Monday, October 07, 2013

Celestial and Cerebral Reunions

When patients come to me distressed about a recent loss, we go through the process of differential diagnosis because there are many types of depression associated with grief.  At some point we get right down to facts:

How we grieve, or bereavement, is beyond our control. We're powerless for the most part.  Crying, tearing up, feeling adrift, lost, disengaged from the rest of humanity-- is a natural response to having lost something of tremendous value, something, someone, that we cannot see anymore, can't feel, touch, hug, cherish, even care for anytime soon, maybe ever.  It is especially natural when the object of grief was complicated, difficult to grasp, or the relationship suffered strain and miscommunication.

I received email yesterday from Mario Trucillo, a doctor under the assumption that I'm a caregiver by trade. He asked for a link to his blog, The American Recall Center It's about FDA recalls

I'm put in the context of caregiver (maybe he didn't read very carefully) because for the past few years, before my parents passed away, I lived closer to them than my brother and could drive here-there-and everywhere, take care of a few daily needs. But technically, I'm not a caregiver.  Even while performing some of the tasks of that job, I always considered myself a daughter, my brother, a son. Caregivers are people on a much higher level.
Proof of Heaven? Maybe

But let's get back to bereavement and tears. It may be American Health Literacy month (according to Dr. Trucillo) but we don't have to stick to what has been found empirically evident.  We can hypothesize, too.

Some people cope with loss by assuming there is an afterlife complete with heavenly reunions.  Sci fi, to me, but my cousin in Israel, hearing about the loss of my mom, wrote:
"Now all of the cousins are together." 
I have to write to her, now that I'm finally getting to thank you notes. It is comforting to her, the thought that our mothers are together now. Just hearing from her is a comfort to me.

Lesson learned: always reach out to your friends, even to random people you know who have suffered a loss.

But something may have been lost in the translation. The thought of heavenly reunions unfortunately, doesn't work yet. A close friend advised a book,  Proof of Heaven: a Neurosurgeon's Journey into the Afterlife by Eben Alexander. I started it yesterday. So I'll let you know.

Moving right along. The DSM V, that new edition, is a wiser 941 page tome of diagnosis than the last.  It required much more concentration than I've had, lately, but it seems, that like its predecessor, bereavement is still a differential diagnosis.  Clinicians are encouraged to especially whether or not a diagnosis of major depressive episode ought not be considered, depending upon the circumstances. We're to take weight loss, insomnia, intense sadness and rumination over a loss very seriously.  Not necessarily just bereavement, in other words.

I don't know if I've said this or not, but I never expected to be grieving my mother, not this much. Denial, obviously.  But I felt that my mother and I had such a good relationship, that there was nothing unresolved, nothing to make a simple matter like loss so difficult.

What happens is that the brain has so much of our lives packed into our central processor,, amygdala and hippocampus, not to mention the cerebellum, basil ganglia and motor cortex, that we can't begin to predict such luck.  What we can predict is that when we have been ultra-involved with our parents, their go-to people as they age, memories will be vivid.   The flashbacks accessible, palpable, real, we become aware of all of the things we could have done to make them more comfortable. And the guilt-- what we should have done for them, as opposed to the little we did by comparison, is unrelenting, as are the thoughts.

Air them, naturally, and they do relent, recede. This is what friends are for.

We can always be a better . . . A nice little PhD thesis for one of you:
The degree of our involvement with a loved one before death will predict the intensity of memories and magnitude and frequency of flashbacks in the first months after death. 
You could use a hired caregiver group as a control, make up your own hypotheses. Other variables matter, too, type of relationship, cultural expectations, external support, income. It is likely, no matter, that if we're a go-to person, almost anything will remind us of the person we lost.

Major Affective Disorder with Depression, sure.  But repeated exposure and the trauma at the end of life, depending upon those other variables, is likely to be associated with Acute Stress Disorder (308.3), too. We consider it anytime there is exposure to actual or threatened death, serious injury, or sexual violation, when a patient has witnessed a disturbing or violent image, say a serious car accident (blood, dismemberment, etc.).

Memories of coma, a parent's eyes pleading for help, those last moments of life, even if they are good, are snapshots that are recorded, indelible. The DSM 5 calls this an acute grief reaction and suggests the adjustment disorders be ruled out, too. We're seeing that no matter the diagnosis, it takes work to put such memories into safe files in our brains, lick those envelopes and put them away.

I had heard about something else, this from an enmeshed patient (she described herself this way) but didn't expect it would happen to me.  Sometimes everything is vetted through thoughts of the deceased.  Nothing is interpreted without an unconscious, non-intentional, surprising, mother-coated lens . She is everywhere.


