Month: July 2014

Depression, symptoms and definition

Slate Star Codex consistently makes me feel bad about the quality of my most sciencey entries by blowing them away.  Here he does it with SSRIs.  One of the many, many data points he offers is that there is a very well known and consistent effect that doctors (and other observers) notice their patients acting less depressed (as measured by sleep patterns, appetite, ability to leave the house, hygiene standards, etc) well before patients report themselves feeling less depressed.

There are a lot of possible explanations for this.  One possible one is that we’ve reversed cause and effect: rather poor sleep, appetite, and executive function being side effects of depression, depression is a consequence of poor sleep, appetite, and executive function.  Moreover, it’s a delayed consequence.  One night of good sleep doesn’t even make up for a week of bad sleep, much less months.  So even if antidepressants instantly removed all the road blocks in someone’s life, it will take a while for those lack of road blocks to translate to feeling better.  Under this model, wondering why you’re still sad a week after starting anti-depressants makes as much sense as wondering why you’re still weak after two sessions of physical therapy. *   If the depression led to some choices with lasting consequences- quitting school, ending a relationship-it might well be impossible to give them back the life they would have had without depression.  That doesn’t mean the drugs aren’t working or aren’t useful, it just means they aren’t magic.

I didn’t intend this, but I think I just re-arrived at my model of depression as a symptom.

*This analogy was originally “starting a diet and being shocked you don’t immediately lose 30 pounds”, but that would reinforce the screamingly incorrect idea that diet has a simple causal effect on weight.

Patterns of pain

When I first regained feeling in my lower right jaw, I could feel everything.  I could feel the vibrations when I talked or drove.  I could feel the change in air pressure when I breathed (even through my nose) or had a fan on me.  I could feel the change in blood pressure driven by my heart beat in the lower right of my jaw.

And by “feel” I mean “felt pain in response to” (the vibration was a separate sensation that accompanied the pain).

The pain ebbs and flows, but I stopped feeling my heartbeat and breath a few days ago .  The fan is still uncomfortable (which is awesome in the middle of a heat wave), there’s a constant ache that is much less susceptible to pain medication, chewing (even on the other side) hurts some, and if I tap my two front right teeth together I want to die.  I nonetheless keep doing it completely on purpose, because I just cannot believe that something so light hurts so much.  If I put something- even hard metal- between them, I can apply much more pressure before it hurts.  I used to have a milder version of the same thing with my right molars and pre-molars, but that has subsided for now.

When I’m not actively experiencing this, it’s kind of fascinating.  I can occasionally feel my heartbeat in my fingers while meditating, but nothing like this.  And how on Earth could teeth detect anything to do with air?  The implication is that my and everyone else’s nerves are always capable of this sensitivity, but choose to ignore it.

I am limited in how much I can research this right now, because nothing breeds neuropathic pain like reading about it.  But my OT found me this continuing dental education article on the teeth as sensory organs.  The gist seems to be that teeth have nerves, and they use this to avoid breaking themselves by biting too hard.  The article doesn’t discuss it, but teeth are temperature sensitive as well, so I assume cold is bad for the teeth as well.  Teeth that have their nerves removed via root canal are more prone to breaking, and the author’s conclusion is that this is because they’re incapable of noticing when they apply too much pressure, the same way lepers injure themselves.

From this, I conclude that my teeth were detecting very minor sensations as dire threats.  This is one reason I think it’s important to keep doing things that hurt (when you know they won’t cause actual injury): the nerve needs to experience a range of experiences so it can learn what genuine danger feels like, so it stops overreacting to minor sensation changes.  This is also why good pain meds are so key to recovery: without them, I couldn’t risk heavier sensations.  I also think they might “train” my nerve to not freak out so much, which would be why at first a tiny dab of topical pain killer brought me hours of relief.

It’s also clear that the nerves on the top and bottom of my jaw are “talking” to each other, or that something in the jaw muscle recognizes “closed” as a state.  That’s the only way it makes sense for two teeth touch to hurt when the same teeth holding a piece of paper or a metal spoon don’t.  Even though the pain feels like it’s only in the lower right front tooth, it’s actually a product of synthesis of several different nerves (or rather, several different branches of the trigeminal nerve).  You have to admit this is pretty cool, even when it’s excruciatingly painful.

