Borderline Personality Week: when your desire to kill yourself is an annoyance to others

Jesus Christ I hate the wordpress post management system.  It published my first BPD entry three days early and then ate drafts of two planned posts.  Let’s see what I can recreate.

There are a lot of insights I get from working at the crisis chat center I would like to talk about, but talking about them requires examples, and using the chats as examples would be a huge violation of privacy, both morally and legally.  Lots of health care workers get around this by writing semi-fictionalized or composite characters, but I don’t feel skilled enough to pull that off.  Luckily, Kiera Van Gelder  wrote a book,The Buddha and the Borderline, about her recovery from learning to cope with Borderline Personality Disorder, and there is absolutely no privacy violation in using her as an example.

The first issue I want to discuss is how health care professionals treat BPDers’ threats of suicide.  Van Gelder was committed for short term stays due to suicidality several times- first as a young adult, and then three times in six months around age 30.   BPD can lead to suicide, at about the same rate depression, bipolar disorder, and schizophrenia do (with the exactly number being hard to determine because co-occurrence and misdiagnosis between BPD and the first two of those disorders is so common).  But BPDers are (perceived as) more likely to enjoy their stays.  That is probably because (crudely) depressed people want to kill themselves because they think everything is hopeless, bipolar people because they simultaneously think think everything is hopeless and have the energy to act on that belief, and schizophrenics think the CIA has told the demons where to find them.  Whereas BPDers are often thinking things like “no one cares about me.” and “I’m all alone.”  A hospital stay with kind staff checking to make sure you haven’t killed yourself salves this directly, and as such can be pleasant.  I can’t even judge them for this because even though I don’t think I’d have fun in a mental hospital, I got my IV nutrition + immune support at a concierge medicine place and it was awesome. *

But after two stays in a few months, the hospital was not so nice.  On the second visit, they told her that if she kept this up insurance would force her into the state hospital, which she would “not find so pleasant”.  When she came back a third time anyway they suggest maybe she needs to just learn to live with being suicidal and when she insists she is.  not.  safe.  they put her in a “rapid recovery unit”, which is basically a holding tank for the hospital to prove they did their due diligence vis a vis keeping her from killing herself while expending as few resources as possible.  It is not warm, it is not comforting, no one is demonstrating they care about her.

Perhaps the fear is that BPDers are faking suicidality, or worse, pushing themselves to become genuinely suicidal, to get attention.  I can’t prove that’s not happening.  And if anyone is going to do it, it’s probably borderlines.  But as I said above, the death-by-suicide rate for borderline personality disorder is only slightly lower than that for depression and bipolar disorder.   That doesn’t mean they have the same chance of following through on a given threat (it’s quite possible BPDers threaten more often), but it seems like the safer plan might be to give them more attention without requiring them to resort to suicide, rather than calling their bluff.

Perhaps it is that the act of denying a BPD sufferer admission to the hospital makes suicide more likely, in a way it doesn’t for other mental illnesses.  You might think that that would make admission a better idea, but a consistent thread in the medical treatment of BPDers is trying to make them get less out of treatment.  I’ll talk about that tomorrow.

[ An important note if you’re dealing with a person with BPD: even if they are making the suicide threat “for attention”, ignoring them doesn’t mean it will go away.  Suicide also looks like a viable means of getting attention and/or coping with not getting attention.  This does not obligate you to indulge their every whim when they mention the word suicide, you are in your rights to cut them off, but if you think the threat is credible, alert their support network or emergency services ]

*Have you ever had a nurse be happy to peel an orange for you?  I have.  Having insurance cover treatment at conceirge locations is like getting bumped to first class when you bought a coach ticket.

Reality is Broken and how to fix it

I am very into video games.  This does not mean I play many video games- I’m below average for people I know, although that’s a skewed sample.  But I do a lot of reading about video games , because I find economics interesting and the business of video games has a confluence of factors that allow me to understand it.  Plus, it’s going through some interesting transformations on both the monetary and art fronts.  That is why I read Reality is Broken by Jane McGonigal.

