind it so I also think of Z as an interesting case study. We'll come back to this story, and others, later.