Monday morning quarterbacking

The infection in my jaw has been growing for either 1.5 or 6 years, depending on how you count the first surgery to remove it.  I was already practiced at ignoring dental pain because I’d had trigeminal neuralgia on the other side for even longer.  In retrospect it’s obvious the pain had been life altering for at least several months, but I either didn’t consciously notice the effects or didn’t link them to the cause.  Now I’m looking over the last six months or so and analyzing what else might have been a side effect of the pain.  I’ve already talked about my concentration and focus, but today it occurred to me my relationship with alcohol had changed too.

I’ve always been a very, very light drinker, a drink or two every few months, because that was the frequency with which it was fun.  It wasn’t a conscious decision, and the frequency was highly variable- I might drink twice in one month if two drinking occasions came up, and then go six months without when none did.  It’s a matter of social environment, and I don’t have a good definition of what the “right” time is, I just know it when I see it.

So it wasn’t really weird that the last drink I remember having was at New Years.  Except it was. My reason for not drinking at a given event was no longer “eh, this is not the day” but “no, that will take something I can’t spare.”  I couldn’t have told you what it was, but I knew I didn’t have enough.  And this isn’t just me applying 20/20 hindsight, I told someone this exact thing before the new infection was diagnosed.

Looking back now, it seems entirely plausible that alcohol would be competing for the cope that was being used to cushion the pain, or would have weakened one of the systems that was fighting the infection (immune,  liver).  I would expect chronic infection to be a drain on the immune system and alcohol to be a tax on the liver, which means one of them has to be crossing over in order to see this effect.  Eyeballing it, I find the liver the more likely crossover point.  I definitely wasn’t drinking enough to have even a marginal effect on the liver of a healthy person, and while I was not healthy, I also wasn’t drinking hardly anything.  If the liver was the shared resource, that implies the infection (and/or the parasite I may have) was kicking out enough toxins to tax my liver.  That’s pretty concerning, given that the liver is enormous and however impressed the dentist was, the absolute volume of the infected tissue was just not that big.

“But look how much bigger it is” is not an actual medical argument, even if you could fit all of my gum tissue in the liver many times over.  A quick googling reveals that bacterial periodontitis leads the liver to produce more C-reactive protein.  I had “cardiac” CRP, which I believe is the same thing, tested a month after my last surgery (timing is a coincidence) and it was low normal.  I don’t have any numbers for the intervening period.  There are several studies showing an association between liver damage and periodontitis.  Most are mostly small, retrospective, and unable to distinguish cause and effect, but this one used both animal models and treatment to demonstrate that bacterial gingivitis taxed the liver.

There’s no way to prove the liver is what I was keying in on, but it certainly looks plausible.  And in a situation where I’ve had almost no information or control, I’m kind of proud of myself for listening and protecting myself, even when I didn’t know from what.

Eating for oral surgery

Eating after dental work is hard.  You have balance total calories, protein, vitamins, and other nutrients against pain, stress, and a limited capacity to chew.  In my case, you have bonus digestive track issues.  In the hopes that this could be useful to someone else about to undergo oral surgery, here’s a list of recipes and tasks to help.

 