Much like researchers of heroin and cocaine before her, McGonical’s approach is to look at something addictive and, rather than declare we’re all weak for liking it, study why it is so addictive/satisfying and what we can do to bring that into our lives in a healthy way.  Her list of things video games provide us- flow, challenge, ownership, accomplishment- read like a list of things my job doesn’t do.  Which I already knew, and has led me to start researching other careers, which led to among other things this blog.  This gave me the idea to start alternating work-type tasks with video games targetted to give the satisfaction of having done work (e.g. Harvest Moon, which is about running your own farm).  For the moment the work type task is “reading books I already wanted to read”, but it nonetheless raised my satisfaction and endurance level significantly, and I’m hopeful it will help when I return to work as well.*

But then McGonigal shifts tacts, and talks about all the ways we can use video games to improve the world.  One example is Foldit, in which players are given the primary structure of a protein and attempt to find the lowest-energy tertiary structure for it.  Scientists actually use these results in their research. **   She also designed World Without Oil, a collaborative fiction game where people brainstormed how to adapt to an oil storage.

She also talked about her prolonged recovery from a concussion.  I identified with this a lot: the lack of tangible progress, the alternation between not having the energy to do what you’re supposed to and being desperate to do something but not knowing what.  In my case there’s also juggling several different problems, and wondering if you’d be happier if you just concentrated on one until it was done, and trying to manage containing the most urgent symptoms and investing in long term solutions.  I responded by writing “this is hard” in my diary.  Jane McGonigal responded by making SuperBetter, a website/service that gamifies convalesence (think fitocracy but for actual health, rather than health-as-codeword-for-skinny).  This was kind of a revelation for me on two levels.  One, it solved a problem I had recently been whining about, and enables me to take better care of myself.  I’ve been using it for a week so far, and while it’s not magic, it is helpful, and it is most helpful when I am least able to act on my own.

Two, it has me thinking about my future.  My volunteer thus far has me very convinced I want to work in adolescent mental health.  I think that is my special talent and while I feel stupid saying it, I genuinely think I could change the world.  I want to do that.  But so far my research has focused on existing career tracks I could jump into (psychiatrist, counselor, etc).  I’d considered programming for a company that made meaningful software but dismissed it, in part because I’d done it before and found it lacking.  But maybe there’s a hybrid.  I could have made SuperBetter.  I mean, the last webpage I made was written in notepad, but I’m capable of learning the skills to make SuperBetter.  Hell, I could probably get a job to pay me to learn the skills to make SuperBetter.  There’s no credential holding me back.  And I think I would be really proud of myself if I did something like that.

MoodGym already exists, so off the top of my head I don’t know what I could create that would add value to the world.  I definitely need more volunteering and reading to find out, and may quite possibly need more formal education.  But my eyes are open to the broader range of possibilities for me to change the world, both now and in the future.

Which is extremely convenient, because the money that would have gone to taking off work and soul searching has gone to taking off work and holding an ice pack to my jaw.  It was a good trade given the circumstances, but it may set formal school back years.  This was an excellent time to acquire hope I can do more in place.

*According to Reality is Broken, this is common strategy among top executives.

**This is how I got through the analytical section of organic chemistry.  I hated all that stuff that was never going to be relevant to me as a behaviorist until I realized it used exactly the same part of my brain as the game Set, which I loved.  I went on to nail that test and enjoyed it more than any other part of orgo.

Borderline Personality Week: sympathy for the devil

Borderline Personality Disorder has an absolutely awful reputation.  Many therapists refuse to see them.  It’s considered absolutely immune to treatment.  They make up a disproportionate number of visitors to crisis chat, and an even more disproportionate number of high frequency callers (we don’t diagnose, but often people share their existing diagnoses).  A fair chunk of our training is about how to handle them, even though the way to handle them is “exactly the same as everyone else, be sure not get lazy enforcing boundaries.”