I get my nails done, first time in three months. The manicurist is a little rough and I think, Good thing I didn't bring Mom here. She might have hurt her.

My 8-month old grandson tends to draw out one note and sing, not say words. He is a little young, we'll cut him some slack, and this is probably how we should all communicate. But he latches onto one note and holds onto it for as long as he can.  The note is loud and clear and beautiful, and I remember that his father did the same thing as a baby and that in the car I would play him tapes of Luciano Paveratti and Placido Domingo. (Today he is a part-time cantor). This thought immediately blends to the anniversary card with the crisp one-hundred dollar bill that my mom would give to me and FD each year for the opera.

I am sitting with a friend and notice her slim hands for the first time. My mind's eye jumps to watching my mother's hands and how they alternatively swelled to purple and blue, sometimes responding to cold or heat, sometimes merely her crazy electrons, completely out of whack.

On those Jewish holidays, just last month, on the holiest day of the year, when the liturgy is especially beautiful, I hear her voice in my head as if she is on my right side, singing in my ear as she did when I was seven!

Last week FD and I visited our kids and grandkids in Atlanta, and waiting on the curb for our ride to the house I think, I have to call my Mom, tell her we're here, arrived safely.  What used to be an obligation, and I think this is the real kicker, is something I wish I could do but no longer can.  My solution is to talk to her anyway, the mock call, an intervention suggested to others.
Hey Mom, we arrived, how ya' doin'?   No, waiting for them to come and get us.  Sure, will call you tomorrow.
Not to mention that one of her great-grandchildren looks like she did as a child.

I find it hard, a one-way call.

Then, on the return to Ohare, in the terminal waiting for FD to deplane I think, Well, that was a nice trip.  Haven't flown since (my son)'s wedding in May.  And this immediately signals the thought that she wanted so badly to go to the wedding and couldn't. And although we set up FaceTime for the ceremony, and she spoke (via an Iphone recording) to the 200 plus guests at dinner, it wasn't enough. She was angry, upset about missing it.

But if you were to ask me how I'm doing I would have to say, Fine.  This isn't a bad thing. The real diagnostic data that matters is functioning, and fortunately, robot that I am, that many of us are when it comes to work, that's still there. Focusing upon others is a natural distraction.  As is Modern Family.

However, if you're taking out a friend who is going through this sort of thing, stages of grieving, just saying, maybe you are going to lunch or to the cemetery, wherever, you might want to be the one behind the wheel of the car.



Syd said...

Thanks for this post. I have finally gotten through a lot of the acute phase of grieving with the loss of my wife's parents who were also like parents to me. Lots of things remind me of them. And going through their things to get the house ready for sale has been difficult for us. I do think that my wife has a lot of unresolved issues with her parents. I mostly resolved those things before they died. Lots of food for thought. And I'm sorry to hear about the death of your mom.

Anonymous said...

all sounds pretty normal to me...
thank you for the clarity of your writing, you put into words what so many of us (in personal and/or professional roles) struggle to express.
my dad's unexpected death a couple of years ago was not too hard for me, for a couple of reasons. He was ill less than 48 hours and he had not accepted any caregiving as he had no plans to become frail or to die (age 88, mind you!)He was abusive to me, but having spent serious time in therapy I had worked out much of the unfinished business and set good boundaries years ago. I can see my 3 sibs continue to struggle as they have not acknowledged his behaviors.

Leora said...

"Some people cope with loss by assuming there is an afterlife complete with heavenly reunions. " My parents are now both buried in a cemetery in Israel, along with my maternal grandmother, my uncle, relatives by marriage, parents of friends ... I imagine them all getting together in an underworld party, and my grandmother cracking funny jokes about the whole scene that makes me giggle. She had clever insights about people.

Anonymous said...

Therapydoc, thank you so much for this blog entry. My mother died last year after a long illness (cancer), and I was with her in the hospital, watching it happen. A lot of what I have read about greif talks about the trauma inherent in a sudden death (which I'm sure is traumatic, perhaps in ways I don't fully understand), but I've seen much less mentioned about how something like "a parent's eyes pleading for help" can be stressful and hard to get out of one's mind. I really appreciated reading it here. Thank you for sharing your experiences and knowledge, and my condolences on your mother's death.

therapydoc said...

Syd, as always, thank you for your compassion. What our intelligence can't heal, time will.

Anon about dad, I hear you. What a difference that makes, the boundaries. Help the sibs if that's possible.

Leora, that makes it easier for me, thinking of them all doing the Yiddish jokes and arguing about what a particular expression really means.

Anon about your mom, thanks for the condolences. The reminders just don't stop. Today I saw her pharmacist (a man who never met her) walking through Target and I wanted to say, Hey! Don't you miss me picking up those meds?