Before Surgery

  1. Find a protein powder you like with a neutral taste.  I use Thorne MediClear because it’s what my doctor recommended.  Before I found out I was sensitive to milk and eggs I used MLO Milk and Egg Powder.  A lot of supplements use soy.  Soy is a great thing to eat in small doses, but it contains xenoestrogens, so be wary using it as your main source of protein.  
  2. The neutral taste is because we’re going to be mixing that powder in with other things.  If you’d like to just drink some protein, consider finding a shake or a flavored powder as well.
  3. Figure out what vitamin supplements you need, and if your protein powder contains them.  This can be very specific to you and your surgery, so ask your doctor.  Mine put a special emphasis on omega three fats (because I have nerve involvement), so I picked up a fish oil supplement.  Post surgery, I’ve also found myself craving iron (which makes sense, since my red meat consumption was low to begin with and is now lower) and Diindolylmethane (DIM).  DIM is a compound found in Cruciferous vegetables like broccoli and brussel sprouts that activates several liver enzymes that can aid in removing toxins from the body; my conjecture is that the surgery and recovery are generating a lot of waste products and this is helping to clear them.  Obviously eating the real vegetables is ideal, but I only have so much chewing in me.
  4. Make stock.  As usual you can throw in whatever you want, but my usual recipe is onions, garlic, ginger (a stomach settler), maybe some spinach, bones (which have meat + marrow still on them), and organ meats.  My dentist loved this idea particularly for the healthy fats.  Freeze the stock before surgery so you can dole it out afterwords.
  5. Make juice.  Ideally, have a friend with a juicer so you can make several Tupperware containers worth of juice from the materials of your choice.  You really can do whatever you want here: the difference in value between produce is so much smaller than the difference between eating it and not that you should optimize for what you’ll drink the most of.  Do try and get a variety, both because it’s healthier and because you will get sick of any one thing really fast.
  6. Find a comfort food that doesn’t require chewing.  I used fudge.  Ice cream is an excellent choice if you eat dairy.
  7. If you plan on taking pain meds, and you should, talk to your doctor about supporting your digestive track.  NSAIDs can do a real number on your stomach especially when it’s empty, which it will be because eating is work.  I was taking so much naproxen before my surgery that I developed serious stomach pain, and had to take some support vitamins.

During recovery

  1. DO NOT USE A STRAW.  I love straws more than anyone older than 7.  In this situation straws look like your friends because they let you consume liquid with less work and keep it away from your surgery site, but it is a dirty, dirty lie.  The suction can dislodge the blood clot protecting your surgery site (the infamous dry socket complication of wisdom tooth removal).  They tell you this is extremely painful, but what they don’t mention is that it also leaves the surgery site vulnerable to infection, requiring many painful and exhausting surgeries to correct.  Learn from my example
  2. Take your pain seriously.  We have a tendency to try and tough out pain, or dismiss it as unimportant.  It’s not.  First, your suffering matters.  Second, pain is extremely disruptive to the healing process.  It makes it hard to eat and sleep.  Third, fear of pain will slow your recovery.  Right after surgery, a lot of activities will hurt you, like eating and talking and in my case, breathing.  It is healthy to restrict those activities for a while (except the breathing, although I did try).  But it is not healthy, physically or emotionally, to hold yourself rigid and withdrawn because you don’t know if you’ve healed enough to do something.  The availability of pain relief can enable you to take more chances, which ultimately leaves you healthier.
  3. Alternate comfort food with one of the medical foods.  For example, I would take a long sip of stock (possibly mixed with protein powder), and then a bite of fudge.  This wasn’t just a bribe or a comfort: the fudge triggered my brain to recognize that I was eating and it should take steps to digest it, and the stock got caught it the cross fire.  This let me eat a lot more medical food than I would have otherwise.  

The recipes

  1. Bone stock + water, salt, and protein powder to taste.
  2. Juicer juice + water, salt, and vitamins.  At a gut level I feel like protein goes with stock and vitamins go with juice, but your gut may vary.
  3. Oatmeal + protein powder + sweetener. It is filling, requires minimal chewing, and gives you protein.  
  4. Oatmeal + nut butter.  Like above, but with one fewer steps.
  5. Congee.  The base recipe is to boil rice for four hours.  It is easy to chew and filling.  You can add some nutritional value by boiling it in bone stock instead of water, or by putting stock ingredients in the pot with the rice (which you remove before eating).  The texture is gross but I love it because I can feel the nutrition coming off it.  I have to toss the fat when I make bone stock because it’s just too gross, which has always been a shame because it has all the fat soluble vitamins, and is an extra shame in this case because my dentist wants me to get omega 3s so much.   With this I can let the rice absorb the fat, and get the vitamins from there.  I plan on continuing to eat this after I’ve healed.  Also, while the texture starts pretty gross, it does not get any more gross on reheating and it keeps for a surprisingly long time.
  6. Applesauce with protein powder.  Apples are actually not as nutritious as their PR would leave to believe, and applesauce doesn’t even have the fiber or skin.  But it’s a fruit, and you’re mixing protein powder in it, and that is good enough for now.
  7. Berries.  They’re relatively easy to chew, full of nutrients, and delicious.  