I’m not a counselor or psychiatrist (yet), but here’s a model I’ve found really useful for BPDs: they’re stuck with the coping skills of a teenager, forever.  At age 14, right before I got my third or fourth period, I was terribly upset over something.  Whatever it was, I knew even as I raged that I was not actually upset over that thing, I was upset because Hormones, and eventually they would subside.  And that made me even angrier, because here I was so upset over something I knew didn’t matter.  Or maybe just because my Hormones had a new target.  Either way, it was super unpleasant, which made me unpleasant to other people, and I was incredibly grateful when that part of puberty subsided.*

BPDs never get over that.  I talk to some extremely self aware borderlines- people who’ve done years of regular therapy and a full course dialectical behavior therapy and many hospitalizations and drugs.  You don’t hear much about this group because they work very hard to keep the symptoms of their BPD hidden.  But for all that, they are- at 30 or 50 or 70- in the emotional place I was when I was 14.  Subject to violent emotional storms they can’t control.  And it’s not their fault.  If it could be changed through effort, it would be changed by now.  You could dump those emotions on “normal” people and they would react approximately the same way, because lashing out and withdrawing are perfectly sane reactions when your body is telling you you’re about to be kicked out of the tribe and eaten by lions.

Not everyone does all that treatment, of course, and even these gold star BPDers are probably very difficult to have a serious relationship with.  But this framing and the clear boundaries of a crisis chat I find it very easy to fulfill the promise of the service, which is to give them a space to be heard without being judged.  I can empathize with the pain they’re in even if it is something internal that inflicts it on them.   And I hope that one day we find a more successful treatment than insurance-billable Buddhism.

*I also enjoyed when my mental image of my body caught up with my near instantaneous physical development and I stopped hitting myself on all of my parents’ beautiful antique furniture with dangerously pointy corners at hip height.  14 was a rough year.

Pain, part 2: Options for Treating Pain

Anesthetic (e.g. Novocain):  This is a very good option for when you need to block an extraordinary amount of pain in a very specific area for a short period of time (e.g. dental work).  However, as someone who received nerve damage from surgery that exactly mimics the effects of local anesthetic, I can tell you that it is not a long term solution.  Feeling nothing is actually very weird, and makes it easy to injure yourself.

Non-steroidal anti-inflammatories (e.g. ibuprofen):  These are great for occasional use, and have their place for long term pain caused by inflammation (e.g. arthritis).  But they carry some heavy risks for long term use.  One, inflammation is often a helpful reaction.  Topical NSAIDs helped my cat’s pain but retarded the growth of blood vessels in the eye which ultimately made the problem worse*.  Suppressing a fever can prolong illnesses.

NSAIDS are also hard on the stomach, which is bad for everyone, but especially bad for someone like me, who has long running stomach problems that interfere with my ability to absorb nutrition.  I completely wrecked my stomach with naproxen the week before surgery.

COX-2 inhibitors are a subclass of NSAIDs that target pain pathways more specifically, while sparing the gastic pathways that cause so many problems.  The problem is they also increase the risk of coronary events, to the point many were taken off the market and others restricted to single use post-surgery.  They’re so out of favor for pain relief that the three different medical professionals I begged for dental pain relief didn’t think to suggest them, even though I have many gastric risk factors and essentially no coronary risk factors.

Even before realizing COX-2 inhibitors might be perfect for me, I was very angry that they had been taken off the market.  The coronary risk was limited to a small subset of patients, of even of those, some might very well choose to live a shorter life in less pain, because pain is depressing.

Non-NSAID analgesics (e.g. tylenol and asprin): You know how new drugs like to advertise themselves as “safer than asprin?”  That’s because asprin is actually pretty dangerous.  Not super dangerous, but dangerous enough it might well be denied FDA approval today.  Asprin is also a blood thinner, which is great for coronary patients but terrible for dental patients because it can melt the blood clot protecting the surgical site, leading to dry socket.  Some descriptions down play dry socket, but it is in fact both extremely painful (because it exposes a nerve to open air), and dangerous (because it leaves the wound open to infection).   Tylenol is the world’s worst way to commit suicide, because there are several days between the point of no return and actual death, and they are extremely painful.

Opioids (e.g. heroin): I’m told these are super fun for some people, but I have had many different kinds over the years (as one dentist after another fucked up trying to fix my mouth), and I hate them.  The milder ones (everything short of percoset) do nothing for me, and the stronger ones (percoset) are so supremely unpleasant I would rather be in pain.  The only exceptions were when I was literally dying of norovirus, and whatever opioid they gave me was apparently integral to me not dying, and when I got dry socket.  And even with dry socket, I only took them to sleep, because they were just so awful. I refused to even get a prescription this time, because they just don’t work for me.

But even for people who find opioids tolerable, they have serious risks.  They depress respiratory function, cause constipation, and reduce mental function.  They’re insanely addictive on a chemical level- which doesn’t mean everyone who takes them once is hooked forever, but does mean that most people who take them will go through an unpleasant withdrawal period, no matter how “legitimate” their reason for use.  People develop tolerance to the pain relief faster than to the negative side effects, and quitting them may leave them in more pain than they were when they started.  For all these reasons, opioids are pretty much exclusively used for acute pain management and terminal patients.  Doctors who stray outside this risk serious sanctions from the DEA and FDA.  Even if I found opioids tolerable, there is absolutely no way I could have safely used them for the months of surgery + recovery I am going through.

And because I’m working my cat into everything: he doesn’t like opioids either.  Even after having four teeth pulled he fought me on taking his medicine, and then he just stood around in a stupor and drooled.

Tricyclic antidepressants: This is a cutting edge use of a very old drug.  I was prescribed topical doxepin by the doctor who did the research proving it was useful for oral pain- and even then, he was researching a different kind of oral pain.  It had some ugly side effects: I fell asleep immediately upon taking it, and couldn’t stand being touched (anywhere) the next day.  It left some numbness that lasted indefinitely- when I ate spicy food I could feel in my throat where the liquid had trickled down.  On the plus side- it left some numbness that lasted indefinitely.  That was a huge improvement over the shooting pain I’d had before.  I eventually stopped because the permanent effects had boosted me to the point it didn’t hurt that much, and the side effects were getting worse, but it was overall a great experience.  If I hadn’t found something better it’s what I’d ask my doctors for now.

Capsacin (aka spicy food): This really only works for dental pain.  When you eat capsacin it activates all your pain receptors at once.  Which hurts a lot, but then you’re good for a couple of hours.

Cannibidiol (i.e. marijuana): This one isn’t as well researched as the others because it’s illegal at the federal level (although, I must stress, legal in my state for both medical and recreational use).  But everything we know about it is awesome.  People tend to use THC and marijuana interchangeably, but that’s not true at all.  Any given strain can very in the amount of THC and CBD, and some strains may not have any THC at all, or the treatment may not activate it.  THC causes a lot of the symptoms traditionally associated with marijuana use, like munchies everything being funny.  CBD causes nerves to stop hurting for no reason, and may do a bunch of other awesome things like reduce inflammation, encourage bone growth, decrease anxiety, fight cancer, and (I can only assume) whiten your teeth while you sleep.  There is essentially no way to kill yourself with it** and there’s no physical dependency.  I used this off and on after all three surgeries, and my use naturally trailed off after each one.  It either doesn’t have any effect on me mentally, or the effect was less than the pain it was stopping.

THC may work synergisticly with CBD.  In my case it makes me sleepy, which is a terrible trait for a recreational drug but an amazing one for convalescent therapy.

A note for dental use in particular:  you are not even allowed to use a straw, so you definitely cannot smoke anything.  The nice people at the medical dispensaries have precisely dosed pills, and if you are lucky, CBD tinctures.  These are meant to be taken sublingually, but if your pain is in your mouth you can apply them to the area and everything stops hurting really really rapidly.  It gave me an amazing sense of control over my pain and enabled me to take more risks, in terms of eating and talking to people, which really sped up my recovery.