Pain, Concentration, and Achievement

The timeline is as follows:

  1. [unknown number of months]: oral pain increases steadily
  2. surgery removes source of pain.  Surgery itself or sheer disorientation leave nerve completely numb.
  3. Two blissful days in which I am completely exhausted but mostly pain free.
  4. Nerve function returns, leaving me to experience the pain of having a portion of my jaw scraped off.  Although actually very little of the pain is at the surgery site.  It’s more likely a compressed nerve due to the influx of blood and lymph

I feel like this has given me a natural experiment of the effect of pain on productivity and concentration, since the shifts were so sharp.

I went to sleep pretty much as soon as I got home from the dentist.  When I woke up 16 hours later, I grabbed the book on my bed and read.  Eventually I looked up, it was two hours later and I’d finished half the book.  I couldn’t remember the last time that happened.  I finished a book a day in the pain free period.  Reading had a sense of flow that I didn’t remember it having in years.  And some of those books were not amazing, but they were pleasant and I felt absorbed, which also hadn’t happened in a long time.  The same thing happened with video games- I was able to enjoy some fun low-brain games instead of something socially worthy like Mass Effect or Papers, Please.  I began to entertain the idea that I might one day play an RPG again.

In the last four days I’ve struggled with two books by authors I’ve enjoyed before.  I dropped one and only finished the other because I figured out what I’m about to tell you:it was impossible for me to have a sense of reading flow.  I’ve always been a little fixated on updating my progress on books on goodreads- down to a percent or two if I’m listening to a mediocre book on my bus commute.  Less in other cases, but present.  That disappeared with the pain, and came back with it too.

Productivity wise, I at least felt way more productive while I was exhausted-but-unpained.  I would watch an episode of TV, do one little chore, then take a three hour nap.  My apartment was actually trending upwards, and I was getting very high quality sleep.  In pain, I don’t sleep well, so I don’t have that burst of energy that lets me clean, so I don’t tire myself, so now both pain and jitters are keeping awake, so I’m spending a lot of time in a stupor accomplishing nothing, including healing.  I have more energy in the sense of “I can walk farther without collapsing”, but am ever so slightly losing to entropy.  I’m not physically incapable of putting my dishes away, and I notice that it needs to be done, just not when I have any reserves to do it.

Elodie Under Glass (no relation) has a guest post up on Captain Awkward about the low mood cycle.  It’s brilliant and you should read it on those merits, but the important point for my story is that humans can get in a cycle of not doing anything because they don’t have any motivation, and not having any motivation because they never get anything done.  She calls it the thought->behavior->outcome cycle.  That point where outcome feeds thoughts and make you feel better?  I call it getting a hit of Accomplishment.*  When I’m in this much pain, there is no hit. I have a few possible explanations speculations for this:

  1. Body has narrowed success criteria for all actions to “did you make the pain go away?”  Moving my dirty dishes in the dishwasher did not make the pain go away, therefor it was a failure, therefor no Accomplishment.
  2. Normally there’s a mini flow state between initiating the action and evaluating the outcome.  When in pain, that walk from the couch to the dishwasher is interrupted every half a second asking if I’m done yet, and registering a failure when I haven’t.  With a 10 second walk, that’s 19 failures to one success- and that’s assuming the washer can accept the dish with no further work, and I don’t see any additional failures in the kitchen to deal with.
  3. Some combination of these
  4. Okay I thought I had more but apparently those are the only two.  In my defense, it’s amazing I’m writing this well considering the level of pain I’m in.

Whatever the explanation, pain clearly is constantly pushing me towards the low mood cycle.  I can break out of it with a big enough Thing, but Things that big are impossible to sustain, leading the cycle to collapse back down to low mood.  One of the few things I’ve been able to sustain for long periods is working at crisis chat, because when people talk it’s a jolt of energy, but then there’s some down time before they respond.**

You may blame the lack of proper closing paragraph on my screaming jaw or the fact that this post is completely speculative.  Or feel free to substitute your own reason.  Ideally something flattering.

*I am going to feel very dumb if there’s an actual drug with the street name of Accomplishment.

**After a few hours at crisis center I came home and couldn’t leave the apartment for two days.  I think that’s an energy thing.