I don’t want to get too much on the “yay marijuana” bandwagon, because it’s entirely possible that as its usage becomes more widespread we’ll find out it has some rare but nasty side effects too.  But I do think it’s a travesty it is treated as worse than ibuprofen or alcohol, when it is clearly better.

*I think his infection was also resistant to the first antibiotics they gave him.

**Weirdly, this may be true for humans but not pets.  When I investigated using CBD to treat pain from my cat’s corneal ulcer, I discovered that we are pretty sure there is no amount so high it can kill your pet in one sitting, but chronic use may lead to something resembling serotonin syndrome (aka the reason you have to be so careful when taking MAOI inhibitors).

Pain, part 1: Pain is bad.

This seems obvious, and yet we as a society seem to have chosen to ignore it.  The problem is not just that pain is painful, although that is a terrible start.  It’s how pain effects you.

Humans on the whole are remarkably adaptive.   Parapelegics can emotionally bounce back from spinal cord injuries in two months.  One of the very few things human beings never, ever adapt to, meaning they produce a permanent lessening of happiness, is pain.  Pain (and long commutes) will continue to depress your happiness forever.  If you lose a limb, phantom limb syndrome is actually a vastly bigger threat to your happiness than the physical disability.

Pain also effects what you are capable of doing.   In the months leading up to dental surgery, I felt like Harrison Bergeron; I had to race to finish my thoughts before shocks of pain broke up the chain entirely, and I couldn’t have a thought that took longer than the space between shocks.  I couldn’t really enjoy books anymore.  I clung desperately to the feeling of accomplishment I got from “finishing a seven season TV series”, because I really couldn’t do anything else. * This is depressing in general, and endangered my ability to keep the job that gave me the money to fix the problem.

Then there’s what fear of pain does to you.  Imagine if every time you socialized, there was a 10% chance you received massive convulsing shocks that took days or weeks to recover from.  That would probably depress your socializing a lot more than 10%.  Now imagine that applied to everything you ever do.  And that fear made the effect worse.  It would take series efforts of will to even hold a job, much less a full and satisfying life.  And while any given bout of socializing could be dismissed as a luxury, human beings inevitably get depressed when deprived of social contact entirely.

Pain makes it harder to treat the root cause of problems.  Exercise helps back pain, but back pain makes it hard to exercise.  I couldn’t get my cat to accept eye drops for his extremely painful corneal ulcer until I started giving him pain medication.  It only took two days for the eye drops to help enough that he no longer needed pain medication, but without those two days he might very well have lost the eye.

So I’m going to proceed from here in the understanding that pain is not only very bad, but often a bigger threat to people’s total well being than physical limitations or even fear of death.

*In fact, you can track my discovery of useful pain relief and when the root problem was fixed via my blogs and my goodreads queue.  I cannot tell you what a relief it is to be able to enjoy reading again.

Differential recall as an objective test for abuse?

Peter Watts is one of my favorite fiction authors, a fact that should probably worry me.  Normally I don’t like hard sci-fi, but Watt’s biology is interesting, plot-integrated, and plausible.*   For example, see this presentation from Blindsight, “literary first-contact novel exploring the nature and evolutionary significance of consciousness, with space vampires”, explaining how vampires came to be.

Those of you who can’t be arsed with videos in blog posts, I understand, and please take my word for it that he presents a very scientific explanation for how a subspecies of humans with vampire-like traits could evolve, interbreed with the normal humans, die out, and then be revived via collection and activation of dormant vampire genes.  And it is absolutely plausible.

His other big work is The Rifters Trilogy, which is based in part on the idea that people with untreated traumatic backgrounds (the protagonist was molested as a child) are more suited than their emotionally healthy peers for dangerous, stressful work (e.g. maintaining a power facility miles under the ocean seeing no one but each other for months).  I don’t remember how much he justified this at the time, because what he said was plausible enough to make for a good story and that was enough for me.

My current non fiction book is Blind to Betrayal.  The awful cover implies it’s solely about infidelity, but it is actually about how people willfully blind themselves to all sorts of betrayal from people they are dependent on- everything from children pretending their parents don’t molest them to people discriminating based on race while claiming to be race blind.  In chapter 8, they discuss divided-attention versus selective attention.  Divided attention is what lets us multitask, selective attention is what let’s us filter out extraneous information.  People (both adults and children) who score highly on the Dissociative Experience Scale (which the authors contend is associated with trauma and selective blindness to evidence of betrayal) tend to score better than low-DESers on divided attention tasks and worse than low-DESers on selective attention tasks.  People with traumatic pasts also have worse memories for trauma-associated words (e.g. rape, kick) and pictures, but no deficit for neutral words and pictures.

I take these results with a grain of salt, because they are very close to implicit association tests and that methodology has come under question.  But if we accept them as correct for now, I see three very obvious conclusions:

  1. Peter Watts was dead on
  2. Human beings are amazingly adaptive, and this is another reminder that what often looks like sheer dysfunction is at least an attempt to adapt, although it doesn’t always work.
  3. If individual variation is low enough, we have a test for abuse.

One of the tragedies of investigating abuse of children is that it’s very very hard.  Children lie, in both directions.  They lie spontaneously, and they lie after being deliberately coached.  A well meaning investigator can accidentally induce a child to invent a story of abuse.  And the investigation can itself be traumatizing to a child if they weren’t actually abused.  But if the variation in recall of trauma to non-trauma words is low enough, you could just give every kid a memory test every year.  Any wild variation from the norm or the kid’s historical record could be flagged for further investigation.

You could also use it when you have worrisome but highly ambiguous indicators, like for example the time I told my girl scout leader “something bad is happening at home” and refused to elaborate. I have no recollection of this, but according to my parents it happened right after my brother had some intensive medical testing, and they had had a talk with me about not blabbing about it around our school.  My girl scout troop leader quite rightly couldn’t let that go, but she also knew my mom worked with kids and even a whiff of investigation could ruin her life forever.  This story turns out okay.  My parents dropped me off for interrogation by my troop leader with instructions to answer everything she asked honestly, she correctly deduced I was not being abused, and she did not report my parents to CPS. But an objective test would have saved everyone a lot of anxiety.  It would also be useful in situations with a high false report rate, such as custody battles.

I don’t know if this research is at the stage where they could use it diagnostically, but I hope someone is working on it.

*Although noticeably less so in his recent release Echopraxia, where I had trouble following both the plot and the science.  I thought it might be surgery-brain, but a friend had the same reaction.

The origins of traumatic bonding

There’s a phenomenon known as traumatic bonding, in which an abused child or spouse bonds to their abuser even more strongly than they would in a health relationship. It’s usually attributed to intermittent reinforcement.

I have an alternative explanation. My cat currently has a retinal tear, which means his life consists of pain, a mysterious cone around his neck that blocks his vision and hinders his movement, and waking up several times a day to the being he loves most in the world, his sole source of food and protection pinning him down and stabbing his eyeball (antibacterial eye drops). Three times in one week this being has put him in a tiny cage and takes him to a place where they torture him even more (fluorescent staining at the vet). He used to love head rubs, now he flinches every time I touch the top of his head, because he associates it with eye drops. He is displaying every symptom of human depression an animal is capable of.

The thing is, I’m inflicting all this on him because I love him.  I am trying to save his eye, and I have absolutely no way to explain that to him.  And it got me thinking: lots of parenting is like this.  Even once the kids are technically old enough to understand English (a feat Nemo looks increasingly unlikely to to master), there’s lots of things you have to do for their long term good that they really hate in the short term.  Some of these things they will eventually understand and be grateful for, some they will always hate.   Either way, no human would ever survive to adulthood if they rejected their parents every time they did something that, from the child’s perspective, looks like torture.

So maybe we’ve evolved to have the capacity to love someone even if they hurt us, because we can’t tell good hurt from bad.  Traumatic bonding could arise either straight from that, or from a perversion of that system, the same way chronic clinical depression arises out of useful emotions.